Assessing potential spinal injury in the intubated multitrauma patient: does MRI add value?

The purpose of the study was to determine the role of magnetic resonance imaging (MRI) in intubated multitrauma patients with normal computed tomography (CT) in excluding unstable ligamentous injury to the cervical spine. A retrospective evaluation was done on those multitrauma patients admitted to the intensive care unit of a level 1 trauma centre who had normal single-slice helical CT cervical spine and underwent MRI for cervical spine clearance from 1/1/04 to 30/6/05. Fifty-five patients met the inclusion criteria. Ten of these patients had a discoligamentous injury identified on MRI; however, all these patients had injuries limited to only one of the three columns of the cervical spine. Single-slice helical CT with sagittal reformats had a negative predictive value of 82% for discoligamentous injury and 100% for unstable injury. A normal single-slice helical CT with sagittal reformats of the cervical spine in intubated trauma patients excluded unstable injuries at follow-up cervical spine MR imaging.     

Calcification of the alar ligament of the cervical spine: imaging findings and clinical course

Ligamentous calcification of the cervical spine has been reported in the yellow ligament, anterior and posterior longitudinal ligaments and interspinous ligament. Calcification in the upper cervical spine is rare, although some cases with calcification of the transverse ligament of the atlas have been reported. Two patients with calcification of the alar ligament with an unusual clinical presentation and course are described. Examination by tomography and computed tomography (CT) showed calcification of the alar ligament and the transverse ligament of the atlas. CT documented decreased calcification as symptoms resolved. There may be a role for CT in the search for calcifications in the upper cervical spine in patients presenting with neck pain and pharyngodynia if radiographs are normal. Received: 13 October 2000 Revision requested: 17 November 2000 Revision received: 18 December 2000 Accepted: 19 December 2000     

Computed tomography for cervical spine trauma. The impact of MDCT on fracture detection and dose deposition

A multidetector computed tomography (MDCT) was installed in our department. Referral rates, examination protocols and detection rates of abnormal findings in CT examinations for cervical spine trauma 6 months before and 6 months after MDCT installation were compared to look for changes in practice. Retrospective analysis of all CT cervical spine examinations in patients with multiple trauma over two contiguous 6-month periods: from July 2003 to December 2003 (helical CT) and from January 2004 to June 2004 (MDCT). Variables recorded were number of CT examinations performed, scan plane coverage and traumatic abnormalities detected. Phantom dosimetry measurements for cervical spine examination in both helical CT and MDCT were compared. One hundred and fifty four patients underwent cervical spine CT during these periods. Helical CT period: of 91 patients undergoing CT cervical spine examination for trauma, 65 (71%) were complete cervical examinations and 26 (29%) were level-specific examinations. Eight patients (9%) had cervical spine fracture, six of which were apparent on radiographs. Dose estimations for thyroid, lens and breast were 24.76, 1.86 and 0.21 mGy, respectively, for complete cervical spine examinations. MDCT period: of 63 patients who underwent CT cervical spine examination for trauma, 61 (97%) were complete examinations and 2 (3%) were level-specific examinations. Six patients (11%) had cervical spine fracture, three of which were apparent on radiographs. Dose estimations for thyroid, lens and breast were 75.8, 9.7 and 0.7 mGy, respectively, for complete cervical spine examinations, which were notably higher than those for helical CT. After installation of MDCT, clinical requests for complete examination of the cervical spine following trauma increased. This changing trend resulted in a significantly higher radiation dose to thyroid, lens and breast.     

Cervical spine injury in the elderly: imaging features

An increase in the elderly population has resulted in an increased incidence of cervical spine injury in this group. No specific type of cervical spine trauma is seen in the elderly, although dens fractures are reported to be common. Hyperextension injuries due to falling and the resultant central cord syndrome in the mid and lower cervical segments due to decreased elasticity as a result of spondylosis may be also characteristic. The imaging features of cervical spine injury are often modified by associated spondylosis deformans, DISH and other systemic disorders. The value of MR imaging in such cases is emphasized. Received: 14 April 2000 Revision requested: 30 June 2000 Revision received: 18 August 2000 Accepted: 4 October 2000     

Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CT screening

OBJECTIVE: We aimed to validate the routine use of a clinical decision rule to direct diagnostic imaging of adult blunt trauma patients at high risk for cervical spine injury. MATERIALS AND METHODS: We previously developed and have since routinely used a prediction rule based on six clinical parameters to identify patients at greater than 5% risk of cervical spine injury to undergo screening helical CT of the cervical spine. During a 6-month period, 4285 screening imaging studies of the cervical spine were performed in adult blunt trauma patients. Six hundred one patients (398 males, 203 females; age range, 16-100 years; median age, 38 years) underwent helical CT, and the remainder underwent 3684 conventional radiographic examinations. Clinical and report data were extracted from the radiology department database, medical records, and the hospital trauma registry. Abnormal findings were independently confirmed by additional imaging studies, autopsy results, or clinical outcome. RESULTS: The true-positive cervical spine injury rates in helical CT- and conventional radiography-screened patients who presented directly to our trauma center were 40 (8.7%) of 462 and seven (0.2%) of 3684, respectively. The cervical spine injury rate in patients who were transferred from outside institutions to our trauma center and who underwent helical CT was 37 (26.6%) of 139. This figure included 20 patients already known to have cervical spine fracture. CONCLUSION: The clinical decision rule can distinguish patients at high and low risk of cervical spine injury, thus supporting its validity.     

Lowering the thyroid dose in screening examinations of the cervical spine

The first objective of this study was to test the hypothesis that a lower-dose (14.1 mGy thyroid dose) protocol for helical computed tomography (CT) of the entire cervical spine demonstrates equivalent technical adequacy and diagnostic accuracy as the standard-dose protocol (26.0 mGy thyroid dose) used at our institution. The second objective was to estimate the excess thyroid cancer mortality for three cervical spine screening protocols. Eight patients underwent two helical CT acquisitions of the entire cervical spine (standard and lower dose); from these acquisitions, a database of 128 randomized images (64 standard dose and 64 lower dose) was constructed. Three radiologists evaluated each of the 128 images for technical adequacy and, if the image was technically adequate, diagnostic accuracy. Historical data of excess thyroid cancer mortality stratified by age and sex were used to estimate the impact of lowering the thyroid dose in cervical spine screening. Estimates used a linear extrapolation of mortality data. The lower-dose protocol for helical CT of the entire cervical spine demonstrates equivalent technical adequacy and diagnostic accuracy as the standard protocol. The excess thyroid cancer mortality is a function of patient age and sex; for 25-year-old men, the excess mortality per 100,000 patients is 96.7 (standard-dose CT), 52.4 (lower-dose CT), and 6.7 (radiographs alone, 1.8 mGy thyroid dose). The equivalent technical adequacy and diagnostic accuracy of a lower-dose protocol for helical CT of the entire cervical spine support its implementation in routine screening. The excess thyroid mortality emphasizes the need to maintain an open dialogue with our referring clinicians with respect to the mechanism of injury, clinical findings, and radiation risks.     

The role of spiral CT vs plain films in acute cervical spine trauma: a comparative study

Purpose: To compare the diagnostic yield of conventional radiographs versus helical computed tomography (CT) in screening acute trauma patients. Methods: We reviewed 604 trauma patients who presented to our level I trauma emergency room and underwent both conventional radiography and spiral CT of the cervical spine of. Results: Of the 604 patients, 30 (5.13 %) had fractures seen on helical CT, only 10 of which were diagnosed on conventional radiography. Conclusion: In the screening of acute trauma patients, conventional radiography is less sensitive in detecting fractures than helical CT. CT should therefore be considered as a standard modality choice in such cases.     

Imaging of cervical spine trauma: are the anteroposterior and odontoid radiographs needed when CT of the entire cervical spine is routine?

Objective: To evaluate the contribution of the anteroposterior (AP) and odontoid radiographs in cervical spine trauma when helical CT of the entire cervical spine is performed in routine screening. Methods: In part 1 of the study, 47 patients with cervical spine fracture (positive) and 92 patients without fracture (negative) were retrospectively assembled into a study population. For each patient, the lateral radiograph and the CT were evaluated for the presence or absence of fracture. The results were compared to the radiology report at the time of injury which was based on the lateral, AP, and odontoid radiographs plus the CT (gold standard). In part 2 of the study, the individual sensitivities of CT and each radiograph were determined by review of the 47 positive patients with the fracture locations known a priori. Results: In all 47 positive patients, the presence of fracture was correctly identified using only the lateral radiograph and the CT. In none of the 92 negative patients was the lateral radiograph plus CT incorrectly interpreted as positive for fracture. The sensitivities for fracture of CT, the lateral radiograph, the AP radiograph, and the odontoid radiograph were 100, 47, 28, and 18 % respectively. Conclusion: The AP and odontoid radiographs did not contribute to the evaluation of suspected cervical spine fracture when the lateral radiograph and helical CT of the entire cervical spine were performed in routine screening.     

Using CT of the cervical spine for early evaluation of pediatric patients with head trauma.

OBJECTIVE: The purpose of this study was to assess the effectiveness of CT of the cervical spine in addition to radiography in pediatric patients with suspected head trauma at the time of the CT head examination. MATERIALS AND METHODS: We identified 63 pediatric patients admitted to the emergency department who had head trauma and who underwent both head CT and neck radiography. Those who underwent CT of the cervical spine at the time of the head CT examination during their initial evaluation were compared for demographics, clinical status, mechanism of injury, and number of excess radiographs (number required by protocol minus number of films obtained) required to evaluate the cervical spine with those patients who did not undergo early CT of the cervical spine. RESULTS: Twenty-one patients (33%) underwent cervical spine CT at the time of the head CT examination. The number of excess radiographs differed significantly between these patients (2.1 +/- 2.6 vs 3.6 +/- 2.7, p = 0.04) and the comparison group. Patients who did not undergo early CT for whom excess radiographs were obtained had the following characteristics: they were older than 8 years (p = 0.03), were unrestrained in a motor vehicle crash (p = 0.04), had a Glasgow coma score of 13-15 (p = 0.01), and were intubated (p = 0.02). CONCLUSION: The number of repeated radiographs required to ascertain that the cervical spine is free of injury after suspected head trauma is significantly fewer when initial CT of the neck is performed at the time of head CT examination. Including cervical spine CT in trauma protocols for subgroups of children with head injuries may lead to more effective clearance of the pediatric cervical spine.     

Screening for cervical spine trauma with helical CT: experience with 676 cases

Purpose: CT scanners with helical capability are commonplace. Evaluation of multiple trauma patients using this technique is fast, and easily performed as part of the radiological evaluation. Our purpose was to ascertain the clinical effectiveness of cervical spine screening with helical CT in a large sample population of multitrauma patients. Materials and methods: A retrospective review was carried out using screening helical CT scans from multitrauma patients referred to the Massachusetts General Hospital emergency department. The radiographic diagnosis was evaluated and tallied along with the clinical diagnosis and outcome for each patient included in the study. Results: Six hundred seventy-six patients conformed to the inclusion criteria. In this series, 59 true-positive, 616 true-negative, 1 false-negative, and no false-positive findings were encountered. These data result in a sensitivity of 98.3 %, a specificity of 100 %, and an accuracy of 99.9 %. Conclusions: Screening helical CT in the evaluation of trauma patients has a high diagnostic accuracy, and is sensitive and specific in diagnosing clinically relevant fractures of the cervical spine.     

Adequacy of plain radiography in the diagnosis of cervical spine injuries

Our hypotheses were (1) that plain radiography of the cervical spine in the evaluation of low risk patients with minor blunt trauma is accurate and (2) that computed tomography (CT) of the cervical spine in the evaluation of low risk patients is unnecessary. This study evaluates those hypotheses. We prospectively recorded findings of all patients with blunt trauma who underwent imaging over a period of 70 days. Injury status was determined by review of all radiographic studies obtained on each patient. Chart reviews were performed to determine mechanism of injury and neurological status. Patients were divided into three groups: very low risk, low risk, and high risk. Study end point was fracture. The study included 219 patients. The very low risk group had 107 patients, none of whom had fractures found on CT (projected specificity of plain radiography: 100%). The low risk group contained 78 patients who had no fractures seen on plain radiography or CT (specificity of plain radiography and CT: 100%). The high risk group consisted of 34 patients; 15 had fractures demonstrated on CT. Plain radiography missed one fracture out of 15. In low risk patients, plain radiography is an efficient diagnostic exam with a specificity of 100%. In high risk patients, plain radiography is a good adjunctive screening exam in conjunction with CT scan, with a sensitivity of 93.3% and specificity of 95%.     

Cervical spine injury: accuracy of helical CT used as a screening technique

Objective: The study objective was to determine the sensitivity and specificity of a helical CT technique to screen for cervical spine injury in a high-risk trauma population. Materials and methods: The helical CT reports for a consecutive series of 601 high-risk adult blunt trauma victims were reviewed. Findings were confirmed using an independent reference standard, which consisted of additional cervical spine imaging (CT, MRI, or radiography), operative findings, autopsy results or clinical outcome. Results: Sensitivity and specificity of helical CT for injury were 77/81 (95 %; 95 % confidence limits: 90–100 %) and 484/520 (93 %; 95 % confidence limits 91–95 %) respectively. Four false negative cases were comprised of three missed ligamentous injuries and one missed fracture. False positive cases (n = 36) were mostly attributed to possible facet fracture (n = 6), possible ligamentous injury (n = 8) or technically inadequate scan (n = 6).The overall accuracy of the helical CT protocol for cervical spine injury in this population was 561/601 (93 %; 95 % confidence limits 91–95 %). Conclusion: Helical CT has high accuracy for cervical spine injury. We believe that helical CT should be the preferred imaging strategy in high-risk blunt trauma patients.     

Can CT eliminate the initial portable lateral cervical spine radiograph in the multiple trauma patient? A review of 200 cases

Purpose: This investigation examines whether there is a continued role for the initial screening lateral portable radiograph in patients whose cervical spine is “cleared” by a CT examination. Methods: A retrospective review of 200 multiple trauma patients suspected of cervical spine injury (CSI) was performed. All patients had a screening lateral portable cervical spine radiograph (LPCSR) followed by cervical spine CT (CSCT). All scans were helical and included coronal and sagittal reformations. Reports of both examinations were compared for all patients. For those patients with signs of acute CSI, the two reports were compared to determine whether the LPCSR contained any information affecting patient outcome that was not detected by CSCT. Results: The CSCT showed no signs of acute CSI injury in 190 patients. Ten CSCT scans showed signs of fracture. In these 10 patients, the screening LPSCR showed signs of fracture in 1 patient, question of fracture in 2 patients, and no fracture in 7 patients. No LPCSR demonstrated significant information not seen on the accompanying CSCT. No LPSCR showed a finding that altered patient management prior to CSCT. Conclusion: The data suggest that an initial LPCSR is unnecessary if the patient is having a screening CSCT.     

CT evaluation of the low severity cervical spine trauma: When is the scout view enough?

The aim of the current study was to compare the diagnostic information obtained from a helical CT examination in low severity cervical spine trauma with that from a lateral CT scout view. We included alert and clinically stable patients, who had suffered acute blunt trauma of low or moderate severity. Their scout images were interpreted independently by two radiologists and the final outcome of the CT exam which was the gold standard. Patient dose was assessed using Monte-Carlo techniques. In 52 of our studies (45%), at least the first five cervical vertebrae were visible with adequate quality, and in 16.5% of the scout views (19 studies) all 7 vertebrae were depicted with excellent quality. Overall sensitivity and specificity of scout view was 70% and 100%, respectively. There were three false negative and one false positive cases. The effective dose value was estimated to be 0.02 mSv which is at least two orders of magnitude lower than that from a CT scan. When clinical examination is not suggestive of a C1-C2 fracture, adequate depiction of an intact cervical spine at the scout view, without proceeding to a full CT scan, is a sufficient dose and time-effective imaging approach.     

颅脑损伤并颈椎颈髓损伤治疗体会

目的探讨颅脑损伤合并颈椎骨折颈段脊髓损伤(颅颈联合伤)的诊疗经验。方法回顾性分析58例颅脑损伤并颈椎颈髓损伤病人,首诊常规颈椎制动和普查影像学资料,筛选此类病例进一步分析研究。结果作者医院创伤外科2007~2008年共收治颅脑损伤患者1107例,通过筛选颅颈联合伤患者共58例。颈椎损伤治疗中,11例予以颈前路椎板减压+椎间盘摘除+自体骨移植复位内固定术,余47例予以颅骨牵引或外固定器械治疗。颅脑损伤治疗中,21例急诊行颅脑手术治疗,非手术治疗37例。本组患者存活55例,死亡3例,生存率94.8%。按格拉斯哥预后评分(GOS)评定为Ⅰ级3例,Ⅱ级2例,Ⅲ级3例,Ⅳ级7例,Ⅴ级43例。结论颅颈联合伤发病率较高,本组约占5.2%。颅颈联合伤的主动普查(影像学)和颈部保护制动,防止脊髓二次损伤,对降低漏诊、提高临床治愈率有重要意义。     

CT在颈椎损伤中的诊断价值

目的：探讨CT扫描在颈椎损伤中的诊断价值。方法：回顾性分析32例颈椎损伤的CT与平片检查资料。结果：骨折28例（其中6例伴脱位）,单纯脱位4例,合并伤10例。结论：CT对颈椎损伤的检出率明显高于平片,能清晰显示其损伤的细节,并对判断失稳及椎管狭窄的程度均有重要价值。     

Prevertebral soft tissue swelling following trauma: usefulness following tube placement

Objective. Prevertebral soft tissue swelling (PVSTS) is an important marker of spinal trauma. In patients with missed or occult cervical fractures, it may be the only indication of serious injury. It has been anecdotally suggested that PVSTS is not useful following placement of a nasogastric (NGT) or endotracheal (ETT) tube because of possible iatrogenic trauma and/or soft tissue compression. Consequently, we investigated trauma patients for evidence of PVSTS, comparing radiographs performed before and after placement of NGTs and/or ETTs. Design and patients. PVSTS at the C2 and C6 levels was measured on lateral cervical spine radiographs in 102 patients with cervical spine fractures. Measurements were obtained in 66 patients before and after placement of either an NGT (23), ETT (8), or both an NGT and ETT (35). They were also obtained in 36 control patients with fractures and neither an NGT nor ETT, at presentation and after an interval temporally matched to that in the patients with tubes in place. Results. The group with ETTs showed variable changes to PVSTS (31% increase, 63% decrease, and 6% no change). The group with NGTs also showed variable changes to PVSTS (33% increase, 53% decrease, and 13% no change). The group with ETTs and NGTs similarly showed variable changes to PVSTS (25% increase, 72% decrease, 3% no change). Surprisingly, the control group showed similar temporal changes without tube placement (49% increase, 36% decrease, 13% no change). Analyses using the one-tailed F-test of the ratio of the variance of the tube to non-tube groups and the Mann-Whitney test were performed. No significant difference was found in the prevertebral soft tissues at the C2 level between those with tubes in place and the control subjects. However, at the C6 level there was statistical significance between the groups with NGTs and both NGTs and ETTs versus the non-tube groups. Probability under the F-test for the groups with NGTs and both NGTs and ETTs was 0.001 and 0.005, respectively. Under the Mann-Whitney test, P values for groups with NGTs and both NGTs and ETTs were 0.0002 and 0.0001, respectively. Conclusion. The appearance of PVSTS showed variable and unpredictable changes following ETT, NGT, or combined ETT/NGT placement at the C2 level. This appears to be an artifact of temporal changes. However, at the C6 level, the presence of PVSTS following NGT or ETT and NGT placement (but not ETT placement alone) may be an accurate indirect sign of cervical spine injury. Received: 14 September 1999 Revision requested: 30 December 1999 Revision received: 4 February 2000 Accepted: 8 February 2000     

The value of routine cervical spine,chest, and pelvis radiographs in children after trauma

The appropriate use of imaging to screen infants and children for injuries after trauma remains controversial, and routine radiographs of the cervical spine, chest, and pelvis are still obtained at some centers. The purpose of this study was to document the abnormalities encountered on such films obtained in 292 pediatric trauma patients to evaluate the worth of obtaining such studies, particularly in children who are asymptomatic and have no clinical findings referable to these areas.The medical records, radiographs, and other imaging studies of 292 children evaluated in the emergency department after trauma were retrospectively reviewed. Ages ranged from 5 months to 17 years (mean =10 years). The numbers and types of abnormal imaging findings were documented for each patient and were correlated with the type of injury, patient complaints, physical examination findings, level of consciousness, and laboratory abnormalities. Final diagnosis and short-term outcome were also documented.The most common causes of injury were motor vehicle accidents (55.1%), automobile-pedestrian accidents (14.7%), and falls (13.4%). Acute cervical spine injuries were found in 2 patients (0.7%), radiographic abnormalities of the chest were found in 11 patients (3.8%), and pelvic fractures were detected in 6 patients (2.0%). All except 1 of the 19 confirmed injuries were associated with local symptoms and/or signs or were found in patients with altered mental status. A stable cervical fracture was found in one infant who was too young to complain of neck pain or tenderness. Twenty-two patients (7.5%) were asymptomatic with no physical findings, and in none of these children were any imaging abnormalities detected.We conclude that routine posttrauma radiographs of the cervical spine, chest, and pelvis are of limited utility and are not warranted in children and adolescents who are alert and demonstrate no associated symptoms or physical findings. Radiography, particularly of the cervical spine, may be worthwhile in infants and young children, but we advocate selective imaging in such patients.     

Should an MR scan be performed routinely after a normal clearance CT scan in the trauma patient? Experience with 59 cases

Magnetic resonance (MR) imaging is not routinely used to exclude ligamentous and other soft tissue injury in the unconscious trauma patient. In order to determine the frequency and types of soft tissue injuries detected by MR imaging but not by computed tomography (CT), we performed a retrospective investigation comparing the MR findings in 59 trauma patients, either alert or unconscious, who previously had undergone a negative clearance multislice CT study of the cervical spine. Six patients had abnormalities not identified on the CT studies, including four cases of ligamentous injury.