A New Cervical Spine Clearance Protocol Using Computed Tomography

Barba, Carlos; Taggert, John B.; Morgan, Anthony; Guerra, José; Bernstein, Bruce; Lorenzo, Manuel; Gershon, Abner; Epstein, Neil

doi:10.1097/00005373-200110000-00005

Cited by 108 publications

(62 citation statements)

References 14 publications

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“…Much of the literature focuses on the specific utility of different radiologic modalities. Several studies have indicated that helical CT alone is sufficient to detect cervical spine injuries [5,18]. Others have recommended the use of MRI acutely to detect ligamentous injuries, as they found that 60 % of flexion extension films are inadequate, consistent with the findings in our patient population [10].…”

Section: Discussionsupporting

confidence: 76%

Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients

et al. 2013

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Background Flexion and extension radiographs are often used in the setting of trauma to clear a cervical spine injury. The utility of such tests, however, remains to be determined. We hypothesized that in patients who underwent a negative computed tomography (CT) cervical spine scan, flexion and extension radiographs did not yield useful additional information. Methods We conducted a retrospective chart review of all patients admitted to a Level I trauma center who had a negative CT scan of the cervical spine and a subsequent cervical flexion-extension study for evaluation of potential cervical spine injury. All flexion-extension films were independently reviewed to determine adequacy as defined by C7/T1 visualization and 30°of change in the angle from flexion to extension. The independent reviews were compared to formal radiology readings and the influence of the flexion-extension studies on clinical decision making was also reviewed. Results One thousand patients met inclusion criteria for the study. Review of the flexion-extension radiographs revealed that 80 % of the films either did not adequately demonstrate the C7/T1 junction or had less than 30°range of motion. There was one missed injury that was also missed on magnetic resonance imaging. Results of the flexion-extension views had minimal effects on clinical decision making. Conclusion Adequate flexion extension films are difficult to obtain and are minimally helpful for clearance of the cervical spine in awake and alert trauma patients.

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Section: Discussionsupporting

confidence: 76%

Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients

et al. 2013

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“…However, with little further effort, the incidence of missed cervical spine and ligamentous injuries could be consistently decreased to fractions of a percent [10,123,127,128,147,150]. Among 15 injuries from 887 dynamic examinations, five could have been detected by plain films and CT, and a further proportion (possibly as high as 71%) detected by entire cervical spine CT. By performing plain films and high resolution entire cervical spine CT scans, the incidence of missed unstable injuries may be reduced to less than 8 ⁄ 887 (0.9%) and possibly to 2-3 ⁄ 887 (0.2-0.3%).…”

Section: Dynamic Fluoroscopymentioning

confidence: 97%

“…In one series, had entire cervical spine CT been omitted while patients were unconscious, three cervical injuries at C2, C5 and C6 ⁄ C7 would have been missed [125]. No cervical spine injuries were missed following 158 entire CT scans in combination with plain films [147]. Entire CT may represent a minimum standard once an injury is detected because 10-31% of cervical fractures have associated non-contiguous fractures [148,149].…”

Section: Computerised Tomographymentioning

confidence: 99%

“…Importantly, one must note the following: d High resolution CT, MRI and dynamic testing have never been prospectively compared. Their performance is probably more comparable than assumed [36,128,129,147,150]. d Given the risks and complications of the transfer of critically ill patients, it is unacceptable not to obtain as much information as possible from the first CT scan.…”

Section: Dynamic Fluoroscopymentioning

confidence: 99%

“…d Given the risks and complications of the transfer of critically ill patients, it is unacceptable not to obtain as much information as possible from the first CT scan. d Unsuspected injuries may be revealed in 8-14% of patients in the mid-cervical spine using entire cervical spine scanning, with a NNT of only 8 to 22 beyond directed CT [129,147,150]. Up to 31% of injuries in this high-risk population are associated with a non-contiguous injury of the cervical spine [149].…”

Section: Dynamic Fluoroscopymentioning

confidence: 99%

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Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening

Morris¹,

McCoy²

2004

Anaesthesia

106

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SummaryCervical spine injury occurs in 5-10% of cases of blunt polytrauma. A missed or delayed diagnosis of cervical spine injury may be associated with permanent neurological sequelae. However, there is no consensus about the ideal evaluation and management of the potentially injured cervical spine and, despite the publication of numerous clinical guidelines, this issue remains controversial. In addition, many studies are limited in their application to the obtunded or unconscious trauma victim. This review will provide the clinician managing unconscious trauma victims with an assessment of the actual performance of clinical examination and imaging modalities in detecting cervical spine and isolated ligamentous injury, a review of existing guidelines in light of the available evidence, relative risk estimates and a proposed management scheme. Cervical spine and associated spinal cord injury significantly affect the individual's functional capacity and quality of life, and carry significant implications for society. It was estimated in 1988 that a 27-year-old rendered tetraparetic would consume US$ 1 million for lifetime care and, with 721 tetraparetic individuals per million of the population, the total aggregate costs were an estimated US$ 5.6 billion per year [1]. In America, cervical, thoracic and lumbar vertebral fractures occur with an incidence of 50 000 per year [2], and cervical spine injury has an annual incidence of 5-10 000 cases per year [3,4]. More recent estimates suggest an incidence of 8-10 000 spinal cord injuries per year, of which 55% are cervical [5]. In the UK, there are approximately 1000 new cases of cervical cord injury each year [6]. Cervical spine injury complicates blunt polytrauma in 2-12% of cases [7][8][9]. However, several larger reviews that include 29 000 blunt trauma victims, and additional prospectively gathered data, demonstrate a generally lower incidence (2.0-5.2%) [10][11][12][13].The presence of a severe head injury increases the relative risk of a cervical spine injury, possibly by 8.5 times, and a focal neurological deficit by 58 times [14]. A Glasgow Coma Scale (GCS) score of < 8 is associated with a 50% increase in the incidence of cervical spine injury to 7.8% [15]. Similarly, Demetriades et al.[16] have shown that although the incidence of cervical spine injury in trauma victims with a GCS score of 13-15 was only 1.4%; this increased to 10.2% if GCS was < 8. 'Primary' cervical spine injury may be associated with head injury in 24-35% of cases [10,[16][17][18][19][20], and among polytrauma victims requiring cervical spine stabilization surgery, only 74% suffered an isolated injury [21]. The prognosis in patients suffering both head and cervical injury is typically poor, with approximately 25% being discharged to a dedicated nursing facility with little prospect of recovery [22]. Traumatic brain injury has a UK incidence of 100 per 100 000 population [23], typically among young, working age males, and therefore the combined consequences of brain and spine injury both ...

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Magnetic Resonance Imaging Is Not Needed to Clear Cervical Spines in Blunt Trauma Patients With Normal Computed Tomographic Results and No Motor Deficits

Schuster

Waxman²,

Sanchez³

et al. 2005

Arch Surg

112

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A New Cervical Spine Clearance Protocol Using Computed Tomography

Cited by 108 publications

References 14 publications

Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients

Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients

Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening

Magnetic Resonance Imaging Is Not Needed to Clear Cervical Spines in Blunt Trauma Patients With Normal Computed Tomographic Results and No Motor Deficits

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