Evolving standards of practice for cervical spine imaging in trauma: a retrospective review

Recently published works on radiology and emergency medicine suggest an increasing role for primary CT imaging of the cervical spine (C-spine) in trauma, rather than plain X-rays. This observational retrospective study of 406 patients was undertaken to examine current practice in a metropolitan teaching hospital setting and to define factors affecting the use of primary imaging for suspected C-spine fracture. This study supports the increasing recognition of the limited accuracy and adequacy of plain films, especially among the more severely injured patients. It is suggested that intubated patients, patients with severe trauma or patients with Glasgow Coma Scale <13 have CT as a primary screening examination for suspected C-spine fracture rather than X-ray. Patients having head CT for suspected intracranial injury may also benefit from included C-spine CT. The increasing usage of primary CT will increase overall imaging costs and resource utilization.     

Assessing cervical spine stability in obtunded blunt trauma patients: review of medical literature

PURPOSE: To review the current medical literature on dynamic fluoroscopic and magnetic resonance (MR) imaging assessment of cervical spine stability in obtunded patients who sustained blunt trauma. MATERIALS AND METHODS: The English-language literature within the Swetswise and Medline databases was searched for articles describing dynamic fluoroscopic or MR imaging assessment of cervical spine stability in patients who sustained blunt trauma. Patients with fractures or radiographic signs of injury were excluded. The frequencies of purely ligamentous injuries, injuries requiring immobilization, and other clinically important nonligamentous abnormalities were determined. RESULTS: The frequency of isolated cervical ligamentous injuries diagnosed with dynamic fluoroscopy, as reported in the literature, was 0.9% (11 of 1166 patients), whereas the reported frequency of these injuries diagnosed with MR imaging was 22.7% (125 of 550 patients). All injuries diagnosed with dynamic fluoroscopy and 101 (80.8%) of those diagnosed with MR imaging required continued cervical immobilization. Six (60%) of 10 injuries diagnosed with dynamic fluoroscopy and seven (5.6%) of 125 injuries diagnosed with MR imaging required surgical or halo stabilization. Five (2.5%) of the 200 obtunded patients assessed with MR imaging and six (0.5%) of the 1166 obtunded patients evaluated with dynamic fluoroscopy required surgery. CONCLUSION: Review of the current medical literature provided no clear evidence of the superiority of either MR imaging or dynamic fluoroscopy in the diagnosis of unstable ligamentous injury, although other relative advantages of MR imaging indicate that it is preferred for assessing cervical spine stability in obtunded blunt trauma patients.     

Controversies in cervical spine imaging in trauma patients

No area of emergency radiology has generated as much discussion in recent years as the subject of cervical spine imaging for trauma patients. This review will be in three parts. The first will examine the indications for cervical imaging and will focus on those factors that make patients at high risk or low risk for cervical injury. The second part will discuss the merits of radiography and computed tomography as the main screening diagnostic examination. In addition to the roles of each modality in the evaluation process, such factors as efficacy of diagnosis, time (duration) of study, and cost will be discussed. Finally, the third part will explore the methods currently employed to clear the cervical spine in comatose patients.Presented at the Annual Meeting of the American Society of Emergency Radiology, Las Vegas, Nevada, 22–25 October, 2003     

Controversies in cervical spine imaging in trauma patients

The subject of cervical spine imaging for trauma patients has generated significant controversy over the past decade and a half. This review considers three aspects of this controversy. The first examines the indications for cervical imaging, focusing on the factors that determine whether trauma patients are at high or low risk for cervical injury. The second discusses the uses of radiography and computed tomography as the main screening diagnostic examination. In addition to the roles of each modality in this evaluation process, other factors such as efficacy of diagnosis, time requirements for study, and cost will be discussed. The final section explores the methods currently used to "clear" the cervical spine in comatose patients.     

MR imaging in cervical spine trauma

Continual improvements in MR imaging, technology and MR imaging-compatible monitoring and fixation devices have allowed the incorporation of this relatively new imaging modality into standard algorithms for cervical spine trauma assessment. The ability of MR imaging to define the type of spinal cord injury, the cause and severity of spinal cord compression, and the stability of the spinal column is unmatched. The heavy reliance of the spinal surgeon on MR imaging for decisions regarding the type of therapy, the timing, the approach of surgical intervention, and for predicting patient outcome attests to the usefulness of this modality.     

MR imaging in acute cervical spine trauma

Fourteen patients with cervical spine injuries, 12 with resultant neurological deficits, were scanned with magnetic resonance (MR) imaging within 7 days following injury. Useful information concerning the status of the spinal canal and disks was obtained in most cases. In addition, MR was able to suggest the nature of the pathological changes within the spinal cord, as well as hemorrhage and edema in the extraspinal soft tissues. These observations indicate that following acute cervical spine trauma, MR is a valuable technique in assessing injury to the spinal cord, surrounding soft tissues, vertebra, and disks.     

Acute cervical spine trauma: evaluation with 1.5-T MR imaging

Twenty-one patients with acute neurologic deficits following cervical spine trauma were evaluated with magnetic resonance (MR) imaging (n = 21), computed tomography enhanced with intrathecal contrast material (CT myelography) (n = 18), myelography (n = 13), cervical spine radiography (n = 21), and intraoperative sonography (n = 7). MR imaging proved superior to other modalities in demonstrating parenchymal spinal cord injuries and cervical intervertebral disk herniation. Although both T1- and T2-weighted studies appear necessary to evaluate the anatomic relationship of the spinal cord, thecal space, intervertebral disks, and surrounding osseous and ligamentous structures, T2-weighted sequences were more sensitive than T1-weighted studies for detection of spinal cord injury. CT myelography was superior to MR imaging in demonstrating cervical spine fractures. In most cases, myelography revealed no information that was not apparent from both CT and MR imaging studies. Preliminary experience with MR imaging of acute cervical spine trauma suggests that it should be the study of choice in symptomatic patients who are otherwise clinically stable. CT may still be required in selected patients to evaluate complex fractures.     

颈椎创伤患者手术的麻醉管理

目的探讨颈椎创伤患者的麻醉特点及管理。方法对本院2005年1月-2009年10月期间156例颈椎创伤患者的麻醉管理进行总结分析。结果所有患者均安全度过围术期,无死亡病例。采用手法固定下直视插管89例,可视喉镜辅助下插管36例,清醒下纤维支气管镜引导下气管插管31例,均插管成功。颈椎创伤患者术中循环稳定性较颈椎病手术患者差,有62例(39.74%)发生低血压,其中有53例(85.48%)使用了麻黄碱。53例(33.97%)发生了心动过缓,其中有50例(94.34%)使用了阿托品。全瘫患者的使用率最高,不全瘫患者使用率高于仅有感觉异常的患者。结论颈椎创伤患者颈部需要有效制动,循环稳定性差。合理管理颈椎创伤患者的气道,维持循环的稳定,积极保护神经功能,可以使患者安全度过围术期。     

Correlation of MR imaging findings with intraoperative findings after cervical spine trauma

BACKGROUND AND PURPOSE: There are limited data correlating MR imaging and anatomic findings of ligamentous injury in cervical spine trauma. This study compares acute MR imaging with surgical observations of disk/ligamentous injury after blunt cervical trauma. MATERIALS AND METHODS: Consecutive patients with acute cervical spine trauma who underwent preoperative MR imaging and surgery from 1998 to 2001 were identified. MR imaging was obtained within 48 hours of injury for most patients. All scans included sagittal T1, T2 fat-saturated, and short tau inversion recovery sequences. At surgery, extent of injury at the operated level was recorded on a standardized form for either anterior or posterior structures or both depending upon the operative approach. MR examinations were separately evaluated by 2 readers blinded to the intraoperative findings. Radiologic and surgical findings were then correlated. RESULTS: Of 31 patients, an anterior surgical approach was chosen in 17 patients and a posterior approach in 13 patients. In one patient anterior and posterior approaches were utilized. Seventy-one percent of patients had spinal cord injury on MR imaging. MR imaging was highly sensitive for injury to disk (93%), posterior longitudinal ligament (93%), and interspinous soft tissues (100%), but it was less sensitive for injury to the anterior longitudinal ligament (71%) and ligamentum flavum (67%). For most ligamentous structures, there was limited agreement between specific MR imaging findings and injury at surgery. CONCLUSION: In acute cervical spine trauma, MR imaging has moderate to high sensitivity for injury to specific ligamentous structures but limited agreement between specific MR imaging findings and injury at surgery. MR imaging may overestimate the extent of disruptive injury when compared with intraoperative findings, with potential clinical consequences.     

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.     

Resource cost analysis of cervical spine trauma radiography

PURPOSE: To determine the resource costs of the technical component of cervical spine radiography in patients with trauma and the factors that drive resource costs, to provide a model for resource cost estimation, and to compare resource costs with other methods of cost estimation. MATERIALS AND METHODS: Direct measurement was made of technologist labor and supply costs of a cohort of 409 consecutive patients with trauma who underwent cervical spine radiography. Probability of cervical spine injury was determined by reviewing emergency department medical records. An animated simulation model was used to combine cost and injury probability estimates to determine resource costs. Sensitivity analysis explored factors that determined costs and estimated uncertainty in model estimations. Comparison was made with other cost estimates. RESULTS: The average technical resource cost for cervical spine radiography was $49.60. Both direct labor ($19.60 vs $13.33; P <.005) and film ($8.39 vs $6.76; P <.005) costs were greater in patients with high probability of injury than in those with low probability of injury. Overall costs in patients with high probability of injury exceeded those in patients with low probability of injury by 33%. Resource costs exceeded Medicare resource-based relative value unit reimbursements for all patients with trauma. CONCLUSION: Resource costs of the technical components of cervical spine radiography varied with patient probability of injury and were higher than Medicare reimbursements.     

Development of an evidence-based guideline for imaging in cervical spine trauma

Cervical spine trauma is a common reason for presentation to an emergency department. However, less than 5% of patients who have suffered possible neck injury actually have an injury requiring medical treatment. Nevertheless, the consequences, both for the patient and the doctor, of a missed injury are well recognized by emergency department medical staff. This results in the vast majority of these patients receiving some form of diagnostic imaging. We describe the development of an evidence-based imaging guideline for use in the patient who has suffered cervical spine trauma. The guideline aims to help clinicians determine, at the bedside, when it is appropriate to use imaging and which imaging modality should be used first. Correct utilization of the guideline should lead to a reduction in the number of imaging tests required to reach a diagnosis without adverse patient outcomes.     

Impact of MRI to clear the cervical spine after a negative CT for suspected spine trauma

Emergency Radiology - To describe the clinical presentation of trauma patients receiving a negative cervical spine MRI (CSMRI) after cervical spine CT (CSCT) without acute findings and calculate...     

Acute cervical spine trauma: correlation of MR imaging findings with degree of neurologic deficit

A retrospective analysis of magnetic resonance (MR) imaging studies of 78 patients with acute cervical spinal cord injuries was undertaken to determine which observations related directly to the neurologic injury. All MR imaging studies were performed on a 1.5-T unit and assessed with respect to 14 parameters related to the bony spine, ligaments, prevertebral soft tissues, intervertebral disks, and spinal cord. Forty-eight patients also underwent non-contrast material-enhanced thin-section computed tomography (CT) of the cervical spine. MR imaging was the definitive modality in the assessment of soft-tissue injury, especially in the evaluation of the spinal cord and intervertebral disks. All patients with a neurologic deficit had abnormal spinal cords at MR imaging. Intramedullary hemorrhage was predictive of a complete lesion. The degree of associated bone and soft-tissue injury had no bearing on the extent of spinal cord injury or neurologic deficit. Patients with residual cord compression following reduction demonstrated greater neurologic compromise than those without compression.     

急性脊柱创伤的影像学分析

目的 :探讨各种影像检查对急性脊柱创伤的诊断价值及限度。方法 :回顾性分析 2 5 2例急性脊柱创伤病例 ,均在伤后 48h内行X线平片、CT及MRI检查。结果 :共检出椎体骨折 2 78例 ,X线平片、CT及MRI检出率相同 ,三者对附件骨折的检出率分别为 9.1%、2 3 .4%、14 .3 %,差异有极显著性意义 (P <0 .0 1)。 15 2例MRI直接显示脊髓损伤。结论 :在急性脊柱创伤的影像诊断中 ,X线平片可作初检手段 ,CT对骨折检出率最高 ,MRI对脊髓损伤诊断最佳 ,三者结合可提高诊断水平。     

急性颈椎外伤的MRI诊断

目的 分析急性颈椎外伤的MRI征象,评价MRI在急性颈椎外伤诊断中的价值及限度。方法收集急性颈椎外伤150例,均有MRI检查和X线平片,15例有CT片,采用14个参数进行分析记录。结果150例中MRI检出骨折51个,小关节脱位30个,椎体脱位35个;外伤性椎间盘突出40个,硬膜外血肿2例;脊髓损伤69例;脊髓受压迫20例;前、后纵韧带损伤21例;棘间韧带和黄韧带损伤15例;椎前血肿或水肿30例;椎旁和背侧软组织损伤40例;X线平片发现椎体骨折55个,椎体脱位35个;小关节脱位35例,附件骨折25个,椎前软组织肿胀20例。15例CT均发现骨折,小关节脱位,椎管狭窄。结论MRI在显示脊髓、韧带、椎间盘和软组织损伤方面优于CT和X线平片。MRI能全面反映颈椎各种损伤的病理特征,为评估颈椎稳定性提供充分的依据;MRI和X线片的骨折检出率没有明显差异,CT应该用于复杂的颈椎骨折检查。