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

Schuster, Rob; Waxman, Kenneth; Sanchez, Barry R.; Becerra, Salvador; Chung, R. Wong; Conner, Scott; Jones, Thomas

doi:10.1001/archsurg.140.8.762

Cited by 112 publications

(75 citation statements)

References 18 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: 75%

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: 75%

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

et al. 2013

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“…58,65,67,85,90 Although a lower threshold for the use of advanced imaging would hypothetically result in the detection and possible prevention of a greater number of CSIs, these benefits must be weighed against the associated risks and considerable costs of performing such studies and the additional treatments initiated due to false-positive results. 18,19,41,77 Indeed, complications have been reported in 6-71% of critically ill patients during and after transport.…”

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confidence: 99%

Prevalence of cervical spinal injury in trauma

Milby

Halpern

Guo

et al. 2008

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117

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Object Diagnosis of cervical spinal injury (CSI) is an essential aspect of the trauma evaluation. This task is especially difficult in patients who are not clinically able to be evaluated (unevaluable) because of distracting painful injuries, intoxication, or concomitant head injury. For this population, the appropriate use of advanced imaging techniques for cervical spinal clearance remains undetermined. This study was undertaken to estimate the prevalence of unstable CSI, particularly among patients in whom clinical evaluation is impossible or unreliable. Methods Estimates of the prevalence of CSI in populations consisting of all trauma patients, alert patients only, and clinically unevaluable patients only were determined by variance-weighted pooling of data from 65 publications (281,864 patients) that met criteria for review. Results The overall prevalence of CSI among all trauma patients was 3.7%. The prevalence of CSI in alert patients was 2.8%, whereas unevaluable patients were at increased risk of CSI with a prevalence of 7.7% (p = 0.007). Overall, 41.9% of all CSI cases were considered to exhibit instability. Conclusions Trauma patients who are clinically unevaluable have a higher prevalence of CSI than alert patients. Knowledge of the prevalence and risk of such injuries may help establish an evidence-based approach to the detection and management of clinically occult CSI.

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“…The false-negative rate for secondary MRI to detect discoligamentous injuries where the initial CT scan was negative was reported to be up to 25 % [8-10, 24, 25]. Several studies have addressed secondary MRI findings when the initial CT scan did not identify cervical instability [8][9][10]26]. A meta-analysis of Schoenfeld [27] including 1,550 patients found injuries in 6 % initially undetected on CT or radiography, but later detected by MRI altering treatment.…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, morphometric criteria can mislead physicians. Previous findings resulted in general acceptance that clearance of the cervical spine can be obtained safely with a CT scan and optionally by MRI [8][9][10]. An accurate radiographic assessment technique to measure segment motion is the quantitative motion analysis (QMA) method [11].…”

Section: Introductionmentioning

confidence: 99%

Hidden discoligamentous instability in cervical spine injuries: can quantitative motion analysis improve detection?

et al. 2013

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Purpose Recent literature shows that occult discoligamentous injuries still remain difficult to diagnose in the first instance. Thresholds as indicators for discoligamentous segmental instability were previously defined. But, since supine radiodiagnostic is prone to spontaneous reduction of a displaced injury, and even some highly unstable injuries reveal only slight radiographic displacement, these criteria might mislead in the traumatized patient. A highly accurate radiographic instrument to assess segmental motion is the computer-assisted quantitative motion analysis (QMA). The aim was to evaluate the applicability of the QMA in the setting of a traumatized patient. Methods Review of 154 patients with unstable cervical injuries C3-7. Seventeen patients (male/female: 1:5, age: 44.6 years) had history of initially hidden discoligamentous injuries without signs of neurologic impairment. Initial radiographs did not fulfill instability criteria by conventional analysis. Instability was identified by late subluxation/dislocation, persisting/increasing neck pain, and/or scheduled follow-up. For 16 patients plain lateral radiographs were subjected to QMA. QMA data derived were compared with normative data of 140 asymptomatic volunteers from an institutional database. Results Data analysis of measurements revealed mean spondylolisthesis of -1.0 mm (-3.7 to ?3.4 mm), for segmental rotational angle mean angulation of -0.9° ( -11.1°to ?17.7°). Analysis of these figures indicated positive instability thresholds in 5 patients (31.3 %). Analysis of center of rotation (COR)-shifts was only accomplishable completely in 3/16 patients due to limited motion or inadequacy of radiographs. Two of these patients (12.5 %) showed a suspect shift of the COR. Conclusions Our data show a high rate of false negative results in cases of hidden discoligamentous injuries by using conventional radiographic analysis as well as QMA in plain lateral radiographs in a trauma setting. Despite the technical possibilities in a modern trauma center, our data and recent literature indicate a thorough clinical and radiographic follow-up of patients with cervical symptoms to avoid secondary complications from missed cervical spine injuries.

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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

Abstract: Hypothesis: Trauma patients with normal motor examination results and normal cervical spine helical computed tomographic (CT) scans with sagittal reconstructions do not have significant cervical spine injury.

Cited by 112 publications

References 18 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

Prevalence of cervical spinal injury in trauma

Hidden discoligamentous instability in cervical spine injuries: can quantitative motion analysis improve detection?

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