Clearing the cervical spine in multiple trauma victims: A time-effective protocol using helical computed tomography

Nuñez, Diego; Ahmad, Adel; Coin, Carl G.; LeBlang, Susan; Becerra, José Luis Téllez; Henry, Robert P.; Lentz, Kimberley; Quencer, Robert M.

doi:10.1007/bf02614949

Cited by 84 publications

(32 citation statements)

References 8 publications

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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, plain films detected 58% of fractures and 93% of subluxations or dislocations (94% of all abnormalities), while CT detected 90% of fractures and 54% of subluxations or dislocations (92% of all abnormalities) [136]. Therefore, CT may miss more ligamentous injuries and malalignments, and plain films more fractures [125,127,138], but the combination is especially powerful, consistently achieving 100% sensitivity in a number of studies [33,125,[127][128][129][136][137][138]. Furthermore, in addition to excellent sensitivity, the use of combined plain films and CT in 879 patients allowed 'major' (associated mechanical instability or neurological findings) and 'minor' injuries to be reliably and functionally distinguished [145].…”

Section: Computerised Tomographymentioning

confidence: 99%

“…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]. Nunez et al [128,129] reviewed 88 patients with fractures previously diagnosed on plain films or directed CT. Entire helical CT detected 32 (36.4%) patients who had suffered 50 additional injuries.…”

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%

“…In a series of 129 patients unable to be cleared on plain films, 52 (40.3%) were due to non-visualisation of the craniocervical junction [127]. Ross et al [34], Borock et al [123], Kirschenbaum et al [127], and Nunez et al [128,129] all describe missed upper cervical spine fractures following inadequate or false negative odontoid views, commonly in the context of head injury. Furthermore, the odontoid view is an anteroposterior projection of an injury typically displaced in the same plane as the X-rays.…”

mentioning

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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Section: Dynamic Fluoroscopymentioning

confidence: 97%

Section: Computerised Tomographymentioning

confidence: 99%

Section: Computerised Tomographymentioning

confidence: 99%

Section: Dynamic Fluoroscopymentioning

confidence: 99%

mentioning

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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Imaging of the Spine in Victims of Trauma

Blackmore

Avey

Evidence-Based Imaging

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Issues of Imaging of the Cervical SpineI. Who should undergo cervical spine imaging? A. NEXUS prediction rule B. Canadian cervical spine prediction rule C. Applicability to children II. What cervical spine imaging is appropriate in high-risk patients? A. Cost-effectiveness analysis III. Special case: defining patients at high fracture risk A. Applicability to children IV. Special case: the unconscious patient Issues of Imaging of the Thoracolumbar SpineV. Who should undergo thoracolumbar spine imaging?A. Applicability to children VI. Which thoracolumbar imaging is appropriate in blunt trauma patients? 319Cervical spine imaging is not necessary in subjects with all five of the following: (1) absence of posterior midline tenderness, (2) absence of focal neurologic deficit, (3) normal level of alertness, (4) no evidence of intoxication, and (5) absence of painful distracting injury (strong evidence).Computed tomography (CT) scan of the cervical spine is costeffective as the initial imaging strategy in patients at high probability of fracture (neurologic deficit, head injury, high energy mechanism) who are already to undergo head CT (moderate evidence).

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