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.     

Radiographic evaluation of cervical spine trauma. Plain radiography and conventional tomography versus computed tomography

Different imaging modalities are available for the diagnosis of cervical spine injuries. There is a controversial discussion about whether plain radiography (PR), conventional tomography (CTO) or computed tomography (CT) should primarily be used. PR and CTO are more often available and less costly than CT. Especially in second-care hospitals, CT is not always available. The diagnostic work-up in these centres has to rely on conventional techniques. The aim of this study was to define the role of PR supplemented by CTO in the diagnosis of cervical spine trauma in comparison to CT. Twenty-five patients were identified who underwent plain radiography (PR), conventional tomography (CTO) and computed tomography (CT) for the diagnosis of a cervical fracture. In 19 patients a fracture of the cervical spine was identified. All images were reviewed by two independent observers to estimate the interobserver variability. The highest detection rate was achieved by CT (18/18 fractures detected for observer 1/2), followed by CTO (16/16 fractures) and then PR (15/14 fractures). When the detection rates of PR and CTO are combined, 18 fractures were detected by each of the observers. The results were analysed for the dens and the rest of the cervical spine independently. For PR and CTO the detection rates were lower for fractures of the dens than for the rest of the cervical spine. We conclude that the combination of PR and CTO accurately detects fractures of the cervical spine compared with CT. If a fracture of the dens is suspected, the patients should be referred to CT due to its superior accuracy in this region. Received: 25 April 2000     

Efficacy of magnetic resonance imaging in the evaluation of posterior cervical spine fractures

STUDY DESIGN: A retrospective study using two independent, blinded musculoskeletal radiologists to evaluate the sensitivity, specificity, and predictive value of cervical spine magnetic resonance imaging in detecting posterior element fractures of the cervical spine. OBJECTIVE: To evaluate the sensitivity, specificity, and predictive value of magnetic resonance imaging, using computed tomographic scanning as the gold standard, in the diagnosis of posterior element cervical spine fractures. SUMMARY OF BACKGROUND DATA: Few investigators have evaluated the accuracy of magnetic resonance imaging in the determination of cervical spine fractures. METHODS: From January 1994 through June 1996, 75 cervical spine fractures in 32 patients were confirmed by computed tomography. Two musculoskeletal radiologists who were blinded to the clinical history and presence or absence of cervical injury among the study population, independently evaluated each cervical magnetic resonance image recording the presence or absence of soft tissue or bony injury. RESULTS: The overall sensitivity and specificity rates for the diagnosis of a posterior element fracture by magnetic resonance imaging was 11.5% and 97.0%, respectively. The positive predictive value for this group was 83%, and the negative predictive value was 46%. In reference to anterior fractures, the sensitivity was 36.7% and the specificity 98%. Positive and negative predictive values were 91.2% and 64%, respectively. CONCLUSIONS: Magnetic resonance imaging was not effective in recognizing bony injury to the cervical spine and in particular was not as sensitive or as specific as computed tomography in identifying cervical spinal fractures. Computed tomography remains the study of choice for the detection and precise classification of bony injuries to the cervical region, especially when plain radiographs are difficult to evaluate. Magnetic resonance imaging, although not as effective as computed tomography in defining specific bony disorders, remains the gold standard in the evaluation of spinal cord injury, occult vascular injury, and intervertebral disc disruption (hyperextension injury), including herniation and other soft tissue disorders (hematoma, ligament tear).     

Variability in computed tomography and magnetic resonance imaging in patients with cervical spine injuries

OBJECTIVE: The purpose of this study was to describe the performance of adjunctive radiologic imaging in patients with cervical spine injury. METHODS: All patients undergoing cervical spine radiography were prospectively enrolled at 16 diverse emergency departments. We recorded the imaging modalities and radiographic interpretations rendered by unblinded faculty radiologists at each center. Only patients with cervical spine injury were included in this analysis. Findings revealed by individual modalities were compared with the final diagnosis (after all evaluations) in each patient. RESULTS: Six hundred eighty-eight patients with 1,302 separate cervical spine injuries were enrolled. Four hundred seventy-six (69%) patients had magnetic resonance imaging (MRI) and/or computed tomography (CT) of the cervical spine. MRI identified the following injuries among 124 imaged patients: osseous fractures, 85 of 154 (55%); spinal cord injury, 69 of 69 (100%); vertebral subluxation/dislocation, 37 of 43 (86%); ligamentous injury, 38 of 38 (100%); and unilateral/bilateral locked facets, 14 of 18 (78%). Among 418 patients undergoing CT, the following injuries were identified: osseous fractures, 721 of 740 (97%); spinal cord injury, 0 of 30 (0%); vertebral subluxation/dislocation, 76 of 88 (86%); ligamentous injury, 9 of 36 (25%); and unilateral/bilateral locked facets, 34 of 35 (97%). CT identified 29 patients with fractures who had normal plain radiographs. Cervical myelograms were obtained in two patients and cervical tomograms in seven patients. CONCLUSION: The majority of patients with cervical spine injury undergo MRI and/or CT imaging. In clinical practice, MRI is superior at identifying soft tissue injuries, whereas CT performs better in identifying bony injuries. Cervical myelograms and tomograms are rarely obtained.     

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.     

创伤性上颈椎损伤的外科治疗

目的：探讨上颈椎损伤的分型以及外科治疗的临床效果。方法：2005年1月至2007年3月收治的16例创伤性上颈椎损伤患者,男11例,女5例;年龄24-75岁,平均44岁。其中齿状突骨折5例,寰椎骨折3例,Hangman骨折5例,寰枢椎脱位3例。颈椎MR检查：5例颈髓有不同程度受压和T2相高信号改变。根据其损伤机制、影像学表现、骨折分型选择合适的手术方式。结果：非手术治疗7例,手术治疗9例,均获随访,时间7～34个月,平均10．5个月。骨折均愈合或植骨融合,内固定无松动,未发生神经根椎动脉或脊髓损伤。结论：X线片、CT扫描及MR检查是上颈椎损伤必要的诊断措施,选择最佳的手术方式牢固固定上颈椎,同时又最大程度保留患者的颈椎活动度。     

Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury

BACKGROUND: Aggressive screening for blunt cerebrovascular injury (BCVI) and prompt anticoagulation for documented injuries has resulted in a significant reduction in ischemic neurologic events. An association between vertebral artery injuries (VAIs) and specific cervical spine fracture patterns has been suggested; however, current screening guidelines would subject all patients with cervical spine fractures to imaging because no distinction has been made for carotid artery injuries (CAIs). We hypothesized that specific cervical spine fracture patterns that warrant screening evaluation exist, hence limiting unwarranted diagnostic imaging. METHODS: Patients undergoing screening for BCVI on the basis of injury patterns and mechanism have been prospectively followed at our regional trauma center since January 1996. RESULTS: During the study period from January 1996 to January 2005, there were 17,007 blunt trauma admissions. Twenty-three patients presented with symptoms of BCVI. Screening angiography was performed in 766 patients (4.5%), and diagnosed 258 (34%) patients with BCVI. One hundred twenty-five patients with BCVI had cervical spine fractures; 18 patients had isolated CAI; 84 had isolated VAI, and 23 had combined CAI and VAI. Eight patients with VAI had minor cervical fractures but underwent screening for other injury patterns. Fractures in the remaining patients with BCVI were 1 of 3 patterns. Subluxations in 56 (48%) patients, C1 to C3 cervical spine fractures in 42 (36%), or extension of the fracture through the foramen transversarium in 19 (16%). Cervical spine fractures were the sole indication for screening in 90% of the study population. Screening yield of all patients admitted with 1 of these 3 fracture patterns was 37%. CONCLUSIONS: Blunt cerebrovascular injury is associated with complex cervical spine fractures that include subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. Patients sustaining such cervical fractures should undergo prompt screening.     

Does 3D CT reconstruction help the surgeon to preoperatively assess calcaneal fractures?

BackgroundWith the advent of 3D volume rendered CT scans, more information is potentially available to aid the surgeon in complex calcaneal fractures. The primary aim was to determine if there is a difference in inter-observer and intra-observer reliability of 3D CT reconstructions compared to 2D CTs of calcaneus fractures based on classification, identification of specific fracture characteristics and proposed treatment. It is hypothesized that the correlation will be greater between experienced surgeons and trainees when using 3D CT. As a secondary aim, the authors wished to investigate the surgeons’ satisfaction with 3D CT.Patients and methodsThere were six raters, split into 2 groups: high and low surgical experience. Both 2D and 3D scans (10 patients) were reviewed by each rater by filling out a validated questionnaire. This sitting was over a period of six months and all scans were sent separately and randomly by our research coordinator. This process was repeated after a four-week break.ResultsThe overall evaluation and satisfaction of CT scans of calcaneal fractures was improved by the additional use of volume rendered 3D images. Inexperienced surgeons benefited more than experienced surgeons in terms of reliabilities with fracture configuration. 3D CTs were more likely to change the surgeons’ operative strategy. The consistency of deciding on the fracture classification and satisfaction was more uniform between all the raters when 3D CT was used.ConclusionInter-observer and intra-observer reliability of 3D CT reconstructions compared to 2D CTs of calcaneus fractures was greater based on classification, identification of specific fracture characteristics and proposed treatment. Inexperienced surgeons were more consistent when interpreting the scans using 3D CTs (improved inter-observer reliability) and were always more satisfied using the 3D CTs. As there is no extra cost or radiation exposure, we propose that 3D CTs may be valuable with preoperative teaching and planning.     

The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients

Background and objectiveThe National Emergency X-Radiography Utilization Study (NEXUS) criteria are used to assess the need for imaging to evaluate cervical spine integrity after injury. The aim of this study was to assess the sensitivity of the NEXUS criteria in older blunt trauma patients.MethodsPatients aged 65 years or older presenting between 1st July 2010 and 30th June 2014 and diagnosed with cervical spine fractures were identified from the institutional trauma registry. Clinical examination findings were extracted from electronic medical records. Data on the NEXUS criteria were collected and sensitivity of the rule to exclude a fracture was calculated.ResultsOver the study period 231,018 patients presented to The Alfred Emergency & Trauma Centre, of whom 14,340 met the institutional trauma registry inclusion criteria and 4035 were aged ≥65 years old. Among these, 468 patients were diagnosed with cervical spine fractures, of whom 21 were determined to be NEXUS negative. The NEXUS criteria performed with a sensitivity of 94.8% [95% CI: 92.1%–96.7%] on complete case analysis in older blunt trauma patients. One-way sensitivity analysis resulted in a maximum sensitivity limit of 95.5% [95% CI: 93.2%–97.2%].ConclusionCompared with the general adult blunt trauma population, the NEXUS criteria are less sensitive in excluding cervical spine fractures in older blunt trauma patients. We therefore suggest that liberal imaging be considered for older patients regardless of history or examination findings and that the addition of an age criterion to the NEXUS criteria be investigated in future studies.     

Sustaining the gains: Reducing unnecessary computed tomography scans in pediatric trauma patients

Background/Purpose“Pan-scanning” pediatric blunt trauma patients leads to exposure to harmful radiation and increased healthcare costs without improving outcomes. We aimed to reduce computed tomography (CT) scans that are not indicated (NI) by imaging guidelines for injured children.MethodsIn July 2017, our Pediatric Trauma Center prospectively implemented validated imaging guidelines to direct CT imaging for trauma activations and consultations for children younger than 16 years old with blunt traumatic injuries. Patients with suspected physical abuse, CT imaging prior to arrival, penetrating mechanism, and instability precluding CT imaging were excluded. We compared CT scanning rates for pre-implementation (01/2016–06/2017) and post-implementation (07/2017–08/2021) time periods. Guideline compliance was evaluated by chart review and sustained through iterative process improvement cycles.ResultsDuring the pre-implementation era, 61 patients underwent 171 CT scans of which 87 (51%) scans were not indicated by guidelines. Post-implementation, 363 patients had 531 scans and only 134 (25%) CTs were not indicated. Total CTs performed declined after initiation of guidelines (2.80 vs 1.46 scans/patient, p<0.0001). Total NI CTs declined (1.41 vs 0.37 NI scans/patient, p<0.0001) reflected in significant reductions in all anatomic regions: head, cervical spine, chest, and abdomen/pelvis. Charges related to NI scans decreased from $1,490.31/patient to $408.21/patient, saving $218,000 in charges. Based on prior utilization, 146 children were spared excessive radiation with no clinically significant missed injuries since guideline implementation.ConclusionsQuality improvement and implementation science methodologies to enhance compliance with imaging guidelines for children with blunt injuries can significantly reduce unnecessary CT scanning without compromising care. This practice reduces harmful radiation exposure in a sensitive patient population and may save healthcare systems money and resources.     

The role of magnetic resonance imaging in acute cervical spine fractures

Background contextThe role of magnetic resonance imaging (MRI) in neurologically intact cervical spine fractures is not well defined. To our knowledge, there are no studies that clearly identify the indications for MRI in this particular scenario. Controversy remains regarding the use of MRI in at-risk patients, primarily the obtunded and elderly patients.PurposeThe purpose of the present study was to examine the predisposing conditions where an MRI would provide additional findings that would affect management in acute cervical spine fractures.Study designRetrospective cohort involving radiographic and clinical review.Patient sampleConsecutive patients with acute cervical injuries at a single institution.Outcome measuresNeurologic recovery.MethodsA review of 830 patients with cervical spinal injuries between 2006 and 2010 was performed. Clinical information was obtained for all the patients: Glasgow Coma Scale, mechanism of injury, major medical comorbidities, associated injuries, neurologic examination, neurologic symptoms, sex, age, and alertness. Two experienced fellowship-trained spine surgeons determined if the MRI study changed the management in the individual cases based on the Sub-axial Cervical Spine Injury classification system.ResultsNinety-nine patients with a cervical fracture were included in the final analysis: median age 54 years (interquartile range, 42 years), mean Glasgow Coma Scale 13 (standard deviation±3.0), 68% males, 32% females, 42% older patients (age>60 years), 30% spondylosis, 27% polytrauma, 67% alert, 28% neurologic deficit. Major medical comorbidities, prior to injury level of activity, atlantoaxial versus subaxial, and gender were not associated with changes in diagnosis and management (p>.05). Age >60 years, neurologic deficit, polytrauma status, alertness, and spondylosis were associated with having additional clinically relevant findings seen on MRI and changes in management (p<.05). The majority of the changes in management were related to MRI's illustration of the spinal cord injury and not due to an occult instability. Eighty-one percent of the changes in management were related to the depiction of the spinal cord compression seen on MRI, whereas 19% of the changes in management were related to occult instability seen on MRI.ConclusionsOlder age (>60 years), obtunded or temporary non-assessable status, cervical spondylosis, polytrauma, and neurologic deficit are predisposing factors for further injury found on MRI but missed on computed tomographic scan alone. These additional findings can affect the management in acute cervical spine fractures. The rational of the on-call spine surgeon to order an MRI for a cervical spine fracture is well founded and often that MRI will affect the fracture management. Magnetic resonance imaging particularly helps with better defining the type of spinal cord compression. Picking up occult instability missed on computed tomographic scan was possible with MRI but not as common.     

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.     

Anterior single-screw fixation in 24 patients with Type II odontoid fractures

BackgroundFractures of the odontoid process make up 9–15% of adult cervical fractures; Type II odontoid fractures are the most common type. Most patients with these fractures recover after early treatment utilizing the proper surgical approach.Purpose/AimsA retrospective study was performed to evaluate the bone union rate and to identify factors that might contribute to non-union in patients undergoing anterior single-screw fixation for Type II odontoid cervical fractures.MethodsFrom November 2000 to December 2008, 24 patients (16 males, 8 females) underwent anterior single-screw fixation for Type II odontoid cervical fractures. Prior to surgery, all patients had cervical spine radiographs and computed tomographic (CT) scans. Surgery to correct the fractures used the technique of Abfelbaum et al, and fluoroscopy was used to confirm spinal stability. At follow-up, bone fusion was considered successful if trabeculation across the fracture site was seen on lateral radiographic studies. Non-union was confirmed when the fracture line was visible on follow-up lateral radiographic studies. After surgery, all patients were followed at approximately 2 weeks, 4 weeks, 6 weeks, 3 months, 6 months, 9 months, and annually thereafter.ResultsAll 24 patients had odontoid fractures confirmed by radiographic films and CT scans. Twenty-three patients had Type II odontoid fractures that were posterior-oblique or horizontal, and one had an anterior oblique fracture. Twenty patients achieved successful fusion. The presence of a lag effect was significantly different between patients who had successful fusion and the four patients with fusion failure. All patients achieved immediate spinal stabilization after surgery and none experienced major neurologic sequelae.ConclusionsAnterior single-screw fixation is an effective and safe surgical approach for patients with Type II odontoid fractures. A satisfactory long-term outcome depends upon careful selection of patients for fracture orientation and attention to the technical aspects of surgery.     

Epidemiology of cervical spine fractures in the US military

Background contextThe epidemiology of cervical spine fractures and associated spinal cord injury (SCI) has not previously been estimated within the American population.PurposeTo determine the incidence of cervical spine fractures and associated SCI and identify potential risk factors for these injuries in a large multicultural military population.Study designQuery of a prospectively collected military database.Patient sampleThe 13,813,333 military servicemembers serving in the US Armed Forces between 2000 and 2009.Outcome measuresThe Defense Medical Epidemiology Database (DMED) was queried to identify all servicemembers diagnosed with cervical spine fractures with and without SCI during the time period under investigation. Data were used to determine the incidence of cervical spine fractures and SCI as well as identify risk factors for their development.MethodsThe DMED was queried for the years 2000 to 2009 using the International Classification of Diseases, Ninth Revision, Clinical Modification code for cervical spine fractures with and without SCI (805.0, 805.1, 806.0, and 806.1). The database was also used to determine the total number of servicemembers within the military during the same period. The incidence of cervical spine fractures and fractures associated with SCI was determined, and unadjusted incidence rates were calculated for the demographic characteristics of sex, race, military rank, branch of service, and age. Adjusted incidence rate ratios were then determined using multivariate Poisson regression analysis to control for other factors in the model and identify significant risk factors for cervical spine fractures and cervical injuries associated with SCI.ResultsFrom 2000 to 2009, there were 4,048 cervical spine fractures in a population at risk of 13,813,333 servicemembers. The overall incidence of cervical spine fractures was 0.29 per 1,000 person-years, and the incidence of fracture associated SCI was 70 per 1,000,000. The cohorts at highest risk of cervical spine fracture were males, whites, Enlisted personnel, those serving in the Army, Navy, or Marine Corps, and servicemembers aged 20 to 29. Risk of fracture-associated SCI was significantly increased in males, Enlisted personnel, servicemembers in the Army, Navy, or Marines, and those aged 20 to 29.ConclusionsThis study is the largest population-based investigation to be conducted within the United States regarding the incidence of SCI and the only study addressing incidence and risk factors for cervical spine fractures. Male sex, white race, Enlisted military rank, service in the Army, Navy, or Marine Corps, and ages 20 to 29 were found to significantly increase the risk for cervical fractures and/or fracture associated SCI. Our findings support previously published data but also represent best available evidence based on the size and diversity of the population under study.Level of evidencePrognostic; Level II.     

Imaging for evaluation of suspected cervical spine trauma: a 2-year analysis

OBJECTIVE: To examine the role of radiography in screening trauma patients with suspected injury to the cervical spine. SUBJECTS AND METHODS: Over a period of 2 years, 5172 people were admitted to our trauma service and 297 (5.4%) were found to have cervical fractures. The radiographic and CT films and reports of 245 of these 297 patients were reviewed. RESULTS: The 245 subjects had sustained 309 distinct individual injuries. Radiography detected injuries in 108 cases (44.1%) and CT detected injuries in 243 cases (99.2%). The two fractures missed by CT occurred at C2; one fracture was obscured by dental artefacts and the other was in the horizontal plane of the scan. Both fractures were detected on lateral radiographs of the region. CONCLUSION: CT is superior to radiography for identification of cervical spine fractures. The fractures most likely to be missed by CT occur at C2. We recommend that CT be used as the primary screening method for people with suspected cervical injury, together with a single lateral view of the cervical spine to include the C2 region.     

Delayed presentation and diagnosis of cervical spine injuries in long-standing ankylosing spondylitis

Patients with ankylosing spondylitis (AS) are vulnerable to cervical spine fractures. Long-standing pain may mask the symptoms of the fracture. Radiological imaging of the cervical spine may fail to identify the fracture due to the distorted anatomy, ossified ligaments and artefacts leading to delay in diagnosis and increased risk of neurological complications. The objectives are to identify the incidence and risk factors for delay in presentation of cervical spine fractures in patients with AS. Retrospective case series study of all patients with AS and cervical spine fracture admitted over a 12-year period at Queen Elizabeth National Spinal Injuries Unit, Scotland. Results show that total of 32 patients reviewed with AS and cervical spine fractures. In 19 patients (59.4%), a fracture was not identified on plain radiographs. Only five patients (15.6%) presented immediately after the injury. Of the 15 patients (46.9%) who were initially neurologically intact, three patients had neurological deterioration before admission. Cervical spine fractures in patients with long-standing AS are common and usually under evaluated. Early diagnosis with appropriate radiological investigations may prevent the possible long-term neurological cord damage.     

CT三维重建技术对肩胛骨骨折的诊断价值

目的：探讨螺旋CT三维表面遮盖法重建(surface shaded display，SSD)及容积重建技术(volume rendering technique，VRT)对肩胛骨骨折的诊断应用价值。方法：使用SIEMENS PLUS4螺旋CT机对20例肩胛骨骨折患者进行扫描，全部数据输入工作站进行SSD及VRT处理，并与X线、二维CT(2D CT)检查结果进行对照分析。结果：2D CT扫描的结果经临床与手术证实为临床诊断的重要依据，经统计学分析，X线检查及SSD的诊断准确率分别为94．44％和97．78％，假阴性率分别为17．65％和7．84％，X线检查的假阳性率为0．76％；VRT诊断正确率为100％。SSD、VRT检出骨折创伤的数量与X线、2D CT的结果差异无显著性意义，但是显示损伤的质量优于X线和2D CT。术后对8例进行3D CT复查，VRT能立体显示术后肩胛骨骨质及内固定物的形态与结构。结论：螺旋3DCT是诊断肩胛骨骨折的有效手段，可指导手术计划的制定和内固定物的选择，应作为诊断复杂性肩部骨折的首选方法。VRT对骨折术后内固定物的位置及复位效果的判断有较高的应用价值。     

Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre

IntroductionThe use of total-body computed tomography (CT) scanning in the evaluation of multiply injured patients is increasing, and their liberal use has stirred debate as to the added benefit relative to the risk of radiation exposure and inappropriate use of limited healthcare resources. Findings unrelated to the clinician's reasons for requesting the radiological examination are often uncovered due to the comprehensive nature of the evaluation at a trauma centre. However, some of these findings are outside the expertise of the trauma team who initially organised the scan and this may lead to uncertainty over who is best qualified to follow-up the incidental finding. We aim to evaluate the frequency of incidental findings on whole body trauma CT scans in a consecutive series of trauma admissions to our unit.Materials and methodsWe identified 104 consecutive major trauma patients who received a whole-body trauma CT (head, cervical spine, chest, abdomen and pelvis) from Jan 2013 to Dec 2013 in our unit (out of a total of 976 trauma admissions in the same year). Patient-specific information was extracted from computerised hospital databases containing admission and progress notes, radiological reports, operation notes and pathology reports.Results57 patients (54.8%) had incidental findings identified on the radiologist report, with a total of 114 individual incidental findings. 6 (5.8%) patients had potentially severe findings that required further diagnostic work up; 65 (62.5%) patients had diagnostic workup dependant on their symptoms, and 43 (41.3%) patients had incidental findings of minor concern which required no follow up.Discussion and conclusionsOur findings reflect the literature noting that incidental findings are increasingly common due to the central diagnostic role of CT imaging in trauma care, but also due to advances in imaging techniques and quality. In keeping with published literature, we note that increased age is associated with an increased incidence of “incidental findings” and this will continue to rise with the ageing population and the mandatory nature of trauma CTs.     

Value of cervical plain radiography in unconscious trauma patient

INTRODUCTION: The aim of this study was to evaluate the diagnostic value of cervical spine standard radiographs, performed in emergency, and compared with entire cervical helical CT with multiplanar reconstructions as reference. STUDY DESIGN: Open prospective study. PATIENTS AND METHODS: We conducted a six months prospective study including all patients over 15 years of age and unconscious (Glasgow Coma Scale < or = 12). Each patient underwent standard radiographs as well as helical CT of the entire cervical spine. Three senior surgeons and one senior radiologist evaluated the standard radiographs quality. The interpretation was performed by 7 different groups of judges. Two radiologists interpreted the helical CT. For each group, the sensibility, the specificity and the count of correct diagnosis for the standard radiographs were evaluated. The results of the correct diagnosis of each group were then compared to determine the most performant group. RESULTS: Fifty-one patients were included. Helical CT diagnosed spine injuries in 11 patients. The quality of standard radiographs was poor with less than 10% judged correct and 90% of the C7-D1 junction not visible. In the best group (radiologist), the sensibility was 50%, the specificity was 85% and the count of correct diagnosis was 78%. For the correct diagnosis, senior radiologist was significantly better than anaesthetist students, radiologist students and emergency physicians. CONCLUSION: The diagnostic value of standard radiographs was weak whatever the physician. Therefore, helical CT of the entire cervical spine is absolutely necessary and must be performed during the initial evaluation, if the haemodynamic conditions are required.     

Surgical treatment of an atlantoaxial fracture after a delayed diagnosis in a comatose patient

Study design

Case report.

Objective

To report a case of fractures of the right lateral atlantoaxial joint and C2 body diagnosed more than 5 months after injury.

Summary of background data

Misdiagnosis of an injury to the cervical spine has been reported frequently. For patients in whom cervical injury is suspected, the primary screening modality is axial CT from the occiput to T1 with sagittal and coronal reconstructions. The inadequacy of this radiological evaluation could delay diagnosis of fractures and lead to unnecessary surgical treatment of the cervical spine.

Methods

We report the case of a 74-year-old woman with an old, displaced combined fracture of the C1 and C2 right facet joint. In this case, CT of the brain was evaluated at the time of injury, but not CT of the cervical spine. As a consequence, diagnosis was delayed and surgical treatment was necessary.

Results

We performed posterior fusion surgery for C1 and C2. A pedicle screw was not inserted on both sides of C2, because of destruction of the insertional point on the right side and a high-riding VA on the left. Alternatively, a lamina screw and hook were used for C2, fixed with lateral mass screws on C1, with a bone graft harvested from the iliac crest.

Conclusions

To avoid unnecessary surgery, surgeons should recognize the possibility of cervical fractures that cannot be detected without CT, especially in patients who are comatose at injury. Atlantoaxial fixation with a hook and lamina screw in C2 is an option for old upper cervical fractures in cases where a pedicle screw cannot be inserted into C2.