Improving the imaging diagnosis of cervical spine injury in the very elderly: implications of the epidemiology of injury

Purpose: To enumerate host and vector factors that affect each phase of cervical spine injury (CSI) among the elderly, and to attribute specific pathoanatomic characteristics of CSI to host and/or vector factors. Methods: Structured review of English literature references selected from MEDLINE keyword search using PUBMED and OVID search engines. Only articles addressing the role of “aging” or being “elderly” (using a variety of definitions) in CSI were included. The following information was abstracted: journal; year of publication; authors' specialty or departmental affiliation; study design; inclusion and exclusion criteria; year(s) of data collection; number of CSI vs. controls; summary findings, including rate estimates, obvious study weaknesses. Results: Seven of 13 articles were medical-record-based case series, most derived from institutional trauma registries. Four were population-based surveys. One was an assessment of Medicare claims data for all-cause trauma and one a review paper. Blunt-force CSI was most commonly related to domestic falls, then to vehicular-pedestrian collisions and finally to vehicular crashes. More than two-thirds of fractures involved CO-C3, especially in individuals with cervical spondylosis and/or osteoporosis. In 15 to 40 % of CO-C3 fractures there is a delay in diagnosis. An adult forme fruste of SCIWORA (spinal cord injury without radiographic abnormality) was a relatively common cause of central and anterior cord syndromes in the absence of observable fractures or dislocations. Conclusions: The epidemiology of CSI in elderly patients should inform triage and imaging decisions. Since most CSI diagnostic errors involve the upper cervical spine, additional attention to the radiographic anatomy of the craniocervical junction and diligent search for abnormalities in this region are warranted.     

Cervical spine injury seen only on an upright lateral view

This report describes a case in which significant cervical spine injuries were demonstrated only on the upright lateral view. On occasion, unstable or potentially unstable cervical spine injuries may only be seen on an upright lateral view.     

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.     

Improving the cervical spine X-ray in trauma patients utilizing dynamic range compression (DRC) modified digital radiography

Purpose: Inadequate cervical spine X-rays delay diagnosis and treatment and add radiation exposure to trauma patients with suspected cervical spine injury. Digital radiography (DR) with dynamic range compression (DRC) modification can improve the visualization of abnormalities in the cervical spine X-ray. Methods: Two digital hard copy cervical spine X-rays from each of 65 trauma patients were used, both with standard DR processing, and with the second image having the DRC algorithm applied. Blinded readers from emergency medicine, surgery, radiology, and critical care specialties evaluated the films with data analyzed by Student's t-test and ϰ²; P < 0.05. Results: Readers cleared more of the DRC than of the non-DRC images: 41 % vs 30 %, P < 0.001. More vertebral bodies were visualized on DRC than on non-DRC images: 65 % vs 53 % showing C7, P < 0.001. For overall impression of the image quality, DRC images rated higher on a 10-cm visual analog scale than non-DRC: 6.7 vs 4.2, P < 0.001. Conclusions: DRC modification of DR images enabled physicians to evaluate cervical spine X-rays more rapidly and accurately after trauma, requiring fewer repeat films.     

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     

Occult and secondary injuries missed by plain radiography of the cervical spine in blunt trauma patients

Background: Plain radiography does not visualize every cervical spine injury sustained by blunt trauma victims. The purpose of this study was to examine the prevalence and types of injuries missed by plain radiographs of the cervical spine and determine how frequently such radiography fails to detect any cervical spine injury. Methods: Images from all radiographic studies performed on blunt trauma victims presenting to 21 participating institutions were reviewed to compile an exhaustive list of all CSIs sustained by each individual. These injuries were then compared with the injuries detected by plain radiography alone. Patients were classified as having a “sentinel” injury if one or more of their injuries were visible on plain radiographs. Patients were classified as having a radiographically “occult” injury if none of their injuries were visible on plain radiographs. The number and types of injuries missed on plain radiographs were then separately tabulated for the sentinel and occult injury groups. Results: Plain radiographs were completed in 570 of 818 victims of acute cervical spine injury and revealed 702 of 1,056 injuries. Plain films failed to detect 98 occult injuries present in 60 patients (10.5 %), and failed to detect 256 secondary injuries in 510 patients (89.5 %) who had a sentinel injury identified. Plain radiographs failed to reveal 79 of 136 (58.1 %) lateral mass injuries and 67 of 105 (63.8 %) lamina injuries, making these the most frequent sites of missed injury. Conclusions: Plain radiographs frequently fail to reveal injuries to the cervical spine, particularly those involving the lamina and lateral mass. The majority of the missed injuries represent secondary injuries in patients with a sentinel injury identified on these films. However, plain films fail to detect any injury in a minority of injured patients.     

Anterior subluxation of the cervical spine

Anterior subluxation (AS), or hyperflexion sprain, generates a disproportionate level of concern in emergency medicine. Anxiety related to this injury arises from the fact that AS may produce delayed mechanical instability of the cervical spine, with resultant pain and neurological impairment. Furthermore, its radiographic presentation may be very subtle, and it may be impossible to reliably diagnose or exclude this injury using standard screening radiographs. Additional studies, such as flexion–extension (FE) radiography and magnetic resonance (MR) imaging, are often used in the acute setting to assess injury status and radiographically exclude AS injury. There are a number of reasons to discourage this latter practice, which can represent an impossible attempt to “radiographically clear the cervical spine” of blunt trauma patients with “100 % certainty.” This is because AS is an uncommon lesion, and the neurological deficits secondary to delayed instability are almost always minor and transient. Furthermore, AS is usually not entirely occult on screening plain films (which are typically “abnormal” even if in nonspecific ways). Finally, FE imaging, done acutely in the presence of spasm, is probably unable to exclude this diagnosis reliably, even when plain films are normal, and emergent MR, probably the most accurate technique, is not widely available. Risk stratification provides a rational alternative approach for assessing injury status. Low-risk patients may be spared further imaging provided they are given appropriate precautionary return instructions. High-risk patients require emergent evaluation by an experienced spine specialist, and may benefit from advanced imaging. Patients at moderate risk may be best managed with symptomatic treatment, warnings to avoid significant physical activity, and delayed FE imaging and evaluation by a spinal specialist. They should also be instructed to seek immediate medical attention if they develop any indications of delayed instability, including severe pain and /or neurological signs. This stratified approach not only increases the likelihood that delayed subluxation will be recognized before it leads to chronic instability, but frees clinicians and radiologists from the quixotic burden of trying to “clear” the cervical spine with 100 % certainty in the acute setting.     

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.     

Cervical spine trauma radiography: comparison of general and musculoskeletal radiologists, with emphasis on number of views

We investigated the number of views necessary to evaluate trauma patients for suspected cervical spine fractures, comparing general and musculoskeletal radiologists. At separate sittings, independently and blindly, two musculoskeletal (MSKR) and two general (GR) radiologists evaluated sets of cervical spine images on a 1- to 5-point confidence scale for the presence of fracture in 68 trauma patients. First they evaluated anteroposterior and lateral views, then these plus an odontoid view, and lastly these three plus bilateral oblique radiographs. Overall, MSKR were slightly more accurate than GR (77.9 % vs. 74 %, P < 0.05). With two views, GR were more accurate (75.7 % vs.72.1 %); with three and five views, MSKR were more accurate (80.1 % vs.73.5 % and 81.6 % vs. 72.8 %). Confidence scores for excluding fractures increased with number of views (1.9, 1.6, 1.4, P < 0.0001); however, confidence scores for diagnosing fractures were affected neither by specialty (MSK = 3.8, GR = 3.9) nor by number of views (3.7, 3.9, 4.0). With more views, MSKR were more accurate and confident in excluding suspected cervical spine fractures than GR.     

CT scan patterns of articular mass injuries of the lower cervical spine

Traumatic lesions of the cervical articular mass are infrequent, are potentially unstable and often require internal fixation. Standard X-rays and CT images can be difficult to analyze in an emergency situation. Standard X-rays must always be performed first, but CT, particularly helical CT, is the definitive imaging modality. Two-dimensional reformations are performed in all cases, together with 3-D reformations when indicated. We here present a simple and logical analysis based on the normal pattern of the interfacetal joint, which is always made of two pieces of bone, and only two, in a precise order. Post-traumatic deviations from this normal pattern reflect an injury, and there exists an accurate correlation between the CT pattern and the pathologic features.     

Normal cervical spine variations mimicking injuries in children

Evaluation of the cervical spine is a constant problem. This communication deals with the various normal variations and congenital anomalies that are frequently misinterpreted for traumatic lesions. Emphasis is on how to identify these anomalies and how to differentiate them from traumatic injuries of the cervical spine.     

Odontoid fractures following blunt trauma

Fractures of the odontoid process typically result from forceful blunt trauma. They often produce instability of the cervical spine, and may be associated with neurologic impairment. This study was designed to examine the epidemiology and demographics of odontoid injuries, including their incidence and prevalence relative to other spine injuries, the prevalence of associated injuries, and the likelihood of neurologic impairment. Of 34,069 enrolled blunt trauma victims, 818 (2.4 %) sustained a cervical spine injury, 94 of whom had a fracture of the odontoid. The relative prevalence of odontoid fractures varied by age, ranging from less than 3 % among individuals under age 20 years, to greater than 20 % in patients over 80 years old. Classification by Anderson–D'Alonzo criteria revealed 6 type I injuries, 60 type II injuries, and 27 type III injuries; one vertical injury could not be categorized. Over half of the odontoid fracture victims sustained additional cervical spine injuries, with 90 % of these injuries involving the atlanto-axial complex. In addition, non-spine-related injuries were found in 52 % of odontoid injury victims, over one-third (34 %) presented with an altered level of alertness, and almost one-quarter (23 %) exhibited some form of focal neurologic deficit associated with their injury. Fractures of the odontoid are among the most frequently encountered cervical spine injuries, and increase in prevalence with increasing patient age. Odontoid fracture victims often have other spine injuries, particularly to the atlanto-axial complex, and may harbor other non-spine-related injuries and neurologic pathology.     

Systematic review of flexion/extension radiography of the cervical spine in trauma patients

Introduction

The aim of this review was to investigate whether Flexion/Extension (F/E) radiography adds diagnostic value to CT or MRI in the detection of cervical spine ligamentous injury and/or clinically significant cervical spine instability of blunt trauma patients.

Methods

A systematic search of literature was done in Pubmed, Embase and Cochrane Library databases. Primary outcome was sensitivity and specificity of F/E radiography. Secondary outcomes were the positive predicting value (PPV) and negative predicting value (NPV) (with CT or MRI as reference tests due to the heterogeneity of the included studies) of each modality and the quality of F/E radiography.

Results

F/E radiography was overall regarded to be inferior to CT or MRI in the detection of ligamentous injury. This was reflected by the high specificity and NPV for CT with F/E as reference test (ranging from 97 to 100% and 99 to 100% respectively) and the ambiguous results for F/E radiography with MRI as its reference test (0–98% and 0–83% for specificity and NPV respectively). Image quality of F/E radiography was reported to have 31 to 70% adequacy, except in two studies which reported an adequacy of respectively 4 and 97%.

Conclusion

This systematic review of the literature shows that F/E radiography adds little diagnostic value to the evaluation of blunt trauma patients compared to CT and MRI, especially in those cases where CT or MRI show no indication of ligamentous injury.     

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.     

Relationship of elongated anterior tubercle to incomplete segmentation in the cervical spine

 Purpose. To describe the elongated anterior tubercle of cervical vertebrae, its association with incomplete segmentation, and its analogy to sacralization of the lower lumbar vertebrae. Materials and methods. Cases with elongated anterior tubercles of the cervical vertebrae detected on plain radiography were collected during routine practice and their features analyzed on plain radiography and MR imaging. Five patients, aged 19–40 years, with the anomaly seen on plain radiography were included in this study. MR imaging was undertaken in one patient. Results. Hypertrophy of the anterior tubercle was associated with incomplete segmentation in three of the five patients. Oblique views were adequate to demonstrate its nature. Conclusions. The association of an elongated tubercle and incomplete segmentation is similar to partial sacralization at the lumbosacral junction. Clinically it is important that these anomalies are not mistaken for pathologic findings.     

Rotational injuries of the cervical spine

Injuries which are caused in part by a rotational mechanism include atlantoaxial rotatory fixation (AARF), traumatic isolation of the articular pillar (TIAP), and unilateral interfacetal dislocation (UID). The anatomy, classification, radiographic findings, and frequency of neurological signs are reviewed. Key points include: AARF: (1) Mild injury is not diagnosed radiographically since the appearance is the same as for physiologic rotation. More significant injuries demonstrate widening of the atlanto-dens interval ( > 3 mm in adults) and/or abnormal rotation ( > 45 °) of C1 on C2. (2) AARF refers to an inability to return the head to a neutral position. This may be due to trauma resulting in subluxation or dislocation or may be due to muscle spasm in torticollis. TIAP: (1) Radiographic diagnosis depends on visualizing ipsilateral pedicle and lamina fractures. (2) Rotation of an articular mass from its normal orientation on radiographs implies the presence of this injury. However, rotation of the articular mass is not always present, and the ipsilateral pedicle and lamina fractures must be seen on radiographs or CT. UID: (1) Less rotational discrepancy than expected can occur in two circumstances: articular mass fracture with dislocation or significant subluxation on the contralateral side. (2) Less anterolisthesis than expected can occur if there is articular mass fracture with dislocation.     

Imaging the cervical spine following rugby related injury

Rugby Union and Rugby League are popular sports with high participation across the world. The high impact nature of the sport results in a high proportion of injuries. Rugby has an association with cervical spine injury which has potentially catastrophic consequences for the patient. Anecdotal evidence suggests that radiographers find it challenging to visualise the cervicothoracic junction on the lateral supine cervical spine projection in broad shouldered athletes. This paper intends to analyse the risk factors for cervical spine injuries in rugby and discuss the imaging strategy in respect to radiography and CT scanning in high risk patient groups such as rugby players who are suspected of suffering a cervical spine injury.     

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.     

Degenerative change in the cervical spine and load-carrying on the head

 Objective. To evaluate the relationship between load-carrying on the head and the development of degenerative change in the cervical spine. Design and subjects. A case-control study was performed with 35 individuals who had carried loads on their head (carriers) and 35 persons who never had carrier loads on their head (non-carriers). A scoring system was utilized for the assessment of the degenerative change in the cervical spine at the C3/C4, C4/C5, C5/C6 and C6/C7 levels on lateral cervical spine radiography. A total score was calculated by summing the scores for the single segments. Results and conclusion. In 31 of the 35 (88.6%) carriers degenerative change was found in the cervical spine, but only in 8 of the 35 (22.9%) non-carriers (P<0.01). The total score and the scores for segments C4/5, C5/C6 anc C6/C7 were significantly higher for the carriers than the non-carriers. It is concluded that the axial strain of load-carrying on the head exacerbates degenerative change in the 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.