Yield of computed tomography of the cervical spine in cases of simple assault

BackgroundComputed tomography (CT) of the cervical spine (C-spine) is routinely ordered for low-impact, non-penetrating or “simple” assault at our institution and others. Common clinical decision tools for C-spine imaging in the setting of trauma include the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian Cervical Spine Rule for Radiography (CCR). While NEXUS and CCR have served to decrease the amount of unnecessary imaging of the C-spine, overutilization of CT is still of concern.MethodsA retrospective, cross-sectional study was performed of the electronic medical record (EMR) database at an urban, Level I Trauma Center over a 6-month period for patients receiving a C-spine CT. The primary outcome of interest was prevalence of cervical spine fracture. Secondary outcomes of interest included appropriateness of C-spine imaging after retrospective application of NEXUS and CCR. The hypothesis was that fracture rates within this patient population would be extremely low.ResultsNo C-spine fractures were identified in the 460 patients who met inclusion criteria. Approximately 29% of patients did not warrant imaging by CCR, and 25% by NEXUS. Of note, approximately 44% of patients were indeterminate for whether imaging was warranted by CCR, with the most common reason being lack of assessment for active neck rotation.ConclusionsCervical spine CT is overutilized in the setting of simple assault, despite established clinical decision rules. With no fractures identified regardless of other factors, the likelihood that a CT of the cervical spine will identify clinically significant findings in the setting of “simple” assault is extremely low, approaching zero. At minimum, adherence to CCR and NEXUS within this patient population would serve to reduce both imaging costs and population radiation dose exposure.     

Cervical spine trauma – Evaluating the diagnostic power of CT,MRI, X-Ray and LODOX

BackgroundTraumatic cervical spine (c-spine) injuries account for 10% of all spinal injuries. The c-spine is prone to injury by blunt acceleration/deceleration traumas. The Canadian C-Spine rule and NEXUS criteria guide clinical decision-making but lack consensus on imaging modality when necessary. This study aims to evaluate the sensitivity and specificity of CT, MRI, X-Ray, and, for the first time, LODOX-Statscan in identifying c-spine injuries in patients with blunt trauma and neck pain.MethodsWe conducted a retrospective monocenter cohort study using patient data from the emergency department at Inselspital, Bern, Switzerland's largest level one trauma center. We identified patients presenting with trauma and neck pain during the recruitment period from 01.01.2012 to 31.12.2017. We included all patients that required a radiographic c-spine evaluation according to the NEXUS criteria. Certified spine surgeons reviewed each case, analyzed patient demographics, injury classification, trauma mechanism, and emergency management. The retrospective full case review was established as gold standard to decide whether the c-spine was injured. Sensitivity and specificity were calculated for CT, MRI, LODOX, and X-Ray imaging methods.ResultsWe identified 4996 patients, of which 2321 met the inclusion criteria. 91.3% (n = 2120) patients received a CT scan, 8.9% (n = 206) a MRI, 9.3% (n = 215) an X-ray, and 21.5% (n = 498) a LODOX scan. By retrospective case review, 186 participants were classified as injured. The sensitivity of CT was 88.6% (specificity 99%), and 89.8% (specificity 99.2%) with orthopedic surgeon consultation. MRI had a sensitivity of 88.5% (specificity of 96.9%); highlighting 14 cases correctly diagnosed as injured by MRI and misdiagnosed by CT. Projection radiography (36.4% sensitivity, 95.1% specificity) and LODOX (5.3% sensitivity, 100% specificity) were unsuitable for ruling out spinal injury.ConclusionWhile CT offers high sensitivity for detecting traumatic c-spine injury, MRI holds clinical significance in revealing injuries not recognized by CT in symptomatic patients. LODOX and projection radiography are insufficient for accurately ruling out c-spine injury. For patients with neurological symptoms, we recommend extended MRI use when CT scans are negative.     

Thoracic injury rule out criteria and NEXUS chest in predicting the risk of traumatic intra-thoracic injuries: A diagnostic accuracy study

IntroductionThis study aimed to compare the diagnostic accuracy of NEXUS chest and Thoracic Injury Rule out criteria (TIRC) models in predicting the risk of intra-thoracic injuries following blunt multiple trauma.MethodsIn this diagnostic accuracy study, using the 2 mentioned models, blunt multiple trauma patients over the age of 15 years presenting to emergency department were screened regarding the presence of intra-thoracic injuries that are detectable via chest x-ray and screening performance characteristics of the models were compared.ResultsIn this study, 3118 patients with the mean (SD) age of 37.4 (16.9) years were studied (57.4% male). Based on TIRC and NEXUS chest, respectively, 1340 (43%) and 1417 (45.4%) patients were deemed in need of radiography performance. Sensitivity, specificity, and positive and negative predictive values of TIRC were 98.95%, 62.70%, 21.19% and 99.83%. These values were 98.61%, 59.94%, 19.97% and 99.76%, for NEXUS chest, respectively. Accuracy of TIRC and NEXUS chest models were 66.04 (95% CI: 64.34–67.70) and 63.50 (95% CI: 61.78–65.19), respectively.ConclusionTIRC and NEXUS chest models have proper and similar sensitivity in prediction of blunt traumatic intra-thoracic injuries that are detectable via chest x-ray. However, TIRC had a significantly higher specificity in this regard.     

Impact of intravenous acetaminophen therapy on the necessity of cervical spine imaging in patients with cervical spine trauma

Objective：We evaluated a new hypothesis of acetaminophen therapy to reduce the necessity of imaging in patients with probable traumatic cervical spine injury.Methods：Patients with acute blunt trauma to the neck and just posterior midline cervical tenderness received acetaminophen （15 mg/kg） intravenously after cervical spine immobilization.Then,all the patients underwent plain radiography and computerized tomography of the cervical spine.The outcome measure was the presence of traumatic cervical spine injury.Sixty minutes after acetaminophen infusion,posterior midline cervical tendemess was reassessed.Results：Of 1 309 patients,41 had traumatic cervical spine injuries based on imaging.Sixty minutes after infusion,posterior midline cervical tenderness was eliminated in 1 041 patients,none of whom had abnormal imaging.Conclusion：Patients with cervical spine trauma do not need imaging if posterior midline cervical tendemess is eliminated after acetaminophen infusion.This analgesia could be considered as a diagnostic and therapeutic intervention.     

False-negative plain cervical spine x-rays in blunt trauma

Although considered very accurate, false-negative plain cervical radiographs of blunt trauma patients will occur with potentially devastating complications. We sought to define the population of patients who fall into this category and the overall accuracy of adequate three-view cervical spine radiography in the blunt trauma population. A retrospective search was carried out of blunt trauma patients entered into our trauma registry. All patients with the ICD-9 codes indicating cervical spine injury with a negative three-view cervical spine radiograph reading had their charts and radiographs reviewed. Institutional statistics for blunt cervical trauma evaluation and injury were obtained from the trauma registry. Fifty-eight of 936 blunt trauma patients (6.2%) were diagnosed with cervical spine injury over the 9-month study period. Of 649 patients with adequate three-view plain radiographs, three patients were identified with negative plain radiographs and significant cervical spine injury, a false-negative rate of 0.5 per cent. Sensitivity was 90.3 per cent, specificity was 96.3 per cent, positive predictive value was 54.9 per cent, and negative predictive value was 99.5 per cent. Three-view plain radiograph series of the cervical spine remains a highly sensitive and specific test for cervical spine injury following blunt trauma. However, the fact that we identified three patients with significant fractures after negative plain radiographs suggests that serious consideration of computed tomography must be applied in treating symptomatic, high-risk blunt trauma patients when plain radiographs do not reveal an injury.     

Screening for blunt cerebrovascular injuries in pediatric trauma patients

BackgroundAdult imaging for blunt cerebrovascular injuries (BCVI) is based on the Denver and Memphis screening criteria where CT angiogram (CTA) is performed for any one of the criteria being positive. These guidelines have been extrapolated to the pediatric population. We hypothesize that the current adult criteria applied to pediatrics lead to unnecessary CTA in pediatric trauma patients.Study designAt our center, a 9-year retrospective study revealed that strict adherence to the Denver and Memphis criteria would have resulted in 332 unnecessary CTAs out of 2795 trauma patients with only 0.3% positive for BCVI. We also conducted a retrospective chart review of 776,355 pediatric trauma patients in the National Trauma Data Bank (NTDB) from 2007 to 2014. Data collection included children between ages 0 and 18, ICD-9 search for blunt cerebrovascular injury, and ICD-9 codes that applied to both Denver and Memphis criteria.ResultsOf 776,355 pediatric trauma activations, 81,294 pediatric patients in the NTDB fit the Denver/Memphis criteria for screening CTA neck or angiography based on ICD-9 codes, while only 2136 patients suffered BCVI. Strict utilization of the Denver/Memphis criteria would have led to a negative CTA in 79,158 (97.4%) patients. Multivariate regression analysis indicates that patients with skull base fracture, cervical spine fractures, cervical spine fracture with cervical cord injury, traumatic jugular venous injury, and cranial nerve injury should be considered part of the screening criteria for BCVI.ConclusionOur study suggests the Denver and Memphis criteria are inadequate screening criteria for CTA looking for BCVI in the pediatric blunt trauma population. New criteria are needed to adequately indicate the need for CT angiography in the pediatric trauma population.Level of evidenceIV.     

A Retrospective Study of Five Clinical Criteria and One Age Criterion for Selective Prehospital Spinal Immobilization

Abstract Abstract Introduction: Full spinal immobilization of blunt trauma victims is a widely accepted prehospital measure, applied in order to prevent (further) damage to the spinal cord. However, looking at the marginal evidence that exists for the effectiveness of spinal immobilization, and the growing evidence for the negative effects following immobilization, a more selective protocol might be able to reduce possible morbidity and mortality as good as the present prehospital immobilization protocol. In a retrospective study, the sensitivity of a selective prehospital immobilization protocol that adds an age criterion to five clinical spine clearance criteria is examined. Materials and Methods: Based on ICD-9 codes, all patients admitted to the trauma center diagnosed with spinal fractures with or without spinal damage were identified. The sensitivity of the combination of five clinical criteria (reduced awareness, evidence of intoxication, neurological deficit, pain of the spine on palpation, (significant) distracting injury) and an age criterion (65 years or older at time of accident) was determined. If one or more criteria were positive, standard full immobilization would be indicated. The other patients would not have been immobilized. Results: A total of 238 blunt trauma victims primarily admitted to the trauma center were included for this study. Median age of the included patients was 39 years (range 5–98), with 32.8% female. A total of 236 had at least one positive criterion (sensitivity 99.2%). The two missed patients were male, 40 and 41 years old. Radiology showed a small fissure in the arch of C2, and a transverse process fracture of L3, respectively. Both patients were discharged the next day without complications or medical interventions. Conclusion: In this retrospective study, a selective protocol based on clinical criteria instead of trauma mechanism showed 99.2% sensitivity for spinal fractures with or without spinal cord damage. Based on this study and the current controversy surrounding spinal immobilization, a prospective study should be considered to evaluate the five clinical criteria and one age criterion in the prehospital setting.     

What defines a distracting injury in cervical spine assessment?

BACKGROUND: The National Emergency X-Radiography Utilization Study defined five criteria for obtaining cervical spine radiographic investigations in blunt trauma patients. Distracting injury was given as the indication for more than 30% of all x-ray studies ordered. The hypothesis of this study was that upper and lower torso injuries would have different effects on clinical cervical spine assessment. METHODS: This is a single-center, prospective, observational study of admitted, alert, adult blunt-trauma patients. All patients underwent cervical spine plain-film radiography. Data were collected on all injuries, physical examination findings, narcotic administration, and radiograph results. Patients with upper and lower torso injuries were compared in their ability complain of pain or midline tenderness relative to a cervical spine fracture. RESULTS: In all, 406 patients participated. All patients received narcotic analgesics before examination. Forty patients (9.9%) had cervical spine fractures, of whom seven had a nontender neck examination. All seven patients with a nontender cervical spine and a neck fracture had at least one upper torso injury. None of the 99 patients with injuries isolated to the lower torso and a nontender neck had a cervical spine fracture (p < 0.05). The frequency of cervical spine fracture among patients with cervical spine tenderness was 19.8% (n = 33). CONCLUSIONS: The National Emergency X-Radiography Utilization Study definition of a distracting injury may be narrowed. Upper torso injuries may be sufficiently painful to distract from a reliable cervical spine examination. Patients may detect spine tenderness in the presence of isolated painful lower torso injuries. Patients with spine tenderness warrant imaging.     

Cervical Spine Clearance in Trauma Patients with an Unreliable Physical Examination

Background

The objective of this study was to describe and compare the timing of cervical spine clearance in trauma patients with an unreliable physical examination.

Methods

We prospectively included adult trauma patients admitted with a cervical collar and an unreliable clinical examination (as defined by the NEXUS criteria) at two level 1 trauma centers: one in the USA (US) and one in Denmark (DK). We excluded patients with cervical spine injuries requiring a collar or surgery as treatment and patients with a collar placed after hospital arrival. The primary outcome was time from emergency department (ED) arrival to collar removal. Secondary outcomes included time to CT of the cervical spine (CTCS). At the US trauma center, an institutional protocol allowing cervical spine clearance exclusively by CTCS was in place. At the Danish trauma center, cervical spine clearance was based on a clinical evaluation by an orthopedic surgeon, usually after CTCS.

Results

A total of 113 patients were included (US: n = 56; DK: n = 57). The median age was 47 years, and 68% were males. The main reasons for an unreliable physical examination were a Glasgow Coma Scale score below 14 (35%), distracting injuries (26%), cervical spine tenderness (13%) and intoxication (13%). The injury severity score at the US trauma center was higher than at the DK trauma center (median: 17 vs. 11, p = 0.03). Both time to CTCS (median: 41 vs. 18 min, p < 0.0001) and time to collar removal (median: 1042 vs. 49 min, p < 0.0001) were significantly greater at the US trauma center.

Conclusions

Time to collar removal was significantly greater in a trauma center utilizing a cervical spine clearance protocol based on CTCS. As patients may develop complications related to the collar, future studies should clarify how early removal can be implemented without increasing the risk of morbidity.

     

Cervical spine clearance in blunt trauma: evaluation of a computed tomography-based protocol

BACKGROUND: Prompt identification of cervical spine injuries has been a critical issue in trauma management. In 1998, the authors developed a new protocol to evaluate cervical spines in blunt trauma. This protocol relies on clinical clearance for appropriate patients and helical computed tomography instead of plain radiographs for patients who cannot be clinically cleared. The authors then prospectively collected data on all cervical spine evaluations to assess the sensitivity and specificity of their approach. METHODS: Any patient without clinical evidence of neurologic injury, alcohol or drug intoxication, or distracting injury underwent cervical spine evaluation by clinical examination. Patients who did not meet these criteria underwent helical computed tomographic scanning of the entire cervical spine. For patients who had neurologic deficits, a magnetic resonance image was obtained. If the patient was not evaluable secondary to coma, the computed tomographic scan was without abnormality, and the patient was moving all four extremities at arrival in the emergency department, the cervical spine was cleared, and spinal precautions were removed. Data were collected for all patients admitted to Santa Barbara Cottage Hospital trauma service between 1999 and 2002. The authors selected for analysis patients with blunt trauma and further identified those with closed head injuries (Glasgow Coma Scale score < 15 and loss of consciousness). In addition, all blunt cervical spine injuries were reviewed. RESULTS: During the period of study, 2,854 trauma patients were admitted, of whom 2,603 (91%) had blunt trauma. Of these, 1,462 (56%) had closed head injuries. One hundred patients (7% of patients admitted for blunt trauma) had cervical spine or spinal cord injuries, of which 99 were identified by the authors' protocol. Only one injury was not appreciated in a patient with syringomyelia. Fifteen percent of patients with spinal cord injury had no radiographic abnormality; all of these patients presented with neurologic deficits. The sensitivity for detecting cervical spine injury was thus 99%, and the specificity was 100%. The risk of missing a cervical spine injury in these blunt trauma patients was 0.04%. The authors missed no spine injuries in patients with head injuries. CONCLUSION: The use of the authors' protocol resulted in excellent sensitivity and specificity in detecting cervical spine injuries. In addition, it allowed early removal of spinal precautions.     

Risk factors for cervical spine injury

IntroductionThe early recognition of cervical spine injury remains a top priority of acute trauma care. Missed diagnoses can lead to exacerbation of an existing injury and potentially devastating consequences. We sought to identify predictors of cervical spine injury.MethodsTrauma registry records for blunt trauma patients cared for at a Level I Trauma Centre from 1997 to 2002 were examined. Cervical spine injury included all cervical dislocations, fractures, fractures with spinal cord injury, and isolated spinal cord injuries. Univariate and adjusted odds ratios (ORs) were calculated to identify potential risk factors. Variables and two-way interaction terms were subjected to multivariate analysis using backward conditional stepwise logistic regression.ResultsData from 18,644 patients, with 55,609 injuries, were examined. A total of 1255 individuals (6.7%) had cervical spine injuries. Motor Vehicle Collision (MVC) (odds ratio (OR) of 1.61 (1.26, 2.06)), fall (OR of 2.14 (1.63, 2.79)), age <40 (OR of 1.75 (1.38–2.17)), pelvic fracture (OR of 9.18 (6.96, 12.11)), Injury Severity Score (ISS) >15 (OR of 7.55 (6.16–9.25)), were all significant individual predictors of cervical spine injury. Neither facial fracture nor head injury alone were associated with an increased risk of cervical spine injury. Significant interactions between pelvic fracture and fall and pelvic fracture and head injury were associated with a markedly increased risk of cervical spine (OR 19.6 (13.1, 28.8)) and (OR 27.2 (10.0–51.3)).ConclusionsMVC and falls were independently associated with cervical spine injury. Pelvic fracture and fall and pelvic fracture and head injury, had a greater than multiplicative interaction and high risk for cervical spine injury, warranting increased vigilance in the evaluation of patients with this combination of injuries.     

Diagnostic performance of isolated orbital CT scan for assessment of globe rupture in acute blunt facial trauma

ObjectivesWe determine the diagnostic performance of emergent orbital computed tomography (CT) scans for assessing globe rupture in patients with blunt facial trauma.MethodsWe performed a retrospective cohort study based on prospectively collected trauma registry and acute care surveillance data in a tertiary-care hospital. Patients aged at least 18 years who underwent isolated orbital CT scanning for assessing potential ocular trauma were examined. Analyses were performed to evaluate the magnitude of agreement between diagnosis by CT scanning and ophthalmic assessment, including globe rupture.ResultsOur study cohort comprised 136 patients, 30% of whom (41 patients) sustained orbital wall fractures. Concordance for orbital CT diagnosis and the ophthalmic assessment of globe rupture was substantial (k = 0.708). The relative risk of globe rupture was 0.692 (95% confidence interval (CI): 0.054–8.849) for superior wall fractures, 0.459 (95% CI: 0.152–1.389) for inferior wall fractures, 2.286 (95% CI: 1.062–4.919) for lateral wall fractures, and 0.637 (95% CI: 0.215–1.886) for medial wall fractures. According to multivariate analysis, lateral wall fractures were an independent risk factor for globe ruptures (adjusted odds ratio (OR) = 12.01, P = 0.011), and medial or inferior wall fracture was a protective factor (adjusted OR = 0.14, P = 0.012). In the stratified analysis of diagnostic performance of CT scan, specificity was highest among patients with orbital wall fractures (97.2%), followed by negative predictive volume (NPV, 97%), and accuracy (95.1%).ConclusionAmong patients with blunt facial trauma who underwent isolated orbital CT scanning as part of ocular trauma assessment, the diagnostic performance of CT in detecting globe rupture is more accurate in patients with orbital wall fractures. Nevertheless, isolated orbital CT alone does not have a sufficiently high diagnostic performance to be reliable to rule out all globe ruptures. Lateral orbital wall fractures in blunt facial trauma patients, in particular, should prompt thorough evaluation by an ophthalmologist.     

Occurrence of massive gluteal muscle necrosis following transcatheter angiographic embolization (TAE) to control pelvic hemorrhage in 6 patients

BACKGROUND: An association between cervical fractures and thoracolumbar fractures after blunt trauma has long been assumed, but not adequately demonstrated. We sought to determine the actual association between these injuries in a large nationwide data set. METHODS: The National Trauma Databank (NTDB) was queried for victims of blunt vehicular trauma with at least minimal injury. An odds ratio was calculated for the association between cervical spine fractures and thoracolumbar fractures. RESULTS: Overall 190,183 NTDB patient records met the criteria of a motor vehicle crash with more than minimal injury. Of these 7.51% (14,292) had cervical spine fractures, 4.73% (8,996) had thoracic spine fractures, 5.93% (11,280) had lumbar spine fractures, and 9.79% (18,623) had either thoracic or lumbar fractures. Of patients with a cervical spine fracture, 13.06% (2,433) also had a thoracic or lumbar fracture, whereas among patients without cervical spine fracture only 6.91% (11,859) had a thoracolumbar fracture. The odds ratio (OR) for a thoracolumbar fracture in the presence of a cervical spine fracture was 2.02 (p < 0.0001) (95% confidence interval 1.9318-2.1201). CONCLUSION: These data confirm a strong association between cervical spine fractures and thoracolumbar fractures after blunt vehicular trauma, and support the practice of imaging the complete spine when a cervical fracture is identified.     

The association of occipitocervical dissociation and death as a result of blunt trauma

Background contextDespite multiple reports of survivability, dissociative occipitocervical injury (OCI) is generally accepted to be fatal in most cases. The actual number of trauma victims where OCI may have made the difference between life and death is unknown because multiple studies have shown that these injuries can be missed with current diagnostic methods. An improved understanding of the relative importance of OCI in blunt trauma mortality may help to refine protocols for the assessment and treatment of patients who arrive alive to the emergency room after severe blunt trauma. One way to improve our understanding is to document the relative frequency OCI relative to brain, liver, aorta, and spleen injuries in blunt trauma fatalities.PurposeIn this study, we aimed to glean a more accurate estimate of the absolute and relative incidence of OCI after death from blunt trauma via a systematic review of data reported in the forensic literature.Study designSystematic literature review.MethodsA systematic literature search and review were undertaken. The search aimed to answer three primary questions: What is the true incidence of cervical spine injuries in blunt trauma fatalities? What is the incidence of dissociative OCIs specifically? and What is the incidence of these injuries relative to other common injuries associated with blunt trauma fatalities (central nervous system, spleen, liver, etc)? For that, two search protocols were used and included postmortem studies of blunt trauma mechanism in adult population.ResultsThe mean reported incidence of cervical spine injuries was 49.7% in blunt trauma fatalities. Dissociative OCIs were found to have a mean incidence of 18.1%. The relative frequencies of injuries were 49.7% for cervical spine, 41.8% for central nervous system, 20.8% for liver, 11.2% for spleen, and 10.8% for aorta.ConclusionsIn this systematic literature review, cervical spine injuries were found to be the most commonly reported finding associated with blunt trauma fatalities, occurring in nearly 50% of cases with occipitocervical dissociation accounting for nearly 20%. Older pathologic studies suggested a lesser overall and relative frequency and may have underestimated their incidence. Typically, these blunt cervical spine injuries were much more commonly found to disrupt the soft tissue stabilizing restraints (ligaments, facet capsules, etc) as opposed to causing bony fractures and, accordingly, were often not detected on plain radiographs. It is likely that the frequency of this injury is underestimated in patients surviving severe blunt trauma, placing them at risk for death from an occult source in the postinjury period. Additional research is needed to determine if improved methods to diagnose OCI and improved patient management protocols to protect against secondary injuries might reduce mortality in blunt trauma victims.     

Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma

BACKGROUND: The purpose of this study was to better define the incidence and characteristics of patients with spinal cord injury without radiographic abnormality (SCIWORA), using the database of the National Emergency X-Radiography Utilization Study (NEXUS). METHODS: This was a prospective, observational study of blunt trauma patients in 21 U.S. medical centers undergoing plain cervical radiography. SCIWORA was defined as spinal cord injury demonstrated by magnetic resonance imaging, when a complete, technically adequate plain radiographic series revealed no injury. RESULTS: Of the 34,069 patients entered, there were 818 (2.4%) with cervical spine injury, including 27 (0.08%) patients with SCIWORA. Over 3,000 children were enrolled, including 30 with cervical spine injury, but none had SCIWORA. The most common magnetic resonance imaging findings among SCIWORA patients were central disc herniation, spinal stenosis, and cord edema or contusion. Central cord syndrome was described in 10 cases. CONCLUSION: In the large NEXUS cohort, SCIWORA was an uncommon disorder, and occurred only in adults.     

Association between spinal immobilization and survival at discharge for on-scene blunt traumatic cardiac arrest: A nationwide retrospective cohort study

IntroductionSpinal immobilization has been indicated for all blunt trauma patients suspected of having cervical spine injury. However, for traumatic cardiac arrest (TCA) patients, rapid transportation without compromising potentially reversible causes is necessary. Our objective was to investigate the temporal trend of spinal immobilization for TCA patients and to examine the association between spinal immobilization and survival.MethodsWe conducted a retrospective cohort study using the Japan Trauma Data Bank 2004–2015 registry data. Our study population consisted of adult blunt TCA patients encountered at the scene of a trauma. The primary outcome was the survival proportion at hospital discharge, and the secondary outcome was the proportion achieving return of spontaneous circulation (ROSC). We examined the association between spinal immobilization and these outcomes using a logistic regression model based on imputed data sets with the multiple imputation method to account for missing data.ResultsAmong 4313 patients who met the inclusion criteria, 3307 (76.7%) were immobilized. The proportion of patients that underwent spinal immobilization gradually decreased from 82.7% in 2004–2006 to 74.0% in 2013–2015. 1.0% of immobilized and 0.9% of non-immobilized patients had severe cervical spine injury. Spinal immobilization was significantly associated with lower survival at discharge (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.42 to 0.98) and ROSC by admission (OR, 0.48; 95%CI, 0.27 to 0.87). There was no significant sub-group difference of the association between spinal immobilization and survival at discharge by patients with or without cervical spine injury (p for interaction 0.73).ConclusionSpinal immobilization is widely used even for blunt TCA patients, even though it is associated with a lower rate of survival at discharge and ROSC by admission. According to these results, we suggest that spinal immobilization should not be routinely recommended for all blunt TCA patients.     

Cervical fracture patterns associated with blunt cerebrovascular injures when utilizing computed tomographic angiography: a systematic review and meta-analysis

BACKGROUND CONTEXTPrior studies have demonstrated an association between cervical spine fractures and blunt cerebrovascular injuries (BCVI) due to the intimate anatomic relationship between the cervical spine and the vertebral arteries. Digital subtraction angiography (DSA) has historically been the gold standard, but computed tomography angiography (CTA) is commonly used to screen for BCVI in the trauma setting. However, there is no consensus regarding which fracture patterns mandate screening. Over aggressive screening may lead to increased radiation, increased false positives, and overtreatment of patients which can cause unnecessary patient harm, and increased healthcare costs.PURPOSEThe aim of this meta-analysis is to analyze which cervical spine fracture patterns are most predictive of BCVI when utilizing CTA.STUDY DESIGN/SETTINGSystematic review and meta-analysis.OUTCOME MEASURESOdds ratios for specific cervical fracture patterns and risk of developing a BCVI.METHODSA systematic literature review of all English language studies from 2000-2020 was conducted. The year 2000 was chosen as the cut-off because use of CTA prior to 2000 was rare. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Scopus, Global Index Medicus, and ClinicalTrials.gov were queried. Studies were included if they met the following criteria: (1) the diagnostic imaging modality was CTA; (2) investigated blunt cervical trauma; (3) noted specific cervical spine fracture patterns associated with BCVI; (4) odds ratios for specific cervical spine fracture patterns or the odds ratio could be calculated; (5) subjects were 18 years old or older. Studies were excluded if they: (1) included DSA or magnetic resonance imaging; (2) included penetrating cervical trauma; (3) included pediatric patients less than 18 years of age; (4) were not written in English. All statistical analysis was performed using R Studio (RStudio, Boston, MA, USA).RESULTSThe initial search, after duplicates were removed, resulted in 10,940 articles for independent review. Six studies met the criteria for inclusion in the meta-analysis. Specific fracture patterns mentioned are isolated C1, C2, C3 fractures, any C1–C3 fracture, any C4–C7 fracture, two-level fractures, subluxation/dislocations, and transverse foramen (TF) fractures. Three studies were included in the meta-analysis for C1, C2, C1–C3, subluxations/dislocations, and TF fractures. Two studies were included in the meta-analysis for C3, C4–C7, and two-level fractures. The pooled odds ratio with 95% confidence interval for: C1 fractures and BCVI is 1.3 (0.8–2.1); C2: 1.6 (0.9–2.8); C3: 1.8 (0.9–3.6); C1–C3: 2.2 (1.1–4.2); C4–C7: 0.7 (0.3–1.7); Two-level: 2.5 (1.4–4.6); Subluxation/Dislocation: 2.9 (1.8–4.5); TF: 3.6 (1.4–8.9).DISCUSSION/CONCLUSIONThis study found that when utilizing CTA for screening of BCVI only fractures in the C1-C3 region, two-level fractures, subluxations/dislocations, and transverse foramen fractures were associated with increased incidence of a BCVI. Further refinement of protocols for CTA in the setting of blunt cervical trauma may help limit unnecessary patient harm from overtreatment and reduce healthcare costs.     

Role of cervical spine radiography in the initial evaluation of stable high-energy blunt trauma patients

Background

Detecting cervical spine injuries in trauma patients is essential because undetected injuries in the this area may result in severe neurological disability and probably quadriplegia. Thus, radiography of the cervical spine is considered mandatory in the initial evaluation of trauma patients according to Advanced Trauma Life Support. This approach results in many unnecessary normal radiographs. Therefore, we performed this study to determine the role of routine cervical radiography in the initial evaluation of stable high-energy blunt trauma patients.

Methods

This was a prospective cross-sectional study including all hemodynamically stable high-energy blunt trauma patients with negative cervical physical examinations referred to our trauma center during a 5-month period (May to September 2010). Cervical radiographs, computed tomography (CT) scanning and magnetic resonance imaging were performed and reviewed for abnormalities.

Results

During the study period, 1,679 high-energy blunt trauma patients were referred to our center, of which 400 were hemodynamically stable and had negative cervical physical examinations. Cervical radiographs were found to be normal in all patients.

Conclusion

Cross-table cervical spine radiographs can be limited to those high-energy blunt trauma patients who have a positive cervical physical examination or those in whom the physical examination is not revealing. These radiographs also have low value for detecting occult cervical spine fractures, and CT imaging is considered the modality of choice in these cases.     

Occipitocervical dissociative injuries: common in blunt trauma fatalities and better detected with objective computed tomography-based measurements

Background contextOccipitocervical injuries (OCIs) are generally not common in blunt trauma victims, but autopsy studies of blunt trauma fatalities consistently report a high prevalence of these injuries. New computed tomography (CT)-based quantitative criteria have recently been developed for use in assessing the occipitocervical spine. The efficacy of these new criteria for detecting OCI would be supported if the high prevalence of OCI in blunt trauma fatalities can also be detected using these objective CT-based criteria.PurposeTo test the hypothesis that the prevalence of OCI in blunt trauma fatalities, determined using objective CT-based measurements and reliable reference data, will be similar to the prevalence reported in prior autopsy studies.Study design/settingRetrospective assessment of the CT examinations of blunt trauma fatalities at a Level 1 trauma center.Patient sampleSeventy-four consecutive patients who died within 21 days of blunt trauma and had a CT examination of the cervical spine.Outcome measuresQuantitative measurements from CT examinations of the occiput–C1 and C1–C2 levels.MethodsMeasurements were made on a Picture Archiving and Communication System (PACS) from the CT images that were originally used for diagnosis and also using imaging software that allowed for precisely reoriented slices that correct for variations in the alignment of the upper cervical spine. The prevalence of abnormal measurements found by each method and the interobserver reliability of the measurements were assessed.ResultsAt least one abnormal measurement was found in 50% of cases based on measurements made on the PACS, and in 34% of cases using measurements from carefully reoriented images. At least three abnormal measurements were found in 22% and 14% of patients, respectively. Only one of the patients had been diagnosed as having an OCI before death. Interobserver reliability measurements of more than 80% were found for most measurements.ConclusionsUsing precise CT-based measurements and reliable reference data for diagnosis of occipitocervical dissociative injuries, the prevalence of injuries in severely injured blunt trauma patients was close to the levels reported in prior autopsy studies (approximately 30%). This supports that with careful measurements, both soft- and hard-tissue OCI can be detected by CT. This study is limited by the fact that a gold standard was not available to confirm the injuries.     

Delayed diagnosis of cervical spine injuries.

Over a 32-month period, the cases of all patients with multiple injuries on whom cervical spine roentgenograms (CSRs) were obtained during blunt trauma evaluation in a trauma center were reviewed to determine the incidence, outcome, and clinical consequence of delayed diagnosis of cervical spine injuries. A total of 1,331 patients had CSRs following blunt injury. Sixty-one (4.6%) of the patients had documented cervical fractures or dislocations. The patients were seriously injured (mean Trauma Score, 12; mean Glasgow Coma Scale score, 11; and mean Injury Severity Score, 30.3). Eleven of the patients died in the trauma room; 9 with fatal atlantoaxial dislocation. Of the 50 survivors (81.9%), neurologic deficits were present in 15 (30%), and 8 of those had complete spinal cord injuries. The diagnosis of the cervical spine injury was made during the initial evaluation in 56 of the 61 patients (91.8%). Five patients had delayed recognition of their cervical spine injury (2-21 days). The reason for the delay was incomplete CSRs in all patients, despite multiple views (up to 13). The missed injuries occurred in patients in whom complete visualization of the spine was most difficult (i.e., severe degenerative arthritis of the cervical spine in two patients; previous cervical fractures in one patient; instability during resuscitation in one patient). Radiologic misinterpretation occurred in one patient. The diagnosis of cervical spine injury was pursued because of persistent neck pain in two patients, and the development of subtle neurologic findings in three. The neurologic deficits in the three patients resolved.(ABSTRACT TRUNCATED AT 250 WORDS)