Detection of cervical spine trauma: Are 3-dimensional reconstructed images as accurate as multiplanar computer tomography?

IntroductionThis study was conducted to assess the diagnostic accuracy of three-dimensional computed tomography (3D-CT) in detection of cervical spine injuries in symptomatic post-trauma patients using multiplanar computed tomography (MP-CT) as reference standard.ApproachThis cross-sectional study was conducted at Aga Khan University from July 2016 to January 2017. Patients were included using a non-probability, consecutive sampling. MP-CT and 3D- CT images were obtained and evaluated by a senior radiologist to identify cervical spine injuries.Results205 patients were included in the study. For fractures, 3D-CT images had sensitivity of 71%, specificity of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 96.8% and diagnostic accuracy of 97%. For dislocations, 3D-CT reported sensitivity of 83.34%, specificity of 100%, positive predictive value of 100% and negative predictive value of 99.5% and diagnostic accuracy of 99.5%.Conclusion3D-CT has good diagnostic accuracy for injuries of the cervical spine but must be reviewed simultaneously with multiplanar CT images.     

Are "cervicogenic" headaches due to myofascial pain and cervical spine dysfunction?

The purpose of this investigation was to evaluate whether the pain of cervicogenic headache could be due to referred symptoms from myofascial trigger points. The presence or absence of cervical spine dysfunction was also of interest. Eleven patients with cervicogenic headaches were systematically examined for myofascial trigger points and cervical spine dysfunction. All patients had at least three myofascial trigger points on the symptomatic side. In eight of these patients, trigger point palpation clearly reproduced their headache. There were 70 myofascial trigger points (35 "very tender", 35 "tender") and 17 non-myofascial tender points on the symptomatic side, compared to 22 myofascial trigger points (one "very tender", 21 "tender") and 19 non-myofascial tender points on the asymptomatic side. These differences were statistically significant [chi-square (2df) = 22.04, p less than 0.0001]. All patients had some evidence of cervical dysfunction. Ten patients (91%) had specific segmental dysfunction of occiput on atlas and/or atlas on axis. Five patients were entered into a non-invasive, interdisciplinary pain management program designed to treat cervical spine dysfunction and myofascial pain. Treated patients reported a significant decrease in the frequency and intensity of their headaches during a median two-year follow-up. It is concluded that myofascial trigger points may be an important pain producing mechanism in cervicogenic headache and that segmental cervical dysfunction is a common feature in such patients. Conservative, non-surgical treatment appears to be effective in reducing the frequency and intensity of cervicogenic headache. These data suggest that surgical approaches should be reserved only for those patients who fail conservative therapy.     

Is helical computed tomography effective for diagnosis of blunt aortic injury?

Computed tomography has had a questionable role in diagnosing blunt aortic injury (BAI). The objective of this study was to determine the effectiveness of helical computed tomography of the thorax (HCTT) for detection of BAI. Trauma Registry data and medical records were reviewed for 2,854 patients admitted over a 32-month period. A total of 243 patients were identified at risk for BAI. Patients were evaluated for BAI because of chest radiograph, physical examination, or clinical suspicion. Eleven of 2,834 patients sustained BAI. Of 243 patients who sustained blunt torso trauma, 232 patients underwent HCTT. Eleven underwent aortography without HCTT. Sixteen patients had an abnormal HCTT, revealing 9 patients with BAI. No delayed BAI were encountered. HCTT effectively screens for BAI. Aortography can be more specifically applied as a diagnostic study when preceded by HCTT. HCTT should not be used as solitary study for BAI as some injuries identified by HCTT do not represent BAI.     

Blunt trauma in intoxicated patients: is computed tomography of the abdomen always necessary?

BACKGROUND: Physical examination to detect abdominal injuries has been considered unreliable in alcohol-intoxicated trauma patients. Computed tomography (CT) plays the primary role in these abdominal evaluations. METHODS: We reviewed medical records of all blunt trauma patients admitted to our trauma service from January 1, 1992, to March 31, 1998. Study patients had a blood alcohol level > or =80 mg/dL, Glasgow Coma Scale (GCS) score of 15, and unremarkable abdominal examination. RESULTS: Of 324 patients studied, 317 (98%) had CT scans negative for abdominal injury. Abdominal injuries were identified in 7 patients (2%), with only 2 (0.6%) requiring abdominal exploration. A significant association was found between major chest injury and abdominal injury. CONCLUSION: The incidence of abdominal injury in intoxicated, hemodynamically stable, blunt trauma patients with a normal abdominal examination and normal mentation is low. Physical examination and attention to clinical risk factors allow accurate abdominal evaluation without CT.     

How do clinical features help identify paediatric patients with fractures following blunt wrist trauma?

Objective

Wrist injuries are a common presentation to the emergency department (ED). There are no validated decision rules to help clinicians evaluate paediatric wrist trauma. This study aimed to identify which clinical features are diagnostically useful in deciding the need for a wrist radiograph, and then to develop a clinical decision rule.

Methods

This prospective cohort study was carried out in the ED of Sheffield Children''s Hospital. Eligible patients were recruited if presenting within 72 hours following blunt wrist trauma. A standardised data collection form was completed for all patients. The outcome measure was the presence or absence of a fracture. Univariate analysis was performed with the χ² test. Associated variables (p<0.2) were entered into a multivariate model. Classification and regression tree (CART) analysis was used to derive the clinical decision rule.

Results

In total, 227 patients were recruited and 106 children were diagnosed with fractures (47%). Of 10 clinical features analysed, six were found by univariate analysis to be associated with a fracture. CART analysis identified the presence of radial tenderness, focal swelling, or an abnormal supination/pronation as the best discriminatory features. Cross fold validation of this decision rule had a sensitivity of 99.1% (95% confidence interval 94.8% to 100%) and a specificity of 24.0% (17.2% to 32.3%). The radiography rate would be 87%.

Conclusions

Radial tenderness, focal swelling, and abnormal supination/pronation are associated with wrist fractures in children. The clinical decision rule derived from these features had a high sensitivity, but low specificity, and would not substantially alter our current radiography rate. The potential for a clinical decision rule for paediatric wrist trauma appears limited.     

Prehospital clearance of the cervical spine: does it need to be a pain in the neck?

Prehospital cervical spine (c-spine) immobilisation is common, despite c-spine injury being relatively rare. Unnecessary immobilisation results in a significant burden on limited prehospital and emergency department (ED) resources. This study aimed to determine whether the incidence of unnecessary c-spine immobilisation by ambulance personnel could be safely reduced through the implementation of an evidence-based algorithm. Following a training programme, complete forms on 103 patients were identified during the audit period, of which 69 (67%) patients had their c-spines cleared at scene. Of these, 60 (87%) were discharged at scene, with no clinical adverse events reported, and 9 (13%) were taken to the local ED with non-distracting minor injuries, all being discharged home the same day. 34 (33%) patients could not have their c-spines safely cleared at scene according to the algorithm. Of these, 4 (12%) patients self-discharged at scene and 30 (88%) were conveyed to an ED as per the normal procedure. C-spine clearance at scene by ambulance personnel may have positive impacts on patient care, efficient use of resources and cost to healthcare organisations.     

Should transient loss of consciousness in blunt head trauma be a pre-hospital trauma triage criterion?

The objective of this study was to evaluate pre-hospital triage of patients with an isolated brief loss of consciousness (LOC) to a regional trauma center (RTC). Data from a 6-month period were retrospectively reviewed from an existing pre-hospital data collection set. Patients were included if either they or a witness claimed a LOC, but they had regained consciousness to at least a Glasgow Coma Score (GCS) > 13 by the time the paramedics arrived. Endpoints for need for trauma center services included positive head computed tomography (CT) scan, the occurrence of emergency non-orthopedic surgery in < 6 h, admission to a surgical intensive care unit (ICU), or a length of stay (LOS) greater than 3 days for surgical evaluation. There were 655 complete records available for 275 cases of vehicular trauma and 380 cases of non-vehicular trauma. There were 170 (62%) patients in the vehicular group, and 287 (76%) in the non-vehicular group evaluated in the emergency department and discharged. In the vehicular group, only one (0.4%) patient required operative intervention in less than 6 h, three (1.1%) had a positive head CT scan, 10 (3.6%) were admitted to a surgical ICU, and four (1.5%) had a LOS > 3 days. In the non-vehicular trauma group, only one (0.3%) had surgery in < 6 h, eight (2.1%) had a positive CT scan, six (1.6%) were admitted to a surgical ICU or had a LOS > 3 days. Overall, 19 (2.9%, CI 0.018–0.045) patients met any one of the end-point criteria for trauma center utilization; however, only one patient (0.2% CI < 0.0001–0.008) required immediate neurosurgical intervention. Transient LOC, in the absence of any other American College of Surgeons (ACS) trauma triage criteria, triaged 97% of patients to a trauma center, who did not require trauma center services based on our criteria.     

Are opioids effective in relieving neuropathic pain?

The purpose of this review is to identify important issues and to review the data that underlie the controversial effectiveness of opioids in relieving neuropathic pain. This controversy seems related to the use of multiple definitions of neuropathic pain together with its distinct mechanisms in both experimental animal models and human neuropathic pain syndromes, methodological shortcomings in available randomized controlled clinical trials, different methods of pain assessment, the inappropriate use of terms like efficacy and responsiveness, differential responses in spontaneous versus evoked pains, interindividual differences to specific opioids and opioid doses, and duration of follow-up. New randomized controlled clinical trials with opioids in neuropathic pain are still needed. These studies should include larger patient samples with rigorously defined homogeneous neuropathic pain syndromes. Active placebo's mimicking side-effects should be included in the double-blind design, and control of unmasking should be performed. Individual titration of the opioid dose and active management of side-effects in long-term follow-up studies need to measure both pain relief and quality of life.     

Where do we go after the three standard cervical spine views in the conscious trauma patient? A survey.

The objective of this study was to assess, by questionnaire survey, national practice in respect of radiological assessment of the cervical spine in the conscious adult patient with suspected neck injury. The physicians in charge of accident and emergency departments with more than 25000 new patients per year were sent a questionnaire. One hundred and ninety-one replies were received from 243 physicians (79%). Sixty-five per cent of departments have written protocols for imaging the cervical spine. Seven per cent of departments use fewer than the three standard views for clearing the cervical spine. If adequate views do not visualize the cervicothoracic junction, 89% use swimmer's views and 12% use supine oblique views, prior to computerized tomography scanning. It is concluded that the majority of departments use three standard views in the first instance. Swimmer's views are the most common additional X-rays taken if the C7-T1 junction is not visualized, even though supine oblique views give better information about spinal alignment. Imaging of the cervical spine following trauma is difficult and guidelines should be drawn up to address these problems.     

Does the novel lateral trauma position cause more motion in an unstable cervical spine injury than the logroll maneuver?

Objective

Prehospital personnel who lack advanced airway management training must rely on basic techniques when transporting unconscious trauma patients. The supine position is associated with a loss of airway patency when compared to lateral recumbent positions. Thus, an inherent conflict exists between securing an open airway using the recovery position and maintaining spinal immobilization in the supine position. The lateral trauma position is a novel technique that aims to combine airway management with spinal precautions. The objective of this study was to compare the spinal motion allowed by the novel lateral trauma position and the well-established log-roll maneuver.

Are too many head CT scans ordered in emergency departments?

Objectives : The aims of this study were to: (i) characterize ordering of head computed tomography scans from the emergency department; (ii) determine the proportion of scans that yield an abnormal result; (iii) correlate results with clinical syndromes and neurological findings; and (iv) identify areas where a change in ordering practice may be warranted. Method : Prospective case identification with detailed explicit review of clinical notes and radiological findings. Results : Two hundred and thirty‐six cases were analysed. The rate of head computed tomography scans was 2.3% of all emergency department attendances. Of the scans, 21.6% were abnormal with the most common abnormalities being haemorrhage or infarction. Indications that correlated highly with abnormal scans were altered mental state (43.7%), focal weakness (36.7%), mild head injury (21.2%) and confusion (18.5%). Headache, transient ischaemic attack and seizure had low correlations with abnormal scans. Conclusion : The results of this study suggest that the overall rate of head computed tomography scans ordered by the study emergency department was appropriate. It also supports the development of guidelines for the ordering of head computed tomography scans in patients with headache, seizure and transient ischaemic attack.     

Does pedicle screw fixation of the subaxial cervical spine provide adequate stabilization in a multilevel vertebral body fracture model? An in vitro biomechanical study

BackgroundCervical vertebral body fractures generally are treated through an anterior-posterior approach. Cervical pedicle screws offer an alternative to circumferential fixation. This biomechanical study quantifies whether cervical pedicle screws alone can restore the stability of a three-column vertebral body fracture, making standard 360° reconstruction unnecessary.MethodsRange of motion (2.0 Nm) in flexion-extension, lateral bending, and axial rotation was tested on 10 cadaveric specimens (five/group) at C2–T1 with a spine kinematics simulator. Specimens were tested for flexibility of intact when a fatigue protocol with instrumentation was used to evaluate construct longevity. For a C4–6 fracture, spines were instrumented with 360° reconstruction (corpectomy spacer + plate + lateral mass screws) (Group 1) or cervical pedicle screw reconstruction (C3 and C7 only) (Group 2).FindingsResults are expressed as percentage of intact (100%). In Group 1, 360° reconstruction resulted in decreased motion during flexion-extension, lateral bending, and axial rotation, to 21.5%, 14.1%, and 48.6%, respectively, following 18,000 cycles of flexion-extension testing. In Group 2, cervical pedicle screw reconstruction led to reduced motion after cyclic flexion-extension testing, to 38.4%, 12.3%, and 51.1% during flexion-extension, lateral bending, and axial rotation, respectively.InterpretationThe 360° stabilization procedure provided the greatest initial stability. Cervical pedicle screw reconstruction resulted in less change in motion following cyclic loading with less variation from specimen to specimen, possibly caused by loosening of the shorter lateral mass screws. Cervical pedicle screw stabilization may be a viable alternative to 360° reconstruction for restoring multilevel vertebral body fracture.     

SOFTLY: Comparison of outcomes of rigid versus soft collar during emergency department investigation for potential cervical spine injury in low-risk blunt trauma patients – A pilot study

Objective

Blunt trauma patients with potential cervical spine injury are traditionally immobilised in rigid collars. Recently, this has been challenged. The present study's objective was comparison of the rate of patient-oriented adverse events in stable, alert, low-risk patients with potential cervical spine injuries immobilised in rigid versus soft collars.

Methods

Unblinded, prospective quasi-randomised clinical trial of neurologically intact, adult, blunt trauma patients assessed as having potential cervical spine injury. Patients were randomised to collar type. All other aspects of care were unchanged. Primary outcome was patient-reported discomfort related to neck immobilisation by collar type. Secondary outcomes included adverse neurological events, agitation and clinically important cervical spine injuries (clinical trial registration number: ACTRN12621000286842).

Results

A total of 137 patients were enrolled: 59 patients allocated to a rigid collar and 78 to a soft collar. Most injuries were from a fall <1 m (54%) or a motor vehicle crash (21.9%). Median neck pain score of collar immobilisation was lower in the soft collar group (3.0 [interquartile range 0–6.1] vs 6.0 [interquartile range 3–8.8], P < 0.001). The proportion of patients with clinician-identified agitation was lower in the soft collar group (5% vs 17%, P = 0.04). There were four clinically important cervical spine injuries (two in each group). All were treated conservatively. There were no adverse neurological events.

Conclusions

Use of soft rather than rigid collar immobilisation for low-risk blunt trauma patients with potential cervical spine injury is significantly less painful for patients and results in less agitation. A larger study is needed to determine the safety of this approach or whether collars are required at all.