Cervical spine injury and radiography in alert, high-risk patients

Controversy exists over the need for cervical spine radiographs in alert, nonintoxicated victims of blunt trauma. We identified 286 patients admitted to a Level II trauma center over a 14-month period who were alert (Glasgow Coma Scale [GCS] greater than 13) and considered at high risk for cervical spine injury by published criteria. All 5 (1.7%) fractures or ligament disruptions occurred in the group with neck pain or tenderness. Of the study group, 141 (49%) were asymptomatic for cervical injury and nonintoxicated (blood alcohol concentration (BAC) less than 100 mg/dL). Mandatory cervical spine radiography in this group would have resulted in an additional cost of $33,699. Routine cervical spine radiography in alert, nonintoxicated asymptomatic victims of blunt trauma is a costly practice that warrants further examination.     

Injuries distracting from intraabdominal injuries after blunt trauma

While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal (“distracting”) injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group I) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group I had IAI compared with 44 of the 208 patients (21.2%) in group 2 (P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.     

Application of clinical criteria for ordering radiographs to detect cervical spine fractures

OBJECTIVE: The aim of the study was to determine if spinal-immobilized patients met clinical criteria for x-rays and which clinical criteria were associated with cervical fractures. METHODS: This was a prospective, observational analysis of clinical findings and radiograph results for patients transported to the emergency department in spinal immobilization by emergency medical services. The presence of altered mentation, distracting injury, cervical spine tenderness, neck pain, neurologic deficit, and palpable deformity was recorded for each subject. RESULTS: Of the 2044 subjects enrolled in the study, 1367 subjects received radiographs and 50 had cervical spine fractures. Sixty percent of subjects met some clinical criteria for radiograph ordering. Cervical spine tenderness and neurologic deficit were the only clinical criteria statistically associated with fractures. All subjects with fractures met 1 or more of the clinical criteria for radiographs. CONCLUSION: Cervical spine radiographs were ordered for a significant number of patients who did not meet the clinical criteria. However, omission of any one of the criterion other than palpable deformity would have potentially resulted in a missed fracture. Strictly following the criteria would have significantly reduced the number of cervical spine radiographs taken.     

Undetected hangman's fracture in a patient referred for physical therapy for the treatment of neck pain following trauma

BACKGROUND AND PURPOSE: This case report describes a patient referred for physical therapy treatment of neck pain who had an underlying hangman's fracture that precluded physical therapy intervention. CASE DESCRIPTION: This case involved a 61-year-old man who had a sudden onset of neck pain after a motor vehicle accident 8 weeks before his initial physical therapy visit. Conventional radiographs of his cervical spine taken on the day of the accident did not reveal any abnormalities. Based on the findings at his initial physical therapy visit, the physical therapist ordered conventional radiographs of the cervical spine to rule out the possibility of an undetected fracture. OUTCOMES: The radiographs revealed bilateral C2 pars interarticularis defects consistent with a hangman's fracture. The patient was referred to a neurosurgeon for immediate review. Based on a normal neurological examination, a relatively low level of pain, and the results of radiographic flexion and extension views of the cervical spine (which revealed no evidence of instability), the neurosurgeon recommended that the patient continue with nonsurgical management. DISCUSSION: In patients with neck pain caused by trauma, physical therapists should be alert for the presence of cervical spine fractures. Even if the initial radiographs are negative for a fracture, additional diagnostic imaging may be necessary for a small number of patients, because they may have undetected injuries that would necessitate medical referral and preclude physical therapy intervention.     

Pitfalls in the clinical diagnosis of vertebral fractures: a case series in which posterior midline tenderness was absent

Objective: There is widespread belief among doctors that posterior midline tenderness is virtually a prerequisite for spinal fracture in alert, sober patients without any painful distracting injury or neurological deficit. This paper examines and challenges this belief.

Methods and results: We present three patients in whom significant thoracic and lumbar vertebral fractures were missed, or were thought to be "old", because of lack of posterior midline tenderness. We also present two further patients, one with a lumbar spine fracture and one with a cervical spine fracture, in whom posterior midline tenderness was absent but in whom the correct diagnosis was made. All these patients were sober and fully alert and none had a neurological deficit or a painful distracting injury.

Conclusion: The absence of posterior midline tenderness does not exclude significant spinal injury. We suggest that patients should satisfy both the Canadian and British guidelines before it is decided that imaging of the cervical spine is unnecessary.

     

Distracting injuries in patients with vertebral injuries

To describe the prevalence and types of distracting injuries associated with vertebral injuries at all levels of the spine in blunt trauma patients. A prospective cohort study was conducted at an urban Level I trauma center. All patients undergoing radiographic evaluation of the cervical, thoracic, or lumbar vertebrae after blunt trauma were enrolled. Patients had a data collection form completed by the treating physician before radiographic imaging and were evaluated for the following upon initial presentation: tenderness to the cervical, thoracic, or lumbar spine, distracting injuries, altered mental status, alcohol or drug intoxication, or neurological deficits. Patients with distracting injuries as the sole documented indication for vertebral radiographs were reviewed for the types of injuries present. A total of 4698 patients were enrolled in the study. There were 336 (7.2%) patients who had distracting injuries as the sole documented indication for obtaining radiographic studies of the vertebrae. Eight (2.4%, 95% CI 1.0-4.6%) of the 336 patients had 14 acute vertebral injuries including compression fractures (5), transverse process fractures (7), spinous process fracture (1), and cervical spine rotatory subluxation (1). There were 13 thoracolumbar injuries and one cervical spine injury. Distracting injuries in the eight patients with acute vertebral injuries included 13 bony fractures. Distracting injuries in those patients without vertebral injuries included bony fractures (333), lacerations (63), soft tissue contusions (62), head injuries (15), bony dislocations (12), abrasions (11), visceral injuries (8), dental injuries (5), burns (3), ligamentous injuries (3), amputation (1), and compartment syndrome (1). In conclusion, in patients with distracting injuries, bony fractures of any type were important for identifying patients with vertebral injuries. Other types of distracting injuries did not contribute to the sensitivity of the clinical screening criteria in the detection of patients with vertebral injuries.     

Evaluation of pediatric cervical spine injuries.

To compare historical features, clinical examination findings, and radiographic results among pediatric patients with cervical spine injury (CSI), a retrospective review of patients who were diagnosed with CSI was undertaken. Two main groups were identified: radiographically evident cervical spine injury (RESCI), and spinal cord injury without radiographic abnormality (SCIWORA). Demographic, historical, clinical, and radiographic information was obtained from patients' charts and analyzed to determine factors associated with CSI and to determine the efficacy of the various radiographic views. Seventy-two children, ages from 1 month to 15 years (median age, 9 yrs), were included in the study. Sports-related injuries were the most common. Forty patients had RESCI and 32 had SCIWORA. Forty-nine (80%) of all the patients had abnormal findings on neck examination, and six (16%) of the RECSI group had abnormal neurological findings. Lateral radiographs had a sensitivity for CSI of 79%; a three-view radiographic series had a sensitivity of 94%. All patients with CSI who were clinically asymptomatic had both a high-risk injury mechanism and a distracting injury. CSI should be suspected in any child with abnormal findings on neck or neurological examination. A minimum of three radiographic cervical spine views should be obtained in the evaluation of CSI in children. Even in the face of a three-view series, CSI should be suspected in patients with an abnormal neck or neurological exam, high-risk mechanism of injury, or distracting injury.     

Cervicogenic dizziness - musculoskeletal findings before and after treatment and long-term outcome

Purpose. To explore musculoskeletal findings in patients with cervicogenic dizziness and how these findings relate to pain and dizziness. To study treatment effects and long-term symptom progress.

Method. Twenty-two patients (20 women, 2 men; mean age 37 years) with suspected cervicogenic dizziness underwent a structured physical examination before and after physiotherapy guided by the musculoskeletal findings. Questionnaires were sent to the patients six months and two years after treatment.

Results. Dorsal neck muscle tenderness and tightness was found in a majority of the patients. Zygapophyseal joint tenderness was found at all cervical levels. Cervical range of motion was equal to or larger than expected age and gender matched values. The cervico-thoracic region was often hypomobile. Most patients had postural imbalance. Dynamic stabilization capacity was reduced. Suboccipital muscles tightness correlated with posture imbalance and poor neck stability. The treatment resulted in reduced tenderness in levator scapula, high and middle paraspinal and temporalis muscles and zygapophyseal joints at C4-C7 and increased cervico-thoracic mobility. Reduction of middle paraspinal muscle tenderness correlated with neck pain relief. Postural alignment improved, as did dynamic stabilization in trunk, neck and shoulders. After 6 months, 13 of the 17 patients had still no or less neck pain and 14 had no or less dizziness. After 2 years, 7 patients had no or less neck pain and 11 no or less dizziness.

Conclusion. Patients with suspected cervicogenic dizziness have some musculoskeletal findings in common. Treatment based on these findings reduces neck pain as well as dizziness long-term but some patients might need a maintenance strategy.     

Cervicogenic dizziness – musculoskeletal findings before and after treatment and long-term outcome

Purpose. To explore musculoskeletal findings in patients with cervicogenic dizziness and how these findings relate to pain and dizziness. To study treatment effects and long-term symptom progress.

Method. Twenty-two patients (20 women, 2 men; mean age 37 years) with suspected cervicogenic dizziness underwent a structured physical examination before and after physiotherapy guided by the musculoskeletal findings. Questionnaires were sent to the patients six months and two years after treatment.

Results. Dorsal neck muscle tenderness and tightness was found in a majority of the patients. Zygapophyseal joint tenderness was found at all cervical levels. Cervical range of motion was equal to or larger than expected age and gender matched values. The cervico-thoracic region was often hypomobile. Most patients had postural imbalance. Dynamic stabilization capacity was reduced. Suboccipital muscles tightness correlated with posture imbalance and poor neck stability. The treatment resulted in reduced tenderness in levator scapula, high and middle paraspinal and temporalis muscles and zygapophyseal joints at C4-C7 and increased cervico-thoracic mobility. Reduction of middle paraspinal muscle tenderness correlated with neck pain relief. Postural alignment improved, as did dynamic stabilization in trunk, neck and shoulders. After 6 months, 13 of the 17 patients had still no or less neck pain and 14 had no or less dizziness. After 2 years, 7 patients had no or less neck pain and 11 no or less dizziness.

Conclusion. Patients with suspected cervicogenic dizziness have some musculoskeletal findings in common. Treatment based on these findings reduces neck pain as well as dizziness long-term but some patients might need a maintenance strategy.     

Whiplash injury of the neck from concepts to facts]

OBJECTIVES: To focus on a topic of traumatology and rehabilitation becoming recently a much debated public health problem. METHOD: A references search from Medline database with whiplash as keyword was carried out. Were selected articles with abstracts in french or english and focusing on accidentology, biomechanics, demonstrated lesions, epidemiology and treatments. RESULTS: From 1664 references found, 232 were reviewed. The usual mechanism of crash is a rear-end collision inducing in the occupants of the bumped vehicle a sudden lower cervical spine extension with upper flexion followed by a global flexion. In nearly 50% of the cases, the stress occurring in the collision is comparable to that observed in bumper cars. The velocity changes are seldom up to 15 km/h. A headrest at the level of the center of gravity of the head restrict significantly the extension of the neck. Every structure of the cervical spine could be damaged and mainly the facet joints but the lesions were only demonstrated in severes traumatisms. The discrepancies in incidence among the different countries could be related to their medicolegal system. Although subjectives, the early symptoms are rather similar among patients suggesting true anatomical or functional disorders but the chronicity seems to be mainly related to social and psychological factors. The association of: no posterior midline cervical tenderness, no intoxication, normal alertness, no focal neurological deficit and no painful distracting injuries has a good predictive value of the lack of osteo-articular lesion on X-rays. Except the grade IV of the Quebec task Force (0, no symptom; 1, pain and stiffness; 2, neck complaint and physical signs; 3, neck complaint and neurological signs; 4, fracture or dislocation) the use of a collar should be avoided and the cervical spine should be mobilized. CONCLUSION: In most whiplash injuries, the mildness should be early stated, mobilization encouraged, and procedures of compensation shortened.     

Evaluation of neck discomfort, neck tenderness, and neurologic deficits as indicators for radiography in blunt trauma victims.

Seventeen of 480 adult blunt trauma victims who sustained cervical spine injuries (CSI) were studied prospectively. In reliable patients, complaints of neck discomfort and tenderness demonstrated sensitivities of 86% and 79%, respectively, for CSI. A positive physical examination, defined as neurologic deficits, or cervical region discomfort or tenderness was noted in 13 of 14 reliable individuals sustaining CSI (sensitivity 93%, specificity 16%, positive predictive value 3.3%, negative predictive value 98.7%). Lack of absolute sensitivity of these studied clinical parameters, either singly or in concert, for CSI suggests that eliminating cervical spine radiography on the basis of the absence of neck discomfort, tenderness, or neurological deficits in reliable blunt trauma victims could result in missed CSI. An enormous prospective data base will be required to definitively address the sensitivity of all clinical parameters currently employed to determine the need for cervical spine radiography in reliable blunt trauma victims.     

Computed tomography for blunt abdominal trauma in the ED: A prospective study

A study was undertaken to determine the criteria for ordering abdominal computed tomography (CT) in the emergency department (ED) for stable patients who sustained blunt trauma and to identify a patient population at high risk for having intra-abdominal injury (IAI) utilizing physical examination, decrease in hematocrit, and hematuria. Patients in a university ED who had abdominal CT from April 1995 to October 1995 were evaluated prospectively. Before the scan, the examining physician completed an entry form that included physical findings, hematocrit, hematuria, Glasgow Coma Scale score, intoxication, distracting injuries, reasons for obtaining the scan, and planned disposition. Patients were followed until discharge. A total of 196 patients were evaluated. Abdominal tenderness was present in 120 patients. Twenty-two patients had IAI. Eight required surgical intervention, and all 8 had abdominal tenderness. A total of 40 potential trauma admissions were averted by obtaining CT within the ED. The combined abnormal abdomen examination and presence of hematuria had a sensitivity of 64%, specificity of 94%, positive predictive value of 56%, and negative predictive value of 95%. Decrease of ≥5 in hematocrit was not statistically significant for detection of IAI. CT had no false negatives in this cohort. These results show that early CT scanning of stable patients who have sustained blunt trauma is an effective screen for IAI and may result in fewer total admissions, but has potential for overuse. Patients with abdominal pain and hematuria should be scanned. The benefit of a CT scan for patients without tenderness or with an isolated decrease in hematocrit is questionable.     

Cervical spine clearance and neck extension during percutaneous tracheostomy in trauma patients

INTRODUCTION: The lack of cervical spine clearance and inability to extend the neck are assumed to be relative contraindications for percutaneous tracheostomy. OBJECTIVE: To determine the necessity of cervical spine clearance and neck extension in trauma patients receiving percutaneous tracheostomy. DESIGN: Prospective analysis of case series from August 1, 1995 to August 31, 1998. SETTING: A university-based Level I trauma center. PATIENTS: A total of 88 consecutive trauma patients receiving percutaneous tracheostomy. Patients were divided into two groups based on the radiographic or clinical status of their cervical spine: cleared and noncleared. RESULTS: The overall success and complication rate were 99% (87/88) and 11% (10/88), respectively. There were no procedure-related deaths. The cleared group consisted of 60 patients; three patients in this group who had "bull" or "thick" necks did not have full neck extension during percutaneous tracheostomy. The noncleared group consisted of 28 patients, 13 of which had known cervical spine fractures; 27 noncleared patients were maintained in the neutral position (no extension) during percutaneous tracheostomy, whereas one patient with low suspicion of spinal injury was partially extended. Of the 13 patients with cervical spine fractures, six patients had been stabilized with a halo or operative fixation, and seven patients were stabilized with a cervical collar at the time of percutaneous tracheostomy. The success rate was 100% (60/60) for the cleared group compared with 96% (27/28) for the noncleared group (p > .05). The complication rate was 13% (8/60) for the cleared group compared with 7.1% (2/28) for the noncleared group (p > .05). We had a 100% success rate and no complications in the seven patients with cervical spine injury who were stabilized with a cervical collar. No patient had spinal cord injury caused by percutaneous tracheostomy. CONCLUSION: Percutaneous tracheostomy can be safely performed in trauma patients without cervical spine clearance and neck extension, including patients with stabilized cervical spine or spinal cord injury.     

The Effect of Soft Cervical Collars on Persistent Neck Pain in Patients with Whiplash Injury

Objective: To assess the efficacy of soft cervical collars in the early management of whiplash-injury-related pain.
Methods: A controlled, clinical trial was conducted in an urban ED. Adults with neck pain following automobile crashes indicated their initial degrees of pain on a visual analog scale. Patients with cervical spine fractures or subluxation, focal neurologic deficits, or other major distracting injuries were excluded. Patients were assigned to receive a soft cervical collar or no collar based on their medical record numbers. Pain at ≥ 6 weeks postinjury was coded as none, better, same, or worse, and analyzed as 3 dichotomous outcomes: recovered (pain = none); improved (pain = none or better); and deteriorated (pain = worse).
Results: Of 250 patients enrolled, 196 (78%) were available for follow-up. Of these patients, 104 (53%) were assigned to the soft cervical collar group, and 92 (47%) to the control group. These groups were similar in age, gender, seat position in the car, seat belt use, and initial pain score. Pain persisted at ≥ 6 weeks in 122 (62%) patients. The groups showed no difference in follow-up pain category (p = 0.59). There was no significant difference between the 2 groups in complete recovery (p = 0.34), improvement (p = 0.34), or deterioration (p = 0.60). The study had a power of 80% to detect an absolute difference of at least 20% in recovery, 17% in improvement, and 7% in deterioration (2–tailed, ex = 0.05).
Conclusions: Most patients with whiplash injuries have persistent pain for at least 6 weeks. Soft cervical collars do not influence the duration or degree of persistent pain.     

Prehospital clinical findings associated with spinal injury

Objective. The objective of this study was to identify clinical findings that are associated with spinal fracture and/or spinal cord injuries in prehospital trauma patients.

Methods. A retrospective chart review was performed at three tertiary referral centers in Southeastern Michigan. All charts of patients with spinal fractures or spinal cord injuries during 1992 and 1993 were reviewed. Patients with available pre-hospital records were included in the study analysis. Prehospital data points included documentation of head injury; altered mental status; neurologic deficit; evidence of intoxication; cervical, thoracic, and lumbar pain or tenderness; nonspecified back pain or tenderness; and a narrative for all other documented injuries. Hospital data collected included type and level of spinal injury and age and sex of the patient.

Results. Of 867 injury patients identified, 536 were excluded, leaving 346 analyzable fractures in 331 patients. The 346 spinal fractures/spinal cord injuries were distributed as: 100 (29%) cervical, 83 (24%) thoracic, 128 (37%) lumbar, and 35 (10%) sacral. Prehospital documentation of altered mental status, neurologic deficit, evidence of intoxication, spinal pain, or suspected extremity fracture was found for every patient with a cervical injury, 82/83 patients with thoracic injuries (99%), and 124/128 patients with lumbar injuries (97%). All five patients who were not documented as having one of the predictors had stable injuries.

Conclusion. Prehospital clinical findings of altered mental status, neurologic deficit, evidence of intoxication, spinal pain, and suspected extremity fracture were documented for all patients with significant spinal injuries in this series. These findings may be useful to identify patients who require prehospital spinal immobilization.     

Clinical findings in a population with back pain. Relation to one-year outcome and long-term sick leave

OBJECTIVE: To investigate whether physical examination findings can be used in predicting recovery from back pain and new episodes of sick leave. DESIGN: One-year prospective study of a single cohort. SETTINGS: Semi-rural Swedish county. POPULATION: A cross-section of a general population with back pain (207 women, 176 men) between 20 and 59 years of age. MAIN OUTCOME MEASURES: Cumulative incidence of sick leave due to back pain, cumulative incidence of sick leave due to back pain > 30 days, incidence of recovery from back pain. RESULTS: For recovery from pain, the absence of tenderness in the trapezius muscle (OR 0.33; CI 0.1-0.5) was predictive. New sick leave was predicted by tenderness in the trapezius muscle (OR 2.67; CI 1.5-4.9), and had a tendency to be associated with a flattened lumbar lordosis and a restricted cervical range of motion. For long-term sick leave, the same findings and also observation of scoliosis (OR 3.44; CI 1.1-10.5) were predictive. CONCLUSION: There are subgroups with back pain predisposed to development of more persistent symptoms and a higher risk for sick-listing.     

Bilateral Mechanical-Pain Sensitivity Over the Trigeminal Region in Patients With Chronic Mechanical Neck Pain

The aim of this study was to investigate bilateral pressure-pain sensitivity over the trigeminal region, the cervical spine, and the tibialis anterior muscle in patients with mechanical chronic neck pain. Twenty-three patients with neck pain (56% women), aged 20 to 37 years old, and 23 matched controls (aged 20 to 38 years) were included. Pressure pain thresholds (PPTs) were bilaterally assessed over masseter, temporalis, and upper trapezius muscles, the C5-C6 zygapophyseal joint, and the tibialis anterior muscle in a blinded design. The results showed that PPT levels were significantly decreased bilaterally over the masseter, temporalis, and upper trapezius muscles, and also the C5-C6 zygapophyseal joint (P < .001), but not over the tibialis anterior muscle (P = .4) in patients with mechanical chronic neck pain when compared to controls. The magnitude of PPT decreases was greater in the cervical region as compared to the trigeminal region (P < .01). PPTs over the masseter muscles were negatively correlated to both duration of pain symptoms and neck-pain intensity (P < .001). Our findings revealed pressure-pain hyperalgesia in the trigeminal region in patients with mechanical chronic neck pain, suggesting spreading of sensitization to the trigeminal region in this patient population.PerspectiveThis article reveals the presence of bilateral pressure-pain hypersensitivity in the trigeminal region in patients with idiopathic neck pain, suggesting a sensitization process of the trigemino-cervical nucleus caudalis in this population. This finding has implications for development of management strategies.     

Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial

BACKGROUND AND PURPOSE: Evidence supports the use of manual physical therapy interventions directed at the thoracic spine in patients with neck pain. The purpose of this study was to compare the effectiveness of thoracic spine thrust mobilization/manipulation with that of nonthrust mobilization/manipulation in patients with a primary complaint of mechanical neck pain. The authors also sought to compare the frequencies, durations, and types of side effects between the groups. SUBJECTS: The subjects in this study were 60 patients who were 18 to 60 years of age and had a primary complaint of neck pain. METHODS: For all subjects, a standardized history and a physical examination were obtained. Self-report outcome measures included the Neck Disability Index (NDI), a pain diagram, the Numeric Pain Rating Scale (NPRS), and the Fear-Avoidance Beliefs Questionnaire. After the baseline evaluation, the subjects were randomly assigned to receive either thoracic spine thrust or nonthrust mobilization/manipulation. The subjects were reexamined 2 to 4 days after the initial examination, and they again completed the NDI and the NPRS, as well as the Global Rating of Change (GROC) Scale. The primary aim was examined with a 2-way repeated-measures analysis of variance (ANOVA), with intervention group (thrust versus nonthrust mobilization/manipulation) as the between-subjects variable and time (baseline and 48 hours) as the within-subject variable. Separate ANOVAs were performed for each dependent variable: disability (NDI) and pain (NPRS). For each ANOVA, the hypothesis of interest was the 2-way group x time interaction. RESULTS: Sixty patients with a mean age of 43.3 years (SD=12.7) (55% female) satisfied the eligibility criteria and agreed to participate in the study. Subjects who received thrust mobilization/manipulation experienced greater reductions in disability, with a between-group difference of 10% (95% confidence interval [CI]=5.3-14.7), and in pain, with a between-group difference of 2.0 (95% CI=1.4-2.7). Subjects in the thrust mobilization/manipulation group exhibited significantly higher scores on the GROC Scale at the time of follow-up. No differences in the frequencies, durations, and types of side effects existed between the groups. DISCUSSION AND CONCLUSION: The results suggest that thoracic spine thrust mobilization/manipulation results in significantly greater short-term reductions in pain and disability than does thoracic nonthrust mobilization/manipulation in people with neck pain.     

Changes in physical examination caused by use of spinal immobilization

The standard of care for patients following blunt trauma includes midline palpation of vertebrae to rule out fractures. Previous studies have demonstrated that spinal immobilization does cause discomfort. Objective. To determine whether spinal immobilization causes changes in physical exam findings over time. Methods. This was a single-blinded, prospective study at a tertiary care university teaching hospital. Twenty healthy volunteers without previous back pain or injuries, 13 male and seven female, were fully immobilized for one hour, with a cervical collar and strapped to a long wooden backboard. Midline palpation of vertebrae to illicit pain was performed at 10-minute intervals. In addition, the participants were asked to rate neck and back pain on a scale from 1 to 10 (1 for no pain, and 10 for unbearable pain), to see whether subjective pain from immobilization correlated with tenderness to palpation. Results. Three patients had point tenderness of cervical vertebrae within 40 minutes. Five patients developed point tenderness of vertebrae by 60 minutes. Eighteen of 20 participants complained of increasing discomfort over time. The median initial pain scale was 1 (range 1-1), in contrast to 4 (range 1-9) at 60 minutes, p < 0.05. Conclusion. This study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness. In order to reduce this high false-positive rate for midline vertebral tenderness, the authors recommend that, initially on arrival to the emergency department, immediate evaluation occur of all immobilized patients. Furthermore, backboards should be modified to reduce patient discomfort to prevent the iatrogenically induced midline vertebral tenderness, thereby reducing subsequent false-positive examinations. PREHOSPITAL EMERGENCY CARE 2002;6:421-424     

Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT

Several recent studies report the sensitivity of computed tomography (CT) to be far greater than that of traditional plain film radiographic studies for evaluation of cervical spine fractures and spinal cord pathology. Nevertheless, plain films continue to be the standard screening examination. CT is used only if fractures are demonstrated or suspected on plain film survey. Recently, three patients with significant head and neck trauma (all three patients had intracranial hemorrhage) had cervical spine evaluation by computed tomography and standard plain film views. CT demonstrated significant C1-C2 fractures, while plain films were completely normal in all three cases. Prospectively studying the next 50 patients with significant head trauma, we added a few more slices to the routine head scan protocol to cover the first three cervical vertebrae. This added very little time or cost to the procedure. The additional CT images demonstrated four upper cervical fractures that could not be seen on plain films, even in retrospect. Our findings suggest that routine inclusion of the upper cervical spine with head CT is appropriate in the evaluation of patients with significant head trauma as defined by intracranial hemorrhage or skull fracture.