Clinical indications for cervical spine radiographs in the traumatized patient

During a 4 1/2 year period, 4,941 trauma patients were admitted to a hospital, and details of their injuries and treatment were entered in a computerized trauma registry. Using that database, patients with cervical spine injury were studied. Of the 4,941 patients, 1,823 (38 percent) had radiographs of the cervical spine. Ninety-four patients (5 percent) of these patients had injuries of the cervical spine or spinal cord. Sixty five of the 94 patients with cervical spine injury were alert. All had either neck pain or neck tenderness. We do not recommend screening cervical spine radiographs for the alert trauma patient without neck pain; however, we do recommend screening for all patients with decreased levels of consciousness and an injury that could have conceivably injured the cervical spine, for all patients with neurologic deficits compatible with a cervical origin, and for all patients with neck pain or tenderness. Lateral cervical spine radiographs were obtained in all injured patients. They demonstrated cervical spine injury in 70 patients (74 percent) and missed the injury in the remaining 24, which resulted in an unacceptable false-negative rate of 26 percent. We believe that all patients at risk for cervical spine injuries must have complete radiographic examinations of the cervical spine. Computerized axial tomography was the most useful modality to confirm a cervical spine injury in those patients whose lateral cervical spines appeared normal radiographically, especially in patients with associated head injury requiring computerized axial tomography of the brain. Computerized axial tomography diagnosed the injury in 14 of the 24 patients requiring study beyond initial screening. Also presented herein is a radiologic screening algorithm for cervical spine injuries in trauma patients.     

Detection of cervical spine injuries in alert, asymptomatic geriatric blunt trauma patients: who benefits from radiologic imaging?

There are differing recommendations in the literature regarding cervical spine imaging in alert, asymptomatic geriatric patients. Previous studies also have not used computed tomography routinely. Given that cervical radiographs may miss up to 60 per cent of fractures, the incidence of cervical spine injuries in this population and its implications for clinical management are unclear. We conducted a retrospective study of blunt trauma patients 65 years and older who were alert, asymptomatic, hemodynamically stable, and had normal neurologic examinations. For inclusion, patients were required to have undergone computed tomography and plain radiographs. The presence and anatomic location of potentially distracting injuries or pain were recorded. Two hundred seventy-four patients were included, with a mean age of 76 +/- 10 years. The main mechanisms of injury were falls (51%) and motor vehicle crashes (41%). Nine of 274 (3%) patients had cervical spine injuries. The presence of potentially distracting injuries above the clavicles was associated with cervical injury when compared with patients with distracting injuries in other anatomic locations or no distracting injuries (8/115 vs 1/159, P = 0.03). There was no association of cervical spine injury with age greater or less than 75 years or with mechanism of injury. The overall incidence of cervical spine injury in the alert, asymptomatic geriatric population is low. The risk is increased with a potentially distracting injury above the clavicles. Patients with distracting injuries in other anatomic locations or no distracting injuries may not need routine cervical imaging.     

Spinal clearance in the difficult trauma patient: a role for screening MRI of the spine

Identifying spinal injuries in trauma patients with altered mental status can be difficult. CT scanning and clinical examination are the basis of our spinal clearance, but screening "trauma protocol" spinal MRI is used to exclude occult injuries. We sought to evaluate the sensitivity of CT scanning for spinal injuries compared with our MRI protocol. Ninety-seven patients underwent MRI cervical spine trauma protocol during 2004. Twenty-nine patients were obtunded, 29 had neurologic symptoms, and 39 had spine pain. MRI confirmed the initial CT findings without new injuries in 83 cases. MRI reclassified fractures as degenerative changes in 12 cases. In 2 cases, the MRI identified new injuries: one a stable partial ligament tear, the second a T7 Chance fracture with ligamental disruption requiring operative fixation. There was no morbidity or mortality documented in obtaining the MRI studies. Overall negative predictive value of CT scanning of the spine was 98 per cent, the positive predictive value was 78 per cent, and the sensitivity and specificity was 94 per cent and 91 per cent, respectively. CT scanning of the cervical and axial spine is sensitive for spinal trauma but not specific. MRI trauma protocol should be reserved for cases when initial CT scanning is suggestive of traumatic injury.     

Facial injuries associated with cervical fractures: recognition, patterns, and management

Publications in both the orthopedic and maxillofacial literature have noted the association of cervical spine and facial injuries. However, because the incidence of spinal injury is low, we found no study which documented the relationship between maxillofacial and cervical spine injuries. The present study reviewed 982 cervical spine injuries in two major trauma centers, finding a 19.3% incidence of facial injury. Fourteen per cent of patients had soft-tissue injuries and 8.6%, facial fractures. Important relationships were noted between fractures of the mandible and upper cervical spine, and soft-tissue injuries of the upper face and fractures of the lower cervical spine. Methods of care adapted to the combined injuries are described. The study concludes that examination of the face for soft-tissue and bony injuries may give important clues on the direction and intensity of the force injuring the cervical spine.     

False-negative plain cervical spine x-rays in blunt trauma

Although considered very accurate, false-negative plain cervical radiographs of blunt trauma patients will occur with potentially devastating complications. We sought to define the population of patients who fall into this category and the overall accuracy of adequate three-view cervical spine radiography in the blunt trauma population. A retrospective search was carried out of blunt trauma patients entered into our trauma registry. All patients with the ICD-9 codes indicating cervical spine injury with a negative three-view cervical spine radiograph reading had their charts and radiographs reviewed. Institutional statistics for blunt cervical trauma evaluation and injury were obtained from the trauma registry. Fifty-eight of 936 blunt trauma patients (6.2%) were diagnosed with cervical spine injury over the 9-month study period. Of 649 patients with adequate three-view plain radiographs, three patients were identified with negative plain radiographs and significant cervical spine injury, a false-negative rate of 0.5 per cent. Sensitivity was 90.3 per cent, specificity was 96.3 per cent, positive predictive value was 54.9 per cent, and negative predictive value was 99.5 per cent. Three-view plain radiograph series of the cervical spine remains a highly sensitive and specific test for cervical spine injury following blunt trauma. However, the fact that we identified three patients with significant fractures after negative plain radiographs suggests that serious consideration of computed tomography must be applied in treating symptomatic, high-risk blunt trauma patients when plain radiographs do not reveal an injury.     

Spinal injuries caused by the flexion mechanism

The clinical documentation of 1,302 patients treated for spine injury from the flexing mechanism in 1965-1987 was analyzed. The relation between the degree of nervous system damage, the obtained neurological results and the character of injury (fracture or dislocation) as well as the level of spine injury was taken into account. It has been found that incidence of flexing injury of various parts of the spine oscillates slightly (39-44 per cent of all injuries). On the other hand, there is a significant predisposition to more frequent occurring of dislocations at flexing injury of the cervical spine and flexing fractures at thoracic spine injuries. The authors previous observations that young persons have more often fracture of the vertebra and older person--dislocation have been confirmed. Deep damage of the spinal cord is present more often at dislocation than fracture. The most serious damage of the spinal cord occurs at thoracic spine injury, in which the authors have found a very high percentage of patients with palsy (83 per cent at fracture, 98 per cent at dislocation).     

Assessment for additional spinal trauma in patients with cervical spine injury

An institutional review board-approved 8-year retrospective trauma registry analysis of cervical spine injuries (CSIs) was done in a Level 1 trauma center. This analysis includes 129 CSI patients (1.3% of trauma admissions). Cervical spine radiographs diagnosed injuries in 71 per cent of CSI patients. Cervical spine radiographs were false negative in 29 per cent of patients, who were found to have CSI on spine CT. Spine CT had 98 per cent sensitivity and detected 45 per cent additional injuries in cervical spine radiograph-positive patients. Spine CT scans were false negative in two patients with soft tissue injury. Cervical spine fractures were isolated in 45 per cent (n = 58) and multilevel in 55 per cent (n = 71) with contiguous fractures in 43 per cent (n = 55) of patients. Injuries involved two adjoining vertebrae in 38 patients and three or more adjoining vertebrae in 7 patients. C1-2 and C5-6 comprised 26 per cent and 20 per cent of all contiguous fractures. The least common was C7-T1, diagnosed in 2 per cent. The most common contiguous fractures were C1-2 in the elderly and C5-6 in children, comprising half of contiguous cervical injuries in the respective age groups. There were 26 (20.2%) noncontiguous injuries: 15 cervical and 11 cervicothoracolumbar. Multiple regions of the vertebral column were involved in 7.8 per cent of CSI patients. Spine CT is the preferred modality to assess CSI. Injuries were isolated in 45 per cent and were multilevel in the remaining CSI patients. Contiguous and noncontiguous injuries involving the cervical and thoracolumbar spine are common. Assessment of the entire spinal column should be done in patients with CSI.     

Spine trauma and associated injuries

A longitudinal, prospectively gathered data base of spine trauma has been developed. A review of 508 consecutive hospital admissions identified the presence of associated injuries in 240 (47%) individuals, most frequently involving head (26%), chest (24%), or long bones (23%). Twenty-two per cent had one associated injury, 15% had two, and 10% had three or more. Most spine fractures involved the lower cervical (29%) or thoracolumbar junction (21%). Comparisons of presence or absence of associated injuries and spine fracture level showed significant differences (p less than 0.001). Eighty-two per cent of thoracic fractures and 72% of lumbar fractures had associated injuries compared to 28% of lower cervical spine fractures. While there was no significant relationship between type of associated injury and spine fracture level, those with associated injuries were less likely to have a neural deficit (p less than 0.05). After hospital admission, there were seven deaths. Early assessment and transport of spine trauma victims must be carried out with appropriate management of associated injuries. Conversely, multiple trauma victims must be handled with due regard for a possible spine fracture. The value of spinal units with specially trained personnel is emphasized.     

Cervical spine injuries in patients with head injuries

It is generally believed that significant head injury after a traffic accident or fall is associated with a high incidence of concurrent cervical spine injury. This study prospectively examined 260 victims of traffic accidents or falls with significant head injury. The incidence of associated cervical spinal injury was only 3.5 per cent. There was no association between the severity of head injury and the incidence of cervical spine injury. The risk of concurrent spinal injury in head injury patients is not higher than the reported risk in patients without head injury. Although care should be taken to protect the cervical spine in patients with head injury, the results of the present investigation show that the risk of cervical spine injury is much less than previously reported.     

Pathomechanisms of spinal cord injuries caused by injuries of the cervical spine

The pathomechanism of injuries of the spinal cord due to injuries of the cervical spine in 158 patients treated during the last ten years has been presented. It has been determined that total and irreversible injuries of the spine occurred most often after fractures of the spine with displacement from hyperflexion (29.7 per cent) crushed fractures (24.7 per cent), and dislocation of the spine (24.7 per cent). In the majority of the patients, the spinal cord was irreversibly damaged already at injury, and in 29.2 per cent, the symptoms of deformity of the lumen of the vertebral canal and compression of the spinal cord remained. In about 24 per cent of the patients, the symptoms of congenital or habitual relative stenosis of the vertebral canal occurred. The performed examination has shown that knowledge of the pathomechanism of injury of the spine may facilitate determination of the degree of injury of the spinal cord as early as immediately after trauma.     

Hand injuries as an indicator of other associated severe injuries

The purpose of this study was to investigate the incidence of disabling or life-threatening injuries in patients with hand injuries. Retrospective data were collected from a level 1 trauma center registry. A total of 472 patients with hand injuries were admitted to the trauma unit between January 2000 and March 2004. Forty-four per cent of patients with hand injuries had life-threatening injuries. Fifty-one per cent of them had motor vehicle crash-related injuries. Motorcycle crashes were the next most common cause followed by explosions, falls, gunshots, machinery, stabs, bites, crushes, and so on. Frequency of associated injuries was as follows: head injuries, 31 per cent, including skull fractures, 22 per cent; spine injuries, 18 per cent, including spine fractures 18 per cent; chest injuries, 36 per cent, including rib fractures, 15 per cent; and abdominal injuries, 13 per cent. The authors focused on the incidence of disabling or life-threatening injuries in patients with hand injuries. Motor vehicle crashes were most common cause of hand injuries. The most common organs to be injured were chest and head. The most common head injury was skull fracture. Other injuries in decreasing order were spine and rib fractures. These data may be helpful in assessing ambulatory patients in the emergency room, in those hand injuries maybe indicative of other simultaneous life-threatening or disabling injuries.     

Injuries to the spinal cord in elderly patients.

There are certain differences between the mechanism of injury and the course and results of treatment of post-traumatic spinal cord injuries in younger and older victims. Between 1965 and 1990 there were 564 patients over 60 years of age with spinal cord or cauda equina injuries treated at the Spinal Cord Centre in Konstancin, Poland. This article presents the level and degree of the nervous system injury, the methods of treatment and early mortality in the series. Of the patients, 43 per cent were aged between 60 and 65 years, but 31 per cent were patients over 70 years of age. More patients sustained injury to the cervical spine (72 per cent), and 42 per cent of lesions to the spinal cord were neurologically assessed as complete transverse cases. This paper stresses the high mortality rate, amounting to 26 per cent overall and 48 per cent in the groups with complete spinal cord lesions.     

Is prevertebral soft tissue swelling a useful sign in injury of the cervical spine?

A group of 58 patients with suspected injuries of the cervical spine were reviewed retrospectively. Prevertebral soft tissue swelling occurred in 20 (49 per cent) of 41 patients with definite bone injury. Soft tissue swelling occurred significantly more frequently with injuries to the anterior portion of the cervical spine than to the posterior vertebral elements. No significant correlation was found between soft tissue swelling and level of injury and age of the patient. Out of 17 patients with cervical injuries, 4 (24 per cent) who were subsequently considered not to have sustained bony injury demonstrated apparent soft tissue swelling. The absence of soft tissue swelling should not be considered as evidence for no bony injury. Its presence does not necessarily indicate bony injury.     

Cervical spine trauma

The conventional radiographic examination remains as the single best initial study in patients with potential cervical spine injury. Computed tomography is the best, most readily available second study. Specific cervical spine injuries are presented as they follow a classification based on mechanism of injury.     

Pathomechanisms of injuries of the spinal cord and spinal nerve roots in trauma of the thoracic and lumbar segments of the spine

Apart from clinical examination, X-ray pictures after administration of contrastive medium to the subarachnoid space and axial computerized tomography were performed in 95 patients with traumatic damage of the spinal cord and the nervous roots. It was found that spinal cord lesion in 46.3 per cent of the patients was caused by the injury acting according to the shearing mechanism with the components of the torsional forces leading to dislocation of the vertebra. As a consequence of the crushing mechanism in the injuries of all three spinal columns, the spinal cord and the nervous roots were injured in 30.5 per cent of the patients. The neurological changes were caused by injury of the anterior and the medial spinal columns in 15.8 per cent of the patients, fracture according to the extension mechanism--4.2 per cent, compression of the spinal cord by the mass of nucleus pulposus--3.2 per cent of the patients. The risk of spinal cord injury increases in the patients with accompanying degenerative changes of the spine, growth disorders, the symptoms of local stenosis of the spinal canal.     

Intraabdominal injury is common in blunt trauma patients who sustain spinal cord injury

The evaluation of the abdomen in patients with spinal cord injury (SCI) is challenging for obvious reasons. There are very little data on the incidence and complications of patients who sustain SCI with concomitant intraabdominal injury (IAI). To determine the incidence and outcomes of IAI in blunt trauma patients with SCI, a trauma registry and record review was performed between January 1998 and December 2005. Baseline demographic data, Injury Severity Score, and associated IAI were collected. Two groups were established and outcomes were analyzed based on the presence or absence of IAI. Intraabdominal and hollow viscus injures were found in 15 per cent and 6 per cent, respectively, of 292 patients with blunt SCI. The presence of intraabdominal injury varied according to the level of the SCI: 10 per cent of cervical, 23 per cent of thoracic, and 18 per cent of lumbar SCI. The overall mortality was 16 per cent. The presence of intraabdominal injury was associated with longer intensive care unit length of stay (13 versus 6 days, P < 0.01), hospital length of stay (23 versus 18 days, P < 0.05), higher complication rate (46% versus 33%, P = 0.09), and higher mortality (44% versus 11%, P < 0.01) when compared with patients with SCI without IAI. Intraabdominal injuries are common in blunt SCI. Liberal evaluation with computed tomography is necessary to identify injuries early.     

Do flexion extension plain films facilitate treatment after trauma?

We hypothesized that flexion extension (FE) films do not facilitate the diagnosis or treatment of ligamentous injury of the cervical spine after blunt trauma. From January 2000 to December 2008 we reviewed all patients who underwent FE films and compared five-view plain films (5 view) and cervical spine CTC with FE in the diagnosis of ligamentous injury. There were 22,929 patients with blunt trauma and of these, 271 patients underwent 303 FE films. Average age was 39.6 years, Injury Severity Score was 10.8, Glasgow Coma Score was 14.1, lactate was 2.6 mmol/L, and hospital length of stay was 6 days. Compared with FE, 5 view and CTC had a sensitivity of 80 per cent (8 of 10), positive predictive value of 47.1 per cent (8 of 17), specificity of 96.55 per cent (252 of 261), and negative predictive value of 99.21 per cent (252 of 254). For purposes of analysis, incomplete and ambiguous FE films were listed as negative; however, 20.5 per cent (62 of 303) were incomplete and 9.2 per cent (28 of 303) were ambiguous. Management did not change for the 2 patients with missed ligament injuries. The 303 studies cost $162,105.00 to obtain. FEs are often incomplete and unreliable making it difficult to use them to base management decisions. They do not facilitate treatment and may lead to increased cost and prolonged cervical collars.     

Fatal cervical spinal injuries in road traffic accidents

The present study analyses fatal road traffic accidents involving private cars and vans in Finland during the period 1972-1982, in which an injury to the cervical spine was the main cause of death. The material consists of 289 victims; this being 10.5 per cent of all the fatalities in this category of road traffic accidents. Front seat and rear seat passengers seem to have an equal risk of sustaining a fatal cervical spinal injury. However, front seat passengers have a significantly greater chance (P less than 0.001) of having fatal cervical spinal injuries than the drivers. Of the victims 21.1 per cent had worn safety belts but there was no statistical difference between those who did and those who did not wear safety belts. Increasing age seems to increase the risk of fatal cervical spinal injuries. Patients between 16 and 25 years of age had the lowest risk and patients over the age of 60 had the highest risk of sustaining a fatal cervical spinal injury (P less than 0.001). In 48.1 per cent of the cases, the victims were multiply injured and this is similar to other main causes of death in road traffic accidents. Wearers of safety belts had significantly (P less than 0.001) more multiple injuries. Of the patients who died of cervical injury, only 8.8 per cent survived transportation to hospital and 1.4 per cent survived longer than 24 hours. A direct blow was the most common mechanism of the cervical injury (47.1 per cent) and deceleration was found in 13.1 per cent of the cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Atypical claudication

In a prospective study the incidence, causes and management of atypical claudication have been investigated. All patients had a clinical assessment, Doppler ultrasound studies and X-rays of the lumbosacral spine, some had epidural injections, myelography with computerized axial tomography and arteriography. The incidence of atypical claudication was low, 13 per cent of all claudicants referred to our department, and although difficulties in diagnosis were encountered an approximately equal incidence of spinal and arterial causes was found. Only one patient had a definite central spinal stenosis. The need for invasive investigations was low (18 per cent) and even lower for surgery (7 per cent); the majority of patients' symptoms responded to conservative management.     

Non-contiguous spinal fractures

A retrospective review of 817 spinal fracture patients revealed a 6.4% (52/817) incidence of non-contiguous spine fractures. Seventy-three per cent of the non-contiguous injuries were comprised of combinations of injuries in the cervical and thoracic regions or in the thoracic and lumbar regions. Forty-five per cent of fractures were a combination of compression fractures, 40% a combination of a compression fracture and a major spine fracture (i.e., one more likely to cause a neurologic deficit), and 15% a combination of major fractures.