High-yield radiographic considerations for cervical spine injuries

A clinical and academic imperative has developed to define high-yield criteria for cervical radiography in the emergency department setting. Presented is a review of key literature, including discussions of epidemiologic and biomechanic considerations; previously derived criteria and their value; and the limitation of the radiograph as a diagnostic tool. We conclude that the identification of truly high-yield criteria will be defined in future prospective, multicenter studies.     

Defining radiographic criteria for flexion-extension studies of the cervical spine.

STUDY OBJECTIVE: We sought to describe and measure 3 radiographic variables in normal male volunteers and determine whether these variables could be useful in establishing more objective radiographic criteria for evaluation of flexion-extension studies of the cervical spine. In addition, we hypothesized that patients with a normal cervical spine should not have greater than 2 mm of subluxation present with flexion or extension. METHODS: A prospective, observational study of normal male volunteers between the ages of 18 and 40 years was performed. We obtained radiographs of all participants in neutral, flexion, and extension positions and measured the amount of subluxation and interspinous distance, as well as the degree of vertebral angulation between C3 and C7. RESULTS: One hundred male volunteers were included in the study. Subluxation during flexion (compared with neutral) was greater than 2 mm in none of the participants at each level from C3 to C7 (95% confidence interval [CI] 0 to 3.6); subluxation in extension was greater than 2 mm in one participant at one level from C3 to C4 (95% CI 0 to 5.5) and none of the participants at each of the remaining 3 levels from C4 to C7 (95% CI 0 to 3.6). Comparing flexion with the neutral position, the mean vertebral angulation and SD were 24.2 degrees and 13.3 degrees, and the 95% certainty interval (CEI) was -1.9 to 50.2. Comparing extension with the neutral position, the mean vertebral angulation was 14.1 degrees, with an SD of 13.3 degrees, and the 95% CEI was -4.6 to 32.8. The mean change in interspinous distance between the neutral position and flexion varied from 1.2 to 4.6 mm (SD 1.7 to 2.4 mm), depending on the level of cervical spine studied. When comparing the neutral position and extension, the mean change in interspinous distance varied from 1.2 to 2.2 mm (SD 1.7 to 1.9). CONCLUSION: Currently, there are no clinically validated criteria for evaluating flexion-extension studies of the cervical spine. Our study suggests that subluxation greater than 2 mm in men 18 to 40 years of age may be a useful variable for further study as an indicator of ligamentous injury. Interspinous distance and vertebral angulation appear less likely to have useful clinical application.     

Use of plain radiography to screen for cervical spine injuries.

STUDY OBJECTIVE: Standard radiographic screening may fail to reveal any evidence of injury in some patients with spinal injury. The purposes of this investigation were to document the efficacy of standard radiographic views and to categorize the frequencies and types of injuries missed on plain radiographic screening of the cervical spine. METHODS: All patients with blunt trauma selected for radiographic cervical spine imaging at 21 participating institutions underwent a standard 3-view series (cross-table lateral, anteroposterior, and odontoid views), as well as any other imaging deemed necessary by their physicians. Injuries detected with screening radiography were then compared with final injury status for each patient, as determined by review of all radiographic studies. RESULTS: The study enrolled 34,069 patients with blunt trauma, including 818 patients (2.40% of all patients; 95% confidence interval [CI] 2.40% to 2.40%) having a total of 1,496 distinct cervical spine injuries. Plain radiographs revealed 932 injuries in 498 patients (1.46% of all patients; 95% CI 1.46% to 1.46%) but missed 564 injuries in 320 patients (0.94% of all patients; 95% CI 0.94% to 0.94%). The majority of missed injuries (436 injuries in 237 patients [representing 0.80% of all patients]; 95% CI 0.80% to 0.80%) occurred in cases in which plain radiographs were interpreted as abnormal (but not diagnostic of injury) or inadequate. However, 23 patients (0.07% of all patients; 95% CI 0.05% to 0.09%) had 35 injuries (including 3 potentially unstable injuries) that were not visualized on adequate plain film imaging. These patients represent 2.81% (95% CI 1.89% to 3.63%) of all injured patients with blunt trauma undergoing radiographic evaluation. CONCLUSION: Standard 3-view imaging provides reliable screening for most patients with blunt trauma. However, on rare occasions, such imaging may fail to detect significant unstable injuries. In addition, it is difficult to obtain adequate plain radiographic imaging in a substantial minority of patients.     

Vertebral artery injuries following chiropractic cervical spine manipulation--case reports

Four patients undergoing cervical spinal manipulations for nonneurologic diseases and with no previous neurologic signs or symptoms all developed significant neurologic deficits, one fatal, following manipulations of the cervical spine. Both the literature and the authors' series show that a number of patients have a prodrome prior to the onset of neurologic changes. There is no established therapy for the syndrome. Perhaps prevention is the best means of reducing neurologic injury.     

Cervifix内固定系统在上颈椎损伤治疗中的应用

目的探讨应用Cervifix内固定系统治疗上颈椎骨折、脱位的效果。方法对12例上颈椎损伤患者(其中寰枢关节陈旧性脱位3例,寰枢关节新鲜脱位3例,枢椎齿状突骨折2例,C_2椎体骨折并寰枢关节半脱位2例,C_(2～3)椎体骨折2例)行后路切开、复位、Cervifix内固定,并行自体髂骨植骨。术前按ASIA分级:A级2例,B级4例,C级5例,D级1例。结果 12例患者均获随访,随访时间8M～5a,平均2.7a。所有病例植骨均融合,植骨融合率100%。无1例发生Cervifix螺钉及固定棒松动、断裂等并发症。术后1年A-SIA分级:A级1例,B级2例,C级3例,D级6例。瘫痪分级明显好于术前,差异有统计学极显著意义(P0.01)。结论 Cervifix内固定系统能够有效地维持上颈椎损伤修复所要求的稳定性,固定效果良好,内固定后融合率高。     

Emergency evaluation of cervical spine injuries: CT versus plain radiographs

The recognition and appropriate initial management of the patient with an acute cervical spine injury in the ED is important because of the devastating and catastrophic effects of spinal cord injury. The use of computed tomography (CT) scan compared with initial plain radiographs in the detection of acute blunt traumatic cervical spine injury was evaluated in 20 patients. There was a disparity between the plain film and the CT scan as read by an attending radiologist in 12 patients (60%). In five patients (25%) the plain radiograph suggested a fracture or dislocation that was confirmed by CT scan. In eight patients (40%) the cervical spine film was read as a fracture, dislocation, or soft tissue widening between the cervical spine vertebrae. CT scan done later after admission was normal. In the remaining seven patients the plain film was read as "normal." CT scan, however, was normal in only three, and in four of these seven patients there was a discrepancy between the plain radiograph and the CT. Thus in four of 20 patients (20%) the plain film was read as "normal," while CT scan showed a fracture in our study. CT scan was superior to plain films in diagnosing cervical spine trauma, and it eliminated the false-positive (40%) and false-negative (20%) results obtained by relying on plain radiographs alone.     

High-yield criteria for urgent cranial computed tomography scans

We conducted a study to establish high-yield criteria for urgent cranial computed tomography (CT) scanning in both medical and surgical conditions. Patients were scanned on an emergency basis and were entered in the study if they met preestablished criteria. The clinical findings of the 407 patients in this study were correlated with CT findings. The majority were scanned on an emergency basis for the following reasons: trauma, seizures, altered mental status, hemiparesis, headache, and coma. The yield for CT scans that altered patient management was moderate to high for each of the following categories: coma, 46%; trauma, 30%; seizures, 23%; hemiparesis, 22%; and headache, 21%. The yield for altered mental status and reasons outside the established criteria were fairly low, 8% and 7%, respectively. The specific clinical correlation with CT results in each category is discussed.     

Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury.

BACKGROUND: The National Emergency X-Radiography Utilization Study (NEXUS) recently validated the ability of a decision instrument to define a population with an extremely low risk of cervical spine injury (CSI) after blunt trauma. It is unclear whether each of the 5 individual criteria is necessary for the decision instrument to maintain its high sensitivity. METHODS: NEXUS was a prospective observational study at 21 emergency departments, which enrolled all patients with blunt trauma for whom cervical spine radiographs were ordered. In this substudy, we examined the NEXUS database to determine the contribution of each of the 5 individual low-risk clinical criteria to the overall sensitivity of the decision instrument. RESULTS: All but 8 of 818 patients with CSI, and all but 2 of 578 patients with significant CSI, were identified by using the decision instrument. A substantial number of patients with CSI (236/818 [29%]) and patients with significant CSI (175/578 [30%]) met only 1 of the 5 non--low-risk criteria, and each of the 5 criteria was the only indicator of non--low-risk status in at least 8 patients with CSI and at least 5 patients with significant CSI. CONCLUSION: Because each of the 5 low-risk criteria was the only marker of non--low-risk status in at least a few patients with significant CSI, modification of the overall NEXUS decision instrument by eliminating any one of the criteria would markedly reduce sensitivity and make the instrument unacceptable for clinical use.     

Alarming rise in the number and incidence of fall-induced cervical spine injuries among older adults

BACKGROUND: Although fall-induced injuries among older adults are said to be a major public health concern in modern societies with aging populations, reliable epidemiologic information on their secular trends is limited. METHODS: We determined the current trend in the number and incidence (per 100,000 persons) of fall-induced severe cervical spine injuries (fracture, cord injury, or both) of older adults in Finland, a European Union country with a well-defined white population of 5.2 million, by taking into account all persons aged 50 years or older who were admitted to all Finnish hospitals for primary treatment of such injury in 1970-2004. Similar patients aged 20-49 years served as a reference group. RESULTS: The number and raw incidence of fall-induced cervical spine injury among Finns aged 50 years or older rose considerably between the years 1970 and 2004, from 59 (number) and 5.2 (incidence) in 1970 to 228 and 12.0 in 2004. The relative increases were 286% and 131%, respectively. Throughout the study period, the age-standardized incidence of injury was higher in men than women, and showed a clear increase in both sexes in 1970-2004 from 8.5 to 17.4 in men (105% increase), and from 2.8 to 6.4 in women (129% increase). A similar finding was observed in the age-specific incidences of the study group. In the reference group, the annual number and incidence of injury decreased slightly over time. Assuming that the observed increase in the age-standardized or age-specific injury incidence continues in Finns aged 50 years or older and the size of this population increases as predicted, the annual number of fall-induced cervical spine injuries in this population will be about 100% higher in the year 2030 (about 400 injuries annually) than it was during 2000-2004 (about 200 injuries annually). CONCLUSIONS: In Finnish persons aged 50 years or older, the number of fall-induced severe cervical spine injuries seems to show an alarming rise with a rate that cannot be explained merely by demographic changes. The finding underscores an increasing influence of falls on health and well-being of our older adults; therefore, wide-scale fall-prevention measures should be urgently adopted to control this development.     

The rheumatoid cervical spine

The cervical spine contains 31 joints and moves about 600 times per hour. This makes it a site with a predilection for synovitis, ligamentous inflammation and mechanical stress in all types of chronic arthritis. Accordingly, eight different atlantoaxial or subaxial sublaxations and numerous other pathologic conditions occur in this area. The vital structures contained in this area impart particular significance to this involvement. Because there are practically no similarities between the structure and function of the lumbar spine and cervical spine, no parallels can be drawn between these two anatomically separate sites. Therefore, the anatomy, physiology, pathology, clinical syndromes, and treatment of the rheumatoid cervical spine have to be understood and dealt with on their own. This review article contains an update of topics of utmost importance in patient care, in light of the most recent basic and clinical science studies. Particular attention has been paid to new imaging and neurophysiologic techniques and their relevance to clinical design and treatment decisions, and modes of treatment in light of new advances in surgical technique and in our understanding of the long-term effects of active expectance and surgical intervention.     

Outcome of posttraumatic fibromyalgia: a 3-year follow-up of 78 cases of cervical spine injuries

OBJECTIVE: To assess the outcome of fibromyalgia syndrome (FMS) after cervical spine injury. METHODS: Seventy-eight of 102 (77%) patients with neck injury were recruited 3 years after the original study in 1996. Twenty of the original 22 patients with FMS were available for reevaluation in 1999. A count of 18 tender points was conducted by thumb palpation, and tenderness thresholds were assessed by dolorimetry at 9 tender sites. All patients were interviewed about the presence and severity of neck and FMS-related symptoms. FMS was diagnosed by using the American College of Rheumatology 1990 criteria. Additional questions assessed measures of physical functioning and quality of life. RESULTS: Sixty percent of the 20 patients who had FMS in 1996 still had it 3 years later. All the 11 women with FMS, but only 1 of the 9 men with FMS, met FMS criteria in 1999. Only 1 of 58 patients who had no FMS in 1996 developed FMS. The quality of life scores for most patients improved, their tenderness scores decreased, and all remained employed. CONCLUSIONS: The outcome of posttraumatic FMS in patients with neck injury seems to be more favorable in men than in women; however, this finding should be interpreted with caution because of the small sample. Patients who do not develop FMS within 1 year of neck injury have a low probability of developing FMS in the future, comparable to the incidence of FMS in the general population.     

Posterior surgical treatment for the rheumatoid cervical spine

Twenty-six patients with rheumatoid disease affecting the cervical spine underwent surgical treatment for neck pain, neurological deficit, or both. Atlantoaxial subluxation (n=13), subaxial subluxation (n=7) and vertical migration of the odontoid (n=6) were treated. Arthrodesis with autologous bone was augmented with wire, Ransford loop, Hartshill rectangle or Magerl technique. Pain relief occurred in 92% of patients. Neurological deficit improved in 89% and was unchanged in the remainder. Radiographic stability was achieved in all but one patient. Posterior surgery effectively relieved pain and neurological deficit, and the complications encountered did not jeopardize the outcome.