| 1. Holmes JF, Miller PQ, Panacek EA, Lin S, Horne NS, Mower WR. Epidemiology of thoracolumbar spine injury in blunt trauma. Academic Emergency Medicine. 8(9):866-72, 2001 Sep. |
Observational-Dx |
152 patients |
To evaluate the prevalence, distribution, and demographics of thoracolumbar (TL) spine injuries following blunt trauma. |
Two thousand four hundred four blunt trauma patients were enrolled. Vertebral injuries were identified in 152 individuals (6.3%, 95% CI = 5.4% to 7.4%). Two hundred sixty distinct anatomic levels of injury were identified in these 152 individuals. Of these 260 injuries, 42 (16.2%) occurred at L1, 38 (14.6%) at L2, 29 (11.1%) at L3, and 27 (10.4%) at T12, making these the most commonly injured vertebrae. Injuries were most common (34 patients) in those aged 30-39 years and were least common (12 patients) in those under 18 years. Compression fractures (52%) were the most common injury in the thoracic spine, while transverse process fractures (48%) were the most common injuries in the lumbar spine. |
2 |
| 2. Lowery DW, Wald MM, Browne BJ, et al. Epidemiology of cervical spine injury victims. Ann Emerg Med 2001;38:12-6. |
Review/Other-Dx |
33,922 patients |
To sought to characterize demographics and injury patterns among patients undergoing emergency department cervical spine radiography for blunt traumatic injury. |
Demographic factors associated with cervical spine injury, present in 818 of 33,922 patients, included the following: age of 65 years or older (relative risk [RR] 2.09; 95% confidence interval [CI] 1.77 to 2.59); "other" ethnicity (RR 1.79, 95% CI 1.46 to 2.19); male sex (RR 1.72, 95% CI 1.48 to 2.00); and white ethnicity (RR 1.50, 95% CI 1.31 to 1.72). Hispanic ethnicity (RR 0.64, 95% CI 0.51 to 0.79), female sex (RR 0.58, 95% CI 0.50 to 0.67), black ethnicity (RR 0.55, 95% CI 0.45 to 0.66), and age of less than 18 years (RR 0.39, 95% CI 0.27 to 0.55) were associated with reduced risk of cervical spine injury. |
4 |
| 3. Sundstrom T, Asbjornsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. [Review]. Journal of Neurotrauma. 31(6):531-40, 2014 Mar 15. |
Meta-analysis |
50 articles |
To discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. |
No results stated in abstract. |
Inadequate |
| 4. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.[Erratum appears in N Engl J Med 2001 Feb 8;344(6):464]. N Engl J Med. 343(2):94-9, 2000 Jul 13. |
Observational-Dx |
34,069 patients; 818 patients had CSI |
Multicenter study. Prospective observational study to determine validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study. (NEXUS). |
Decision instrument had sensitivity of 99% [95% CI, 98.0%-99.6%]), NPV of 99.8% (95% CI, 99.6%-100%), specificity 12.9%, and PPV 2.7%. Decision instrument based on clinical criteria can help physicians identify patients who need radiography of the cervical spine after blunt trauma. Application of this instrument could reduce the use of imaging in such patients. |
3 |
| 5. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 286(15):1841-8, 2001 Oct 17. |
Observational-Dx |
8,924 patients; 151 (1.7%) had C-spine injury |
Multicenter study. Prospective cohort study to derive a clinical decision rule that is highly sensitive for detecting acute CSI and to allow emergency department physicians to be more selective in their use of cervical radiography. |
Canadian decision rule is composed of 3 questions: Any high risk factors present? Any low risk factor which allows safe assessment of range of motion? Can the patient rotate neck 45 degrees to the left and right? Rule had 100% sensitivity (95%, CI: 100%) and 42.5% specificity (95%, CI: 40%-44%). The rule proved sensitive. |
3 |
| 6. Denver D, Shetty A, Unwin D. Falls and Implementation of NEXUS in the Elderly (The FINE Study). Journal of Emergency Medicine. 49(3):294-300, 2015 Sep. |
Observational-Dx |
169 patients |
To determine the validity of the NEXUS criteria in the elderly population with low-mechanism injuries. |
There were 169 patients included in the final analyses. One hundred twenty (71%) patients in the cohort were classified as "NEXUS positive." Eleven patients (6.5% of the cohort) had cervical spine injury (CSI) detected on computed tomography (CT) imaging of the cervical spine. Nine patients had clinically significant CSI. The NEXUS decision instrument demonstrated 88.9% sensitivity (50.7-99.4%) and 98% negative predictive value (NPV) (87.8-99.9%) in detecting clinically significant CSI. The NEXUS decision instrument demonstrated 81.8% sensitivity (47.8-96.8%) and 95.9% NPV (84.9-99.3%) in detecting any CSI. |
3 |
| 7. Goode T, Young A, Wilson SP, Katzen J, Wolfe LG, Duane TM. Evaluation of cervical spine fracture in the elderly: can we trust our physical examination?. American Surgeon. 80(2):182-4, 2014 Feb. |
Observational-Dx |
2785 blunt trauma patients |
To compare National Emergency X-Radiography Utilization Study (NEXUS) criteria (NC) with computed tomography (CT) as the gold standard to evaluate cervical spine (C-spine) fractures in elderly blunt trauma patients. |
A total of 2785 blunt trauma patients were included of whom 320 were E (average age, 75 years) and 2465 were NE (average age, 36 years). Incidence of C-spine fracture was 12.8 per cent (E) versus 7.4 per cent (NE) (P = 0.002). Age was an independent predictor of fracture (P = 0.01). NC had a sensitivity of 65.9 per cent in E and PPV of 19.3 per cent in E (P = 0.001) versus a sensitivity of 84.2 per cent in NE and PPV of 10.6 per cent (P < 0.0001). The specificity was 59.5 per cent for E versus 42.6 per cent for NE (NPV, 92.2% E vs 97.1% NE). This study suggests that NEXUS criteria are not an appropriate assessment tool when applied to severe blunt trauma patients, particularly in the elderly population who had more missed injures than their younger counterparts. |
3 |
| 8. Tran J, Jeanmonod D, Agresti D, Hamden K, Jeanmonod RK. Prospective Validation of Modified NEXUS Cervical Spine Injury Criteria in Low-risk Elderly Fall Patients. The Western Journal of Emergency Medicine. 17(3):252-7, 2016 May. |
Observational-Dx |
800 patients |
To validate a modified NEXUS criteria in a low-risk elderly fall population with two changes: a modified definition for distracting injury and the definition of normal mentation. |
We enrolled 800 patients. One patient fall event was excluded due to duplicate enrollment, and four were lost to follow up, leaving 795 for analysis. Average age was 83.6 (range 65-101). The numbers in parenthesis after the negative predictive value represent confidence interval. There were 11 (1.4%) cervical spine injuries. One hundred seventeen patients had midline tenderness and seven of these had CSI; 366 patients had signs of trauma to the face/neck, and 10 of these patients had CSI. Using signs of trauma to the head/neck as the only distracting injury and baseline mental status as normal alertness, the modified NEXUS criteria was 100% sensitive (CI [67.9-100]) with a negative predictive value of 100 (98.7-100). |
2 |
| 9. Inaba K, Byerly S, Bush LD, et al. Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial. The Journal of Trauma and Acute Care Surgery. 81(6):1122-1130, 2016 12. |
Observational-Dx |
10,765 patients |
To evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury. |
Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3%] unevaluable/distracting injuries, 5,040 [49.0%] midline C-spine tenderness, 576 [5.6%] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 9 (IQR, 4-16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery (153 [1.5%]) or halo (25 [0.2%]) or cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (0.03%) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease. |
2 |
| 10. Griffith B, Kelly M, Vallee P, et al. Screening cervical spine CT in the emergency department, Phase 2: A prospective assessment of use. AJNR Am J Neuroradiol. 34(4):899-903, 2013 Apr. |
Observational-Dx |
507 CT |
To ascertain the number of unnecessary cervical spine computed tomography (CT) studies on the basis of proper application of established clinical guidelines and, secondarily, to determine indications for ordering studies in the absence of guideline criteria. |
Of 507 CT examinations, 5 (1%) were positive and 497 (98.0%) were negative for acute cervical spine injury. Five studies (1%) were indeterminate for acute injury but demonstrated no abnormality on subsequent imaging and clinical follow-up. Of the 502 studies without cervical spine injury, 81 (16.1%) were imaged despite meeting all 5 NEXUS criteria for nonimaging. Of these, the most common study indication was dangerous mechanism of injury (48.1%) followed by subjective neck pain (40.7%). |
2 |
| 11. Duane TM, Wilson SP, Mayglothling J, et al. Canadian Cervical Spine rule compared with computed tomography: a prospective analysis. J Trauma. 71(2):352-5; discussion 355-7, 2011 Aug. |
Observational-Dx |
192 patients |
To determine the need for radiographic evaluation of the cervical spine (c-spine) incorporating both clinical findings and mechanism. |
There were 192 patients with c-spine fractures versus 3,009 without fracture on computed tomography (CT). The fracture group was older (42.7 +/- 19.0 years vs. 37.8 +/- 17.5 years, p = 0.0006), had a lower Glasgow Coma Scale score (13.8 +/- 4.2 vs. 14.4 +/- 4.3, p < 0.0001), and lower systolic blood pressure (133.3 +/- 23.8 mm Hg vs. 139.5 +/- 23.1 mm Hg, p = 0.0023). The sensitivity of Canadian cervical spine rule (CCS) was 100% (192/192), specificity was 0.60% (18/3009), positive predictive value was 6.03% (192/3183), and negative predictive value was 100% (18/18). Logistic regression identified only 8 of the 19 factors included in the CCS to be independent predictors of c-spine fracture. |
3 |
| 12. Sixta S, Moore FO, Ditillo MF, et al. Screening for thoracolumbar spinal injuries in blunt trauma: an Eastern Association for the Surgery of Trauma practice management guideline. The Journal of Trauma and Acute Care Surgery. 73(5 Suppl 4):S326-32, 2012 Nov. |
Review/Other-Dx |
21 articles |
To determine the answer to the following: (1) What is the appropriate imaging modality to screen patients for TLS injuries? (2) Which trauma patients require radiographic screening for TLS injuries? (3)Does a patient who is awake and alert without distracting injuries require radiologic workup to rule out TLS injuries? |
Practice patterns have changed regarding screening blunt trauma patients for TLS injuries. Software reformatted multidetector computed tomographic scans are more sensitive and accurate than plain films. Multidetector computed tomographic scans have become the screening modality of choice and the criterion standard in screening for TLS injuries. The literature supports a Level 1 recommendation to validate this based on a preponderance of Class II data. Patients without altered mentation or significant mechanism may be excluded by clinical examination without imaging. Patients with gross neurologic deficits or concerning clinical examination findings with negative imaging should receive a magnetic resonance imaging expediently, and the spine service should be consulted. |
4 |
| 13. Katsuura Y, Osborn JM, Cason GW. The epidemiology of thoracolumbar trauma: A meta-analysis. J. orthop.. 13(4):383-8, 2016 Dec. |
Meta-analysis |
21 articles |
To describe the epidemiology of thoracolumbar fractures and associated injuries in blunt trauma patients. |
he rate of thoracolumbar fracture in blunt trauma patients was 6.90% (+/-3.77, 95% CI). The rate of spinal cord injury was 26.56% (+/-10.70), and non-contiguous cervical spine fracture occurred in 10.49% (+/-4.17). Associated injury was as follows: abdominal trauma 7.63% (+/-9.74), thoracic trauma 22.64% (+/-13.94), pelvic trauma 9.39% (+/-6.45), extremity trauma 18.26% (+/-5.95), and head trauma 12.96% (+/-2.01). Studies that included cervical spine fracture with thoracolumbar fracture had the following rates of associated trauma: 3.78% (+/-5.94) abdominal trauma, 21.65% (+/-16.79) thoracic trauma, 3.62% (+/-1.07) pelvic trauma, 18.36% (+/-4.94) extremity trauma, and 15.45% (+/-11.70) head trauma. A subgroup of flexion distraction injuries showed an associated intra-abdominal injury rate of 38.70% (+/-13.30). The most common vertebra injured was L1 at a rate of 34.40% (+/-15.90). T7 was the most common non-junctional vertebra injured at 3.90% (+/-1.09). Burst/AO type A3 fractures were the most common morphology 39.50% (+/-16.30) followed by 33.60% (+/-15.10) compression/AO type A1, 14.20% (+/-8.08) fracture dislocation/AO type C, and 6.96% (+/-3.50) flexion distraction/AO type B. The most common etiology for a thoracolumbar fracture was motor vehicle collision 36.70% (+/-5.35), followed by high-energy fall 31.70% (+/-6.70). |
Good |
| 14. Inaba K, DuBose JJ, Barmparas G, et al. Clinical examination is insufficient to rule out thoracolumbar spine injuries. J Trauma. 70(1):174-9, 2011 Jan. |
Observational-Dx |
884 patients |
To assess the sensitivity and specificity of a standardized clinical examination for diagnosing thoracolumbar (TL) spine injuries after blunt trauma. |
Of the 884 patients enrolled, 81 (9%) had a TL spine injury. More than half (55.6%) had two or more fractures with 30.9% having three or more. Isolated L-spine fractures occurred in 56.8%, T-spine fractures occurred in 34.6% only, and combination injuries sustained in 8.6%. The most commonly identified fractures were of the transverse process (67.9%) followed by the vertebral body (30.9%) and spinous process (12.3%). Among the 666 patients who were evaluable, 56 (8%) had a TL spine fracture. Of these, 29 (52%) had a negative clinical examination, of which 2 (7%) had clinically significant compression fractures. For evaluable patients who had localized pain or tenderness elicited on examination, although the finding triggered imaging appropriately, the site of pain correlated to the site of actual injury in only 61.5% of cases. The sensitivity and specificity of clinical examination for TL spine fractures were 48.2% and 84.9%, respectively, for all fractures and 78.6% and 83.4% for those that were clinically significant. |
3 |
| 15. Venkatesan M, Fong A, Sell PJ. CT scanning reduces the risk of missing a fracture of the thoracolumbar spine. Journal of Bone & Joint Surgery - British Volume. 94(8):1097-100, 2012 Aug. |
Observational-Dx |
51 patients |
To identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of 'missed injury'. |
There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. |
3 |
| 16. Cason B, Rostas J, Simmons J, Frotan MA, Brevard SB, Gonzalez RP. Thoracolumbar spine clearance: Clinical examination for patients with distracting injuries. J Trauma Acute Care Surg. 80(1):125-30, 2016 Jan. |
Observational-Dx |
950 patients |
To prospectively assess the sensitivity of clinical examination to screen for thoracolumbar spine (TLS) injury in awake and alert blunt trauma patients with distracting injuries. |
A total of 950 blunt trauma patients were entered, 530 (56%) of whom had at least one distracting injury. Two hundred nine patients (40%) with distracting injuries had a positive TLS clinical examination result, of whom 50 (25%) were diagnosed with TLS injury. Three hundred twenty-one patients (60%) with distracting injuries were initially clinically cleared, in whom 17 (5%) TLS injuries were diagnosed. There were no missed injuries that required surgical intervention, with only four injuries receiving TLS orthotic bracing. This yielded an overall clinical clearance sensitivity for injury of 75% and sensitivity for clinically significant injury of 89%. |
3 |
| 17. Inaba K, Nosanov L, Menaker J, et al. Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma Multi-Institutional Trials Group Study. J Trauma Acute Care Surg. 78(3):459-65; discussion 465-7, 2015 Mar. |
Observational-Dx |
3,065 adults |
To develop a clinical decision rule for evaluating the TL-spine after injury. |
Of 12,479 patients screened, 3,065 (24.6%) met inclusion criteria (mean [SD] age, 43.5 [19.8] years [range, 15-103 years]; male sex, 66.3%; mean [SD] Injury Severity Score [ISS], 8.8 [7.5]). The majority underwent computed tomography (93.3%), 6.3% only plain films, and 0.2% magnetic resonance imaging exclusively. TL-spine injury was identified in 499 patients (16.3%), of which 264 (8.6%) were clinically significant (29.2% surgery, 70.8% TL-spine orthosis). The majority was AO Type A1 282 (56.5%), followed by 67 (13.4%) A3, 43 (8.6%) B2, and 32 (6.4%) A4 injuries. The predictive ability of clinical examination (pain, midline tenderness, deformity, neurologic deficit), age, and mechanism was examined; positive clinical examination finding resulted in a sensitivity of 78.4% and a specificity of 72.9%. Addition of age of 60 years or older and high-risk mechanism (fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian) increased sensitivity to 98.9% with specificity of 29.0% for clinically significant injuries and 100.0% sensitivity and 27.3% specificity for injuries requiring surgery. |
3 |
| 18. Holmes JF, Panacek EA, Miller PQ, Lapidis AD, Mower WR. Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients. J Emerg Med. 24(1):1-7, 2003 Jan. |
Observational-Dx |
2404 patients |
To examine if use of clinical screening criteria for selective radiography of blunt trauma patients can identify all patients with thoracolumbar (TL) spine injuries. |
A total of 2404 patients were enrolled. TL spine injuries were identified in 152 patients. Of these 152 patients with spine injuries, all 152 (100%, 95% confidence interval 98-100%) were considered high risk by having at least one of the high-risk criteria. These criteria have a specificity of 3.9%, a positive predictive value of 6.6%, and a negative predictive value of 100%. All of the high-risk criteria but intoxication with ethanol or drugs were important as sole predictors of TL spine injury. The use of high-risk clinical screening criteria identified virtually all blunt trauma patients with acute TL spine injuries. |
3 |
| 19. Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging. [Review] [22 refs]. Injury. 34(6):426-33, 2003 Jun.Injury. 34(6):426-33, 2003 Jun. |
Review/Other-Dx |
200 patients |
Literature review and retrospective chart review to determine the clinical diagnostic pathway for imaging the thoracolumbar spine in trauma patients. |
Cervical fractures are associated with a high incidence of associated thoracolumbar fractures. The high-risk indications are identical to those for cervical injuries: 1) back pain/midline tenderness, 2) local signs, 3) abnormal neurological signs, 4) cervical spine fracture, 5) GCS <5, 6) Major distracting injury, and 7) Alcohol/drug intoxication. |
4 |
| 20. Hercz D, Montrief TD, Kukielski CJ, Supino M. Thoracolumbar Evaluation in the Low-Risk Trauma Patient: A Pilot Study Towards Development of a Clinical Decision Rule to Avoid Unnecessary Imaging in the Emergency Department. Journal of Emergency Medicine. 57(3):279-289, 2019 Sep. |
Observational-Dx |
4612 patients |
To collect and analyze evidence for the development of a clinical decision rule (CDR) to evaluate the TL spine in patients with non-severe blunt trauma and avoid dedicated imaging in low-risk cases. |
Of 4612 patients screened, 1049 (22.7%) met inclusion criteria. Thirty-six (3.4%) patients were found to have TL spine injury, of which 88.9% received spinal bracing, orthosis, or surgery. Absence of midline tenderness conveyed the highest negative predictive value, followed by a non-severe mechanism of injury, lack of neurologic examination findings, and age < 65 years. No patients in this cohort with these four findings had a TL spine injury. |
2 |
| 21. Yelamarthy PKK, Chhabra HS, Vaksha V, et al. Radiological protocol in spinal trauma: literature review and Spinal Cord Society position statement. [Review]. European Spine Journal. 29(6):1197-1211, 2020 06. |
Review/Other-Dx |
545 articles |
To provides recommendations for the use of each modality, i.e., radiographs (X-rays), computed tomography (CT), magnetic resonance imaging (MRI), as well as vascular imaging, and makes suggestions on identifying or clearing spinal injury in trauma patients. |
For imaging cervical and thoracolumbar spine trauma patients, CT without contrast is generally considered to be the initial line of imaging and radiographs are required if CT is unavailable or unaffordable. CT screening in polytrauma cases is best done with a multidetector CT by utilizing the reformatted images obtained when scanning the chest, abdomen, and pelvis (CT-CAP). MRI is indicated in cases with neurological involvement and advanced cervical degenerative changes and to determine the extent of soft tissue injury, i.e., disco-ligamentous injuries as well as epidural space compromise. MRI is also usually performed when X-rays and CT are unable to correlate with patient symptomatology. These slides can be retrieved under Electronic Supplementary Material. |
4 |
| 22. O'Connor E, Walsham J. Review article: indications for thoracolumbar imaging in blunt trauma patients: a review of current literature. [Review] [41 refs]. Emergency Medicine Australasia. 21(2):94-101, 2009 Apr. |
Review/Other-Dx |
16 articles |
To conduct a literature review evaluating studies of thoracolumbar injury in trauma patients to generate indications for thoracolumbar imaging |
We evaluated 16 articles; 5 prospective observational studies (1 cohort study) and 11 retrospective observational studies. Predictors of TL injury in prospective studies - high-risk injury mechanism, distracting injury, impaired cognition, symptoms/signs of vertebral fracture and known cervical fracture--were defined and used to construct a decision algorithm, which in a total of 14189 trauma patients from all eligible studies recommended TL screening in 856(99.1%) of 864 patients with TL fractures and would probably have directed TL imaging in the remaining 8 patients. There is limited low level evidence guiding surveillance TL imaging in adult blunt trauma patients. Despite this, we propose and evaluate an algorithm with a high negative predictive value for TL fractures. This should be incorporated into spinal injury assessment protocols. |
4 |
| 23. Nelson DW, Martin MJ, Martin ND, Beekley A. Evaluation of the risk of noncontiguous fractures of the spine in blunt trauma. The Journal of Trauma and Acute Care Surgery. 75(1):135-9, 2013 Jul. |
Observational-Dx |
654,052 patients |
To determine the incidence of NC spinal fractures and the relationship between injury pattern and mechanism. |
Among 654,052 blunt trauma patients, 83,338 (13%) had a diagnosed spine fracture. The mean (SD) Injury Severity Score (ISS) was 15 (11). Of these, 7% (5,496) sustained spinal cord injury, and 17% (14,413) underwent spinal surgery during their index hospitalization. Among those with spinal column fractures, the overall incidence of NC fractures was 19% and was associated with severe truncal injuries, primarily involving the chest. The relative incidences of cervical, thoracic, and lumbar fractures were 41% (34,480), 37% (30,383), and 43% (35,778), respectively. Rates of NC fractures of the spine included 9% cervicothoracic (7,406), 4% cervicolumbar (3,415), and 10% thoracolumbar (7,929). The slight majority (57%) of patients with spinal fractures sustained high-velocity trauma compared with 43% associated with low-velocity trauma. However, NC fractures of the spine were strongly associated with high-velocity trauma. |
2 |
| 24. Agarwal V, Shah LM, Parsons MS, et al. ACR Appropriateness Criteria® Myelopathy: 2021 Update. J Am Coll Radiol 2021;18:S73-S82. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for myelopathy 2021 update. |
No results stated in abstract. |
4 |
| 25. Boulter DJ, Job J, Shah LM, et al. ACR Appropriateness Criteria® Plexopathy: 2021 Update. J Am Coll Radiol 2021;18:S423-S41. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for plexopathy 2021 update. |
No results stated in abstract. |
4 |
| 26. Kadom N, Palasis S, Pruthi S, et al. ACR Appropriateness Criteria® Suspected Spine Trauma-Child. J Am Coll Radiol 2019;16:S286-S99. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for suspected spine trauma-child. |
No abstract available. |
4 |
| 27. Duane TM, Young A, Mayglothling J, et al. CT for all or selective approach? Who really needs a cervical spine CT after blunt trauma. The Journal of Trauma and Acute Care Surgery. 74(4):1098-101, 2013 Apr. |
Observational-Dx |
324 patients |
To identify predictors of positive Computed tomography (CT) in an effort to decrease future CT use without compromising patient care. |
There were 324 patients with a fracture, for an incidence rate of 6.25%. Fracture patients were older (43.89 +/- 18.83 years vs. 38.42 +/- 17.45 years, p <; 0.0001), with a lower GCS (Glasgow Coma Scale) score (13.49 +/- 3.49 vs. 14.32 +/- 2.34, p < 0.0001), than nonfracture patients. Clinical examination had a 100% (324 of 324) sensitivity, 0.62% (30 of 4,858) specificity, 6.29% (324 of 5,152) positive predictive value, and 100% (30 of 30) negative predictive value. A total of 77.8% (14 of 18) criteria were significantly associated with fracture by univariate analysis, seven of which were independent predictors of fracture by logistic regression (midline tenderness, GCS score < 15, age >/=65 years, paresthesias, rollover motor vehicle collision, ejected, never in sitting position in emergency department). Evaluation of these seven factors demonstrated a sensitivity of 99.07% (321 of 324), positive predictive value of 6.95% (321 of 4,617), specificity of 11.57% (562 of 4,858), and negative predictive value of 99.47% (562 of 565). |
3 |
| 28. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003; 349(26):2510-2518. |
Observational-Dx |
8,283 patients; 394 physicians |
Multicenter study. Prospective cohort study to compare Canadian C-spine Rule with NEXUS low-risk criteria as decision rules for guiding use of radiography in trauma patients. |
First analysis (excluded indeterminate cases): Canadian C-spine Rule more sensitive than NEXUS low-risk criteria (99.4% vs 90.7%, P<0.001) and more specific (45.1% vs 36.8%, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9% vs 66.6%, P<0.001). Second analysis (included all patients): Assuming indeterminate cases were positive, sensitivity and specificity of Canadian C-spine Rule, were 99.4% and 40.4%, respectively (P<0.001 for both comparisons with the NEXUS low-risk criteria). Assuming Canadian C-spine Rule was negative for all indeterminate cases, these rates were 95.3% (P=0.09 for the comparison with the NEXUS low-risk criteria) and 50.7% (P=0.001). Study concludes Canadian C-spine Rule is better than NEXUS low-risk criteria with regards to sensitivity and specificity for cervical-spine injury. |
3 |
| 29. Bailitz J, Starr F, Beecroft M, et al. CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison. J Trauma. 66(6):1605-9, 2009 Jun. |
Observational-Dx |
1,505 consecutive patients |
Prospective blinded study to compare the sensitivity of cervical CT to cervical spine radiographs in the initial diagnosis of blunt CSI for patients meeting one or more of the NEXUS criteria. |
Of 1,505 patients, 78 (4.9%) had evidence of a radiographic injury by cervical spine radiographs or cervical CT. Of these 78 patients with radiographic injury, 50 (3.3%) patients had clinically significant injuries. Cervical CT detected all patients with clinically significant injuries (100% sensitive), whereas cervical spine radiographs detected 18 (36% sensitive). Of the 50 patients, 15 were at high risk, 19 at moderate risk, and 16 at low risk for CSI according to previously published risk stratification. Cervical spine radiographs detected clinically significant injury in 7 high risk (46% sensitive), 7 moderate risk (37% sensitive), and 4 low risk patients (25% sensitive). Results demonstrate the superiority of cervical CT compared with cervical spine radiographs for the detection of clinically significant CSI. The improved ability to exclude injury rapidly provides further evidence that cervical CT should replace cervical spine radiographs for the initial evaluation of blunt CSI in patients at any risk for injury. |
2 |
| 30. Patel MB, Humble SS, Cullinane DC, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. [Review]. The Journal of Trauma and Acute Care Surgery. 78(2):430-41, 2015 Feb. |
Review/Other-Dx |
5 article: 1017 patients |
To perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question:In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance? |
Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT. |
4 |
| 31. Ertel AE, Robinson BR, Eckman MH. Cost-effectiveness of cervical spine clearance interventions with litigation and long-term-care implications in obtunded adult patients following blunt injury. The Journal of Trauma and Acute Care Surgery. 81(5):897-904, 2016 11. |
Observational-Dx |
N/A |
To hypothesize that the cost-effectiveness of strategies that include additional imaging may contradict current guidelines. |
Collar removal was more effective and less costly than collar use or MRI (19.99 vs. 19.35 vs. 18.70 quality-adjusted life-years; $675,359 vs. $685,546 vs. $685,848) in the base-case analysis. When the probability of missed cervical injury was greater than 0.04 adjunct imaging with MRI dominated, however, collar removal remained cost-effective until the probability of missed injury exceeded 0.113 at which point collar removal exceeded the $50,000 threshold. Collar removal remained the most cost-effective approach until the probability of complications from collar use was reduced to less than 0.009, at which point collar maintenance became the most cost-effective strategy. Early collar removal dominates all strategies until the risk of complications from MRI positioning is reduced to 0.03 and remained cost-effective even when the probability of complication was reduced to 0. |
4 |
| 32. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. [Review] [21 refs]. Journal of Trauma-Injury Infection & Critical Care. 58(5):902-5, 2005 May. |
Meta-analysis |
712 articles |
To compare test performance of radiographs and CT in the detection of CSI in trauma patients. |
Radiographs were 52% sensitive (95% CI: 47%-56%); CT was 98% (95%, CI: 96%-99%). CT outperforms radiography as a screening tool for cervical injury in high risk patients. There is insufficient evidence that CT should replace radiography for low risk patients. |
M |
| 33. Leichtle SW, Banerjee D, Schrader R, et al. Blunt cerebrovascular injury: The case for universal screening. J Trauma Acute Care Surg. 89(5):880-886, 2020 11. |
Observational-Dx |
4,659 patients |
To implement universal screening for BCVI with computed tomography angiography of the neck at our level 1 trauma center, hypothesizing that only universal screening would identify all clinically relevant BCVIs. |
A total of 4,659 patients fulfilled the inclusion criteria, 2.7% (n = 126) of which had 158 BCVIs. For the criteria outlined in the American College of Surgeons Trauma Quality Improvement Program Best Practices Guidelines, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 72.2%, 64.9%, 6.8%, 98.5%, and 65.2%, respectively; for the risk factors suggested in the more extensive expanded Denver criteria, they were 82.5%, 50.4%, 5.3%, 98.9%, and 51.4%, respectively. Twenty-three percent (n = 14) of patients with BCVI grade 3 or higher would not have been captured by any screening criteria. Cervical spine, facial, and skull base fractures were the strongest predictors of BCVI with odds ratios and 95% confidence intervals of 8.1 (5.4-12.1), 5.7 (2.2-15.1), and 2.7 (1.5-4.7), respectively. Eighty-three percent (n = 105) of patients with BCVI received antiplatelet agents or therapeutic anticoagulation, with 4% (n = 5) experiencing a bleeding complication, 3% (n = 4) a BCVI progression, and 8% (n = 10) a stroke. |
2 |
| 34. Harper PR, Jacobson LE, Sheff Z, Williams JM, Rodgers RB. Routine CTA screening identifies blunt cerebrovascular injuries missed by clinical risk factors. Trauma surg. acute care open. 7(1):e000924, 2022. |
Review/Other-Dx |
17 054 patients |
To analyze the incidence of patients with BCVI who did not meet any of the risk factors included in the expanded Denver criteria. |
During the study period, 17 054 blunt trauma patients were evaluated, and 29% (4923) underwent CTA of the neck to screen for BCVI. 191 BCVIs were identified in 160 patients (0.94% of all blunt trauma patients, 3.25% of patients screened with CTA). 16% (25 of 160) of patients with BCVI had none of the risk factors outlined in the Denver criteria. |
4 |
| 35. Muther M, Sporns PB, Hanning U, et al. Diagnostic accuracy of different clinical screening criteria for blunt cerebrovascular injuries compared with liberal state of the art computed tomography angiography in major trauma. The Journal of Trauma and Acute Care Surgery. 88(6):789-795, 2020 06. |
Observational-Dx |
4,104 patients |
To assess diagnostic accuracy of different CSC for BCVI in a population of patients diagnosed with BCVI after the use of liberal CTA. Second, anatomical locations and grades of BCVI in CSC false negatives are analyzed. |
From 4,104 patients with suspicion of major trauma, 91 (2.2%) were diagnosed with 126 BCVI through liberal usage of CTA. Sensitivities of different CSC ranged from 57% to 84%. Applying the set of CSC with the highest sensitivity, false-negative BCVIs were found more often in the petrous segment of the carotid artery (p = 0.01) and more false negatives presenting with pseudoaneurysmatic injury were found in the vertebral artery (p = <0.01). |
2 |
| 36. Duane TM, Cross J, Scarcella N, et al. Flexion-extension cervical spine plain films compared with MRI in the diagnosis of ligamentous injury. Am Surg. 76(6):595-8, 2010 Jun. |
Observational-Dx |
22,929 patients; 271 patients had 303 flexion/extension films. 49 also had MRI |
To compare flexion/extension plain films with MRI as the gold standard in the diagnosis of ligamentous injury of the cervical spine after trauma. A retrospective review of patients sustaining blunt trauma who had both flexion/extension and MRI of the cervical spine was performed. |
Flexion/extension film sensitivity was 0% (0/8), specificity 98 % (40/41), PPV 0% (0/1), and NPV 83 % (40/48). Although classified as negative for purposes of analysis, flexion/extension was incomplete 20.5% (62/303) and ambiguous 9.2% (28/303) of the time. The charge of flexion/extension is $535 so $48,150 (90 incomplete/ambiguous films) could have been saved by eliminating these films. Flexion/extension should no longer be used to diagnose ligamentous injury. Given the rare incidence of these injuries, MRI should be used when there is high clinical suspicion of injury. |
3 |
| 37. Khan SN, Erickson G, Sena MJ, Gupta MC. Use of flexion and extension radiographs of the cervical spine to rule out acute instability in patients with negative computed tomography scans. J Orthop Trauma. 25(1):51-6, 2011 Jan. |
Observational-Dx |
311 patients |
To investigate the usefulness of flexion and extension radiographs of the cervical spine as a screening tool for the acute evaluation of ligamentous injury in cases of awake blunt trauma in patients with a negative cervical computed tomography scan. |
A total of 311 patients were included in the study. The intraobserver reliability for the four fixed criteria for adequacy of flexion and extension radiographs was excellent. Only 97 (31%) flexion and extension radiographs were deemed adequate. Two hundred fourteen (69%) patient radiographs were deemed inadequate but were interpreted as normal by the radiologists. Not a single radiograph was identified with evidence of acute instability (true-positive = 0). One hundred seventy-one (55%) of patients had follow-up within 3 months of discharge from the hospital of which one (0.5%) patient developed signs of instability necessitating surgery. The sensitivity was 0%, specificity 99%, positive predictive value 0%, and negative predictive value 31%. |
2 |
| 38. Duane TM, Scarcella N, Cross J, et al. Do flexion extension plain films facilitate treatment after trauma?. Am Surg. 76(12):1351-4, 2010 Dec. |
Observational-Dx |
22,929 patients; 271 patients had 303 flexion/extension films |
Retrospective study to determine whether flexion/extension plain films facilitate treatment after trauma. Authors reviewed all patients who underwent flexion/extension films and compared 5-view plain films and CT of the cervical spine with flexion extension in the diagnosis of ligamentous injury. |
Compared with flexion/extension, 5-view and cervical CT had a sensitivity of 80% (8/10), PPV of 47.1% (8/17), specificity of 96.55% (252/261), and NPV of 99.21% (252/254). For purposes of analysis, incomplete and ambiguous flexion/extension films were listed as negative; however, 20.5% (62/303) were incomplete and 9.2% (28/303) were ambiguous. Management did not change for the 2 patients with missed ligament injuries. The 303 studies cost $162,105.00 to obtain. Flexion/extension is 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. |
3 |
| 39. Nasir S, Hussain M, Mahmud R. Flexion/extension cervical spine views in blunt cervical trauma. Chinese Journal of Traumatology. 15(3):166-9, 2012. |
Review/Other-Dx |
200 cases |
To examine the contribution of flexion and extension radiographs in the evaluation of ligamentous injury in awake adults with acute blunt cervical spine trauma, who show loss of cervical lordosis and neck pain. |
A total of 200 cases were reviewed, of whom 90 (45%) underwent repeat X-rays because of either inadequate exposure or limited motion. None of the patients with loss of lordosis on cross-table view had positive flexion and extension views of cervical spine for instability. |
4 |
| 40. McCracken B, Klineberg E, Pickard B, Wisner DH. Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients. Eur Spine J. 22(7):1467-73, 2013 Jul. |
Observational-Dx |
1000 patients |
To hypothesize that in patients who underwent a negative computed tomography (CT) cervical spine scan, flexion and extension radiographs did not yield useful additional information. |
One thousand patients met inclusion criteria for the study. Review of the flexion-extension radiographs revealed that 80% of the films either did not adequately demonstrate the C7/T1 junction or had less than 30 degrees range of motion. There was one missed injury that was also missed on magnetic resonance imaging. Results of the flexion-extension views had minimal effects on clinical decision making. |
3 |
| 41. Sim V, Bernstein MP, Frangos SG, et al. The (f)utility of flexion-extension C-spine films in the setting of trauma. Am J Surg. 206(6):929-33; discussion 933-4, 2013 Dec. |
Observational-Dx |
355 radiographs |
To evaluate their adequacy. We hypothesized that a significant proportion is inadequate. |
Three hundred fifty-five flexion-extension radiographs were examined. Ninety-five percent% of these studies were inadequate (51% because of the inability to visualize the top of T1, whereas 44% had less than 30 degrees of angulation from neutral). Two hundred ten studies were performed acutely; of these, 97% were inadequate. When performed 7 days or longer from injury, 91% were inadequate. |
3 |
| 42. Bogduk N.. On cervical zygapophysial joint pain after whiplash. [Review]. Spine. 36(25 Suppl):S194-9, 2011 Dec 01. |
Review/Other-Dx |
N/A |
To summarize the evidence that implicates the cervical zygapophysial joints as the leading source of chronic neck pain after whiplash. |
Postmortem studies show that a spectrum of injuries can befall the zygapophysial joints in motor vehicle accidents. Biomechanics studies of normal volunteers and of cadavers reveal the mechanisms by which such injuries can be sustained. Studies in cadavers and in laboratory animals have produced these injuries.Clinical studies have shown that zygapophysial joint pain is very common among patients with chronic neck pain after whiplash, and that this pain can be successfully eliminated by radiofrequency neurotomy. |
4 |
| 43. Sterling M, Elliott JM, Cabot PJ. The course of serum inflammatory biomarkers following whiplash injury and their relationship to sensory and muscle measures: a longitudinal cohort study. PLoS ONE [Electronic Resource]. 8(10):e77903, 2013. |
Observational-Dx |
58 patients |
To prospectively investigate changes in serum inflammatory biomarker levels from the acute (<3 weeks) to chronic (>3 months) stages of whiplash injury. To determine relationships between biomarker levels and hyperalgesia, fatty muscle infiltrates of the cervical extensors identified on MRI and psychological factors. |
40 volunteers with acute WAD and 18 healthy controls participated. Participants with WAD were classified at 3 months as recovered/mild disability or having moderate/severe disability using the Neck Disability Index. At baseline both WAD groups showed elevated serum levels of CRP but by 3 months levels remained elevated only in the moderate/severe group. The recovered/mild disability WAD group had higher levels of TNF-a at both time points than both the moderate/severe WAD group and healthy controls. There were no differences found in serum IL-1ß. Moderate relationships were found between hyperalgesia and CRP at both time points and between hyperalgesia and IL-1ß 3 months post injury. There was a moderate negative correlation between TNF-a and amount of fatty muscle infiltrate and pain intensity at 3 months. Only a weak relationship was found between CRP and pain catastrophising and no relationship between biomarker levels and posttraumatic stress symptoms. The results of the study indicate that inflammatory biomarkers may play a role in outcomes following whiplash injury as well as being associated with hyperalgesia and fatty muscle infiltrate in the cervical extensors. |
2 |
| 44. Jull G. Whiplash Continues Its Challenge. J Orthop Sports Phys Ther. 46(10):815-817, 2016 Oct. |
Review/Other-Dx |
N/A |
To reflect the multifaceted nature of whiplash-associated disorders and the wide-ranging research in the field. |
No results stated in the abstract. |
4 |
| 45. Hlavata Z, Solinas C, De Silva P, et al. The Abscopal Effect in the Era of Cancer Immunotherapy: a Spontaneous Synergism Boosting Anti-tumor Immunity?. Targeted Oncology. 13(2):113-123, 2018 04. |
Review/Other-Dx |
N/A |
To summarize the current pre-clinical and clinical data on the immune effects of radiotherapy and their potential implications for cancer immunotherapy. |
No results stated in the abstract. |
4 |
| 46. de Zoete RMJ, Coppieters I, Farrell SF. Editorial: Whiplash-associated disorder-advances in pathophysiology, patient assessment and clinical management. Front Pain Res (Lausanne) 2022;3:1071810. |
Review/Other-Dx |
N/A |
To discuss the Whiplash-associated disorder-advances in pathophysiology, patient assessment and clinical management |
No results stated in the abstract. |
4 |
| 47. Elliott J, Sterling M, Noteboom JT, Treleaven J, Galloway G, Jull G. The clinical presentation of chronic whiplash and the relationship to findings of MRI fatty infiltrates in the cervical extensor musculature: a preliminary investigation. Eur Spine J. 18(9):1371-8, 2009 Sep. |
Observational-Dx |
79 subjects |
To determine whether any measurable changes in sensory responses, kinesthetic sense, cervical motion, and psychological features were related to established fatty infiltration values in the cervical extensor musculature in subjects with persistent whiplash. |
of this study indicate the presence of altered physical, kinesthetic, sensory, and psychological features in this cohort of patients with chronic whiplash. Combined factors of sensory, physical, kinesthetic, and psychological features all contributed to a small extent in explaining the varying levels of fatty infiltrate, with cold pain thresholds having the most influence (r (2) = 0.28; P = 0.02). Identifying and relating quantifiable muscular alterations to clinical measures in the chronic state, underpin some clinical hypotheses for possible pathophysiological processes in this group with a chronic and recalcitrant whiplash disorder. |
3 |
| 48. Anderson SE, Boesch C, Zimmermann H, et al. Are there cervical spine findings at MR imaging that are specific to acute symptomatic whiplash injury? A prospective controlled study with four experienced blinded readers. Radiology. 262(2):567-75, 2012 Feb. |
Observational-Dx |
100 patients |
To compare the magnetic resonance (MR) imaging findings in patients with acute whiplash injury with those in matched control subjects. |
Accuracy of MR imaging and interreader reliability were generally poor (sensitivity, 0.328; specificity, 0.728; positive and negative likelihood ratios, 1.283 and 1.084, respectively). MR imaging findings significantly associated with whiplash injuries were occult fracture (P<.01), bone marrow contusion of the vertebral body (P=.01), muscle strain (P<.01) or tear (P<.01), and the presence of perimuscular fluid (P<.01). While 10 findings thought to be specific for whiplash trauma were significantly (P<.01) more frequent in patients (507 observations), they were also regularly found in healthy control subjects (237 observations). There were no serious occult injuries that required immediate therapy. |
1 |
| 49. Farrell SF, Smith AD, Hancock MJ, Webb AL, Sterling M. Cervical spine findings on MRI in people with neck pain compared with pain-free controls: A systematic review and meta-analysis. Journal of Magnetic Resonance Imaging. 49(6):1638-1654, 2019 06. |
Review/Other-Dx |
31 studies |
To compare the presence of cervical spine MRI findings in people with WAD or NSNP with pain-free controls. |
In total, 31 studies were included (eight comparing acute WAD to controls, 14 comparing chronic WAD to controls, 12 comparing chronic NSNP to controls) comprising 4032 participants. Rectus capitis posterior major cross-sectional area was smaller in people with chronic NSNP than controls (two studies: SMD -1.18 [95% confidence interval [CI] -1.65, -0.71]). The remaining meta-analysis comparisons showed no group differences in MRI findings. The quality of evidence was mostly low due to small sample sizes and high heterogeneity. |
4 |
| 50. Lund N, Dahlqvist Leinhard O, Elliott JM, et al. Fatty infiltrate and neck muscle volume in individuals with chronic whiplash associated disorders compared to healthy controls - a cross sectional case-control study. BMC Musculoskelet Disord. 24(1):181, 2023 Mar 11. |
Observational-Dx |
50 patients |
To investigate dorsal neck muscle volume (MV) and muscle fat infiltration (MFI) in relation to self-reported neck disability among 30 participants with chronic WAD grade II-III compared to 30 matched healthy controls. |
Higher MFI was found in right trapezius (p = 0.007, Cohen's d = 0.9) among participants with severe chronic WAD compared to healthy controls. No other significant difference was found for MFI (p = 0.22-0.95) or MV (p = 0.20-0.76). |
2 |
| 51. Como JJ, Thompson MA, Anderson JS, et al. Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma?. J Trauma. 63(3):544-9, 2007 Sep. |
Review/Other-Dx |
115 patients |
Prospective study to show that MRI of the cervical spine does not contribute relevant information and is not necessary for clearing the spine in obtunded patients. Both CT and MRI were performed. |
MRI identified microtrabecular injuries, intraspinous ligament injuries, a cord signal abnormality and epidural hematoma, none of which changed management. MRI is unnecessary in obtunded patients with a normal cervical CT. |
4 |
| 52. Diaz JJ, Jr., Aulino JM, Collier B, et al. The early work-up for isolated ligamentous injury of the cervical spine: does computed tomography scan have a role? J Trauma. 2005; 59(4):897-903; discussion 903-894. |
Observational-Dx |
1,577 patients; 3 observers |
Prospective blinded study to assess whether helical CT can be used as a screening tool for isolated ligamentous injury in blunt trauma. Patients also had radiographs and MRI. |
278 had 416 cervical spine fractures. Radiographs failed to identify 299/416 (72%) cervical spine fractures in 208/278 (74.8%). Of 1,299 (82%) with no fracture, 85 (6.5%) required an MRI. Sensitivity for radiographs and helical CT for ligamentous injury were 16% and 32%, respectively. NPV for radiographs and helical CT were 74% and 78%, respectively. While helical CT is best modality for screening the cervical spine bony injuries, it is not an effective modality for screening for cervical ligamentous injury where MRI is clearly superior. The indications for MRI include abnormalities on helical CT, neurologic deficits, cervical pain or tenderness on examination, or the inability to clear the cervical spine in the obtunded patient. |
2 |
| 53. Foster G, Russell B, Hibble B, Shaw K, Stella J. Magnetic resonance imaging cervical spine in trauma: A retrospective single-centre audit of patient outcomes. Emergency Medicine Australasia. 34(1):65-72, 2022 Feb. |
Observational-Dx |
228 Patients |
To investigates the MRI findings and surgical outcomes of patients in this cohort. |
Two hundred and twenty-eight patients with persistent midline tenderness and/or persistent neurology following blunt trauma and negative CT report were included. One hundred and eighty-one patients received an MRI for persistent tenderness of which 35 revealed abnormal MRI findings. Twenty-one cases required no treatment, 14 cases were treated with a rigid collar with no patients requiring operative management. Forty-seven patients received an MRI for neurological symptoms following blunt trauma and negative CT, with 11 abnormal MRI findings. Management included no treatment (three cases), application of rigid collar (six cases) and operative management (two cases). |
2 |
| 54. Menaker J, Philp A, Boswell S, Scalea TM. Computed tomography alone for cervical spine clearance in the unreliable patient--are we there yet? J Trauma. 2008; 64(4):898-903; discussion 903-894. |
Review/Other-Dx |
734 patients |
Retrospective study to demonstrate that an admission cervical spine CT with no acute injury is not sufficient for clearance in an unreliable patient. Patients had MRI. |
203 patients had “no acute injury” on CT; 184 had a negative MRI and collars were removed. 18 patients had an abnormal MRI, 2 of whom required operative repair and 14 required extended collar use; 1 patient had a suboptimal MRI and was discharged in a collar. Study recommends MRI for clearance in unreliable patients. |
4 |
| 55. Menaker J, Stein DM, Philp AS, Scalea TM. 40-slice multidetector CT: is MRI still necessary for cervical spine clearance after blunt trauma?. Am Surg. 76(2):157-63, 2010 Feb. |
Review/Other-Dx |
213 patients |
Retrospective study to determine if a negative cervical spine CT using 40-slice MDCT is sufficient for ruling out CSI in unreliable blunt trauma patients or if MRI remains necessary for definitive clearance. Also, study sought to clarify the frequency by which MRI alters treatment in patients with a negative cervical spine CT who have a reliable examination with persistent clinical symptoms. |
Overall, 24.4 % patients had abnormal MRIs. Fifteen required operative repair; 23 required extended cervical collar; and 14 had collars removed. A total of 8.3% of patients with an unreliable examination and 25.6% of reliable patients had management changed based on MRI findings. Overall, MRI changed clinical practice in 17.8% of all patients. Despite newer 40-slice CT technology, MRI continues to be necessary for cervical spine clearance in patients with unreliable examinations or persistent symptoms. |
4 |
| 56. Plackett TP, Wright F, Baldea AJ, et al. Cervical spine clearance when unable to be cleared clinically: a pooled analysis of combined computed tomography and magnetic resonance imaging. [Review]. Am J Surg. 211(1):115-21, 2016 Jan. |
Review/Other-Dx |
1,714 patients |
To evaluate clinically the unevaluable blunt trauma patients has been called into question by several recent studies. |
Data for 1,714 patients were available. All patients had a negative computed tomography scan and then underwent an magnetic resonance imaging (MRI). There were 271 (15.8%) patients who had a previously undocumented finding on MRI with the majority (98.2%) being a ligamentous injury. Only 5 injuries (1.8%) resulted in surgical intervention. |
4 |
| 57. Schoenfeld AJ, Bono CM, McGuire KJ, Warholic N, Harris MB. Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma. 68(1):109-13; discussion 113-4, 2010 Jan. |
Meta-analysis |
11 studies; 1,550 patients with negative CT scan |
Meta-analysis was performed to determine whether adding MRI provide useful information that alters treatment when a CT scan reveals no evidence of injury. CT alone was compared to CT and MRI in the identification of occult injuries to the cervical spine. |
MRI detected abnormalities in 182 patients (12%). 90 traumatic injuries were identified, including ligamentous injuries (86/182), fractures, and dislocations (4/182). In 96 cases (6% of the cohort), the MRI identified an injury that altered management. 84 patients (5%) required continued collar immobilization and 12 (1%) required surgical stabilization. The Q-statistic p value for heterogeneity was 0.99, indicating the absence of heterogeneity among the individual study populations. Reliance on CT imaging alone to “clear the cervical spine” after blunt trauma can lead to missed injuries. This study supports a role for the addition of MRI in evaluating patients who are obtunded, or unexaminable, despite a negative CT scan. |
M |
| 58. Tomycz ND, Chew BG, Chang YF, et al. MRI is unnecessary to clear the cervical spine in obtunded/comatose trauma patients: the four-year experience of a level I trauma center. J Trauma. 2008; 64(5):1258-1263. |
Observational-Dx |
690 patients |
Retrospective study to demonstrate that CT is adequate in clearing the spine in obtunded patients. Patients also had MRI. |
180 patients (26%) had normal CT and normal neurologic examinations. MRI identified 38 patients with acute traumatic findings. None had an unstable injury, required surgery, or developed delayed instability. CT using modern imaging protocols, in patients without neurologic deficit is adequate for clearing the spine in obtunded patients. |
3 |
| 59. Muchow RD, Resnick DK, Abdel MP, Munoz A, Anderson PA. Magnetic resonance imaging (MRI) in the clearance of the cervical spine in blunt trauma: a meta-analysis. J Trauma. 64(1):179-89, 2008 Jan. |
Meta-analysis |
464 patients 5 level I protocols |
Meta-analysis of both prospective and retrospective studies to determine the efficacy of clearing the cervical spine in symptomatic patients with negative radiographic or CT studies. |
5 studies had zero false negatives with NPV of 100%. Log odds meta-analysis produced a 94.2% PPV (95% CI, 75.0, 989), 97.2% sensitivity (95% CI, 89.5, 99.3), and 98.5% specificity (95% CI, 91.8, 99.7). 97 patients (21%) had abnormalities identified by MRI that were not found with radiographs with or without CT. MRI study that is normal can conclusively exclude a spinal injury and should be considered the gold standard. |
M |
| 60. Zhuge W, Ben-Galim P, Hipp JA, Reitman CA. Efficacy of MRI for assessment of spinal trauma: correlation with intraoperative findings. J Spinal Disord Tech. 28(4):147-51, 2015 May. |
Observational-Dx |
35 patients |
To assess the efficacy of magnetic resonance imaging (MRI) for detecting spinal soft tissue injury after acute trauma using intraoperative findings as a reference standard. |
MRI was 100% sensitive and specific in detecting injury to the anterior longitudinal ligament. MRI was moderately sensitive (80%) but highly specific (100%) for injury to the posterior longitudinal ligament. In contrast, MRI was highly sensitive but less specific in detecting injury to paraspinal muscles (100%, 77%), intervertebral disk (100%, 71%), and interspinous ligament (100%, 64%). MRI was moderately sensitive and specific in detecting ligamentum flavum injury (80% and 86.7%) but poorly sensitive for facet capsule injury (62.5%). |
2 |
| 61. Chew BG, Swartz C, Quigley MR, Altman DT, Daffner RH, Wilberger JE. Cervical spine clearance in the traumatically injured patient: is multidetector CT scanning sufficient alone? Clinical article. J Neurosurg Spine. 19(5):576-81, 2013 Nov. |
Observational-Dx |
1004 patients |
To be determined if these injuries represent a source of occult instability that requires continued spinal immobilization or a subclinicalfinding of minimal significance. |
A total of 1004 patients were reviewed, of whom 614 were male, with an overall mean age of 47 years. The indication for MRI was neck pain in 662 patients, altered mental status in 467, and neurological signs or symptoms in 157. The magnetic resonance imaging (MRI) studies were interpreted as normal in 645 patients, evidencing ligamentous injury alone in 125, and showing nonspecific degenerative changes in the remaining patients. Of the 125 patients with ligamentous injuries, 66 (52.8%) had documentation of clearance (29 clinical, 37 with flexion-extension radiographs). Another 32 patients were presumed to be self-cleared, bringing the follow-up rate to 82% (98 of 119). Five patients died prior to clearance, and 1 patient was transferred to another facility prior to clearance. Based on these data, the 95% confidence interval for the assertion that clinically irrelevant ligamentous injury in the face of normal multidetector Computed Tomography (MDCT) is 97%-100%. No patient with ligamentous injury on MRI was documented to require a surgical procedure or halo orthosis for instability. Thirty-nine patients ultimately underwent cervical surgical procedures (29 anterior and 10 posterior; 5 delayed) for central cord syndrome (21), quadriparesis (9), or discogenic radicular pain (9). None had an unstable spine. |
3 |
| 62. Maung AA, Johnson DC, Barre K, et al. Cervical spine MRI in patients with negative CT: A prospective, multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). J Trauma Acute Care Surg. 82(2):263-269, 2017 02. |
Observational-Dx |
767 patients |
To determine the rates of abnormal magnetic resonance imaging (MRI) after a negative cervical spine Computed Tomography (CSCT) . |
A total of 767 patients had MRI because of cervicalgia (43.0%), inability to evaluate (44.1%), or both (9.4%). MRI was abnormal in 23.6% of all patients, including ligamentous injury (16.6%), soft tissue swelling (4.3%), vertebral disc injury (1.4%), and dural hematomas (1.3%). Rates of abnormal neurological signs or symptoms were not different among patients with normal versus abnormal MRI. (15.2 vs. 18.8%, p = 0.25). The c-collar was removed in 88.1% of patients with normal MRI and 13.3% of patients with an abnormal MRI. No patient required halo placement, but 11 patients underwent cervical spine surgery after the MRI results. Six of the eleven had neurological signs or symptoms. |
2 |
| 63. Panczykowski DM, Tomycz ND, Okonkwo DO. Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma. [Review]. J Neurosurg. 115(3):541-9, 2011 Sep. |
Meta-analysis |
17 studies with 14,327 patients |
Meta-analysis was performed to determine the comparative effectiveness of multislice helical CT alone to diagnose acute unstable CSI following blunt trauma. |
The overall sensitivity and specificity for modern CT were both >99.9% (95% CI, 0.99-1.00 and 0.99-1.00, respectively). The negative likelihood ratio of an unstable cervical injury after a CT scan negative for acute injury was <0.001 (95% CI, 0.00-0.01), while the NPV of a normal CT scan was 100% (95% CI, 0.96-1.00). Global severity of injury, CT slice thickness, and study quality did not significantly affect accuracy estimates. Modern CT alone is sufficient to detect unstable cervical spine injuries in trauma patients. Adjuvant imaging is unnecessary when the CT scan is negative for acute injury. Results of this meta-analysis strongly show that the cervical collar may be removed from obtunded or intubated trauma patients if a modern CT scan is negative for acute injury. |
M |
| 64. Culhane J, Parr A, Mercier P. Accuracy of ct evaluation for cervical spine clearance in the ground level fall population - a retrospective cohort study. BMC Emergency Medicine. 22(1):106, 2022 06 11. |
Observational-Dx |
18506 patients |
To examine the ground level fall (GLF) population to analyze whether computed tomography (CT) alone can rule out unstable injury in this group with lower force mechanism. |
Sixty-nine (2.0%) of patients had CS injury without acute CT abnormality. Of these, 11 (0.3%) required surgery and were considered unstable. All patients who required surgery had a neurologic deficit. Negative predictive value (NPV) of CT for unstable CS injury was 99.7%. The combination of acute CT findings and neurologic deficit ruled out unstable CS injury with 100% NPV. |
4 |
| 65. Khurana B, Keraliya A, Velmahos G, Maung AA, Bono CM, Harris MB. Clinical significance of "positive" cervical spine MRI findings following a negative CT. Emergency Radiology. 29(2):307-316, 2022 Apr. |
Observational-Dx |
54 patients |
To review and analyze the clinical significance of positive acute traumatic findings seen on MRI of the cervical spine (MRCS) following a negative CT of the cervical spine (CTCS) for trauma. |
Among 35 unevaluable patients, MRCS showed one unstable (hyperextension) and two potentially unstable (hyperflexion) injuries. Subtle findings were seen on CTCS in 2 of 3 patients upon careful retrospective review that would have suggested these injuries. Of 19 patients presenting with cervicalgia, 2/5 (40%) patients with neurological deficit demonstrated clinically significant findings on MRCS with predisposing factors seen on CT. None of the 14 patients with isolated cervicalgia and no neurological deficit had clinically significant findings on their MRCS. |
1 |
| 66. Pourtaheri S, Emami A, Sinha K, et al. The role of magnetic resonance imaging in acute cervical spine fractures. Spine J. 14(11):2546-53, 2014 Nov 01. |
Observational-Dx |
830 patients |
To examine the predisposing conditions where an MRI would provide additional findings that would affect management in acute cervical spine fractures. |
Ninety-nine patients with a cervical fracture were included in the final analysis: median age 54 years (interquartile range, 42 years), mean Glasgow Coma Scale 13 (standard deviation ± 3.0), 68% males, 32% females, 42% older patients (age>60 years), 30% spondylosis, 27% polytrauma, 67% alert, 28% neurologic deficit. Major medical comorbidities, prior to injury level of activity, atlantoaxial versus subaxial, and gender were not associated with changes in diagnosis and management (p>.05). Age >60 years, neurologic deficit, polytrauma status, alertness, and spondylosis were associated with having additional clinically relevant findings seen on MRI and changes in management (p<.05). The majority of the changes in management were related to MRI's illustration of the spinal cord injury and not due to an occult instability. Eighty-one percent of the changes in management were related to the depiction of the spinal cord compression seen on MRI, whereas 19% of the changes in management were related to occult instability seen on MRI. |
2 |
| 67. Kaale BR, Krakenes J, Albrektsen G, Wester K. Whiplash-associated disorders impairment rating: neck disability index score according to severity of MRI findings of ligaments and membranes in the upper cervical spine. J Neurotrauma. 2005;22(4):466-475. |
Observational-Dx |
87 persons with a WAD2 diagnosis and 29 control individuals |
To determine whether reported pain and functional disability in WAD patients is associated with specific soft tissue abnormalities in the upper cervical spine, as assessed by MRI. |
Symptoms and complaints among WAD patients is linked with structure abnormalities in ligaments and membranes in the upper cervical spine, in particular the alar ligaments. |
2 |
| 68. Matsumoto M, Ichihara D, Okada E, et al. Cross-sectional area of the posterior extensor muscles of the cervical spine in whiplash injury patients versus healthy volunteers--10 year follow-up MR study. Injury. 43(6):912-6, 2012 Jun. |
Observational-Dx |
23 patients |
To elucidate the changes in the posterior extensor muscles 10 years after whiplash injury. |
The mean total CSA per patient (the sum of the area from C3-4 to C5-6) was 4811.6+/-878.4 mm(2) in the whiplash patients and 4494.9+/-1032.7 mm(2) in the controls at the initial investigation (p=0.20), and 5173.4+/-946.1 mm(2) and 4713.0+/-1065.3 mm(2) at the follow-up (p=0.07). The mean change in CSA over time was 361.8+/-804.9 mm(2) in the whiplash patients and 218.1+/-520.7 mm(2) in the controls (p=0.34). Ten whiplash patients (43.5%) had neck pain and 11 (47.8%) had shoulder stiffness. However, there was no difference in the change in CSA over time between the symptomatic and asymptomatic patients. |
3 |
| 69. Dullerud R, Gjertsen O, Server A. Magnetic resonance imaging of ligaments and membranes in the craniocervical junction in whiplash-associated injury and in healthy control subjects. Acta Radiol. 2010;51(2):207-212. |
Observational-Dx |
28 patients; 27 healthy controls |
To assess the ligaments and membranes in the craniocervical junction with MRI in patients with WAD and to compare them with healthy control subjects. |
High signal intensity of the alar and transverse ligaments was quite common and was reported at an average of about 50% both among patients and control subjects. The incidence of abnormalities of the tectorial and posterior atlantooccipital membranes was low in both groups. No statistically significant difference between control subjects and patients with WAD was revealed for any of the structures assessed. Additional fat-suppressed images seemed to reduce the number of reported anomalies. |
4 |
| 70. Stenneberg MS, Rood M, de Bie R, Schmitt MA, Cattrysse E, Scholten-Peeters GG. To What Degree Does Active Cervical Range of Motion Differ Between Patients With Neck Pain, Patients With Whiplash, and Those Without Neck Pain? A Systematic Review and Meta-Analysis. [Review]. Arch Phys Med Rehabil. 98(7):1407-1434, 2017 Jul. |
Meta-analysis |
27 articles |
To quantify differences in active cervical range of motion (aCROM) between patients with neck pain and those without neck pain, in patients with whiplash-associated disorders (WADs) and nontraumatic neck pain, and in patients with acute complaints versus those with chronic complaints. |
The search yielded 6261 hits; 27 articles (2366 participants, 13 low risk of bias) met the inclusion criteria. The neck pain group showed less aCROM in all movement directions compared with persons without neck pain. Mean differences ranged from -7.04 degrees (95% CI, -9.70 degrees to -4.38 degrees ) for right lateral bending (11 studies) to -89.59 degrees (95% CI, -131.67 degrees to -47.51 degrees ) for total aCROM (4 studies). Patients with WADs had less aCROM than patients with nontraumatic neck pain. No conclusive differences in aCROM were found between patients with acute and patients with chronic complaints. |
Good |
| 71. Black JA, Abraham PJ, Abraham MN, et al. Universal screening for blunt cerebrovascular injury. The Journal of Trauma and Acute Care Surgery. 90(2):224-231, 2021 02 01. |
Observational-Dx |
6,800 patients |
To accurately determine the incidence of BCVI and to evaluate the diagnostic performance of the Denver criteria (DC), expanded Denver criteria (eDC), and Memphis criteria (MC) in selecting patients for screening. |
A total of 6,800 patients who had suffered blunt trauma were evaluated, of whom 6,287 (92.5%) had a neck CTA. Of these, 480 (7.6%) patients had CTA evidence of BCVI. The eDC identified the most BCVI cases (sensitivity 74.7%) but had the lowest positive predictive value (14.6%). The DC and MC had slightly greater positive predictive values (19.6% and 20.6%, respectively) and had the highest diagnostic ability in terms of likelihood ratio (2.8 and 2.9) but had low sensitivity (57.5% and 47.3%). Consequently, if relying on the traditional screening criteria, the DC, eDC, and MC would have respectively resulted in 42.5%, 25.3%, and 52.7% of patients with BCVI identified by universal screening not receiving a neck CTA to screen for BCVI. |
2 |
| 72. Harrigan MR, Hadley MN, Dhall SS, et al. Management of vertebral artery injuries following non-penetrating cervical trauma. Neurosurgery 2013;72 Suppl 2:234-43. |
Review/Other-Dx |
N/A |
To discuss the management of vertebral artery injuries following non-penetrating cervical trauma |
No results stated in the abstract |
4 |
| 73. Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg. 72(2):330-5; discussion 336-7, quiz 539, 2012 Feb. |
Observational-Dx |
418 patients |
To identify injury patterns of patients with blunt cerebrovascular injuries (BCVIs) that are not currently recommended screening criteria. |
During the 14-year study period, 585 BCVIs were identified in 418 patients (66% men; age, 40 years ± 0.7 years). Eighty-three (20%) patients with BCVI did not have standard screening criteria; 66% were asymptomatic at diagnosis. Injury patterns in these patients included mandible fracture (27 patients), complex skull fractures (21 patients), traumatic brain injury with thoracic trauma (6 patients), scalp degloving (6 patients), and great vessel or cardiac injuries (4 patients). Other injuries (11 patients) and no injuries (8 patients) were identified in the remainder. Of the 307 asymptomatic patients who received antithrombotic treatment, one patient suffered stroke (0.3%) and one patient a transient ischemic attack (0.3%). |
3 |
| 74. Chung D, Sung JK, Cho DC, Kang DH. Vertebral artery injury in destabilized midcervical spine trauma; predisposing factors and proposed mechanism. Acta Neurochir (Wien). 154(11):2091-8; discussion 2098, 2012 Nov. |
Observational-Dx |
91 patients |
To evaluate, by logistic regression analysis, the data from patients with traumatically destabilized blunt cervical spine injuries that required surgery who were potential candidates for VAI management. |
Eighteen patients (19.8 % of 91 patients) had a VAI associated with midcervical spine trauma (C2-C6). In univariate statistical analysis, transverse foramen fracture (P = 0.002), facet dislocation (P = 0.014), and facet fracture (P = 0.001) were significant risk factors. However, only facet fracture was determined to be significant risk factor after multivariate analysis (P = 0.006, odds ratio 20.98). It is hypothesized that a VAI occurs in a midcervical spine injury when a facet fracture allows the bony compartment to impinge on the relatively narrow free space of the intervertebral foramen, which is also occupied by the cervical root. |
3 |
| 75. Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 139(5):540-5; discussion 545-6, 2004 May. |
Observational-Dx |
41 patients |
To analyze our recent experience with anticoagulation, as we hypothesize that early diagnosis and prompt anticoagulation are effective. |
A CAI was identified in 114 patients during the 7-year study period; the majority were men (71%), with a mean ± SD age of 34 ± 1.3 years and a mean ± SD Injury Severity Score of 29 ± 1.5. Seventy-three patients underwent anticoagulation after diagnosis (heparin in 54, low-molecular-weight heparin in 2, antiplatelet agents in 17); none had a stroke. Of the 41 patients who did not receive anticoagulation (because of a contraindication in 27, symptoms before diagnosis in 9, and carotid coil or stent in 5), 19 patients (46%) developed neurologic ischemia. Ischemic neurologic events occurred in 100% of patients who presented with symptoms before angiographic diagnosis and those receiving a carotid coil or stent without anticoagulation. |
3 |
| 76. Even J, McCullough K, Braly B, et al. Clinical indications for arterial imaging in cervical trauma. Spine. 37(4):286-91, 2012 Feb 15. |
Observational-Dx |
159 patients |
To evaluate the clinical indications for acquiring arterial imaging in cervical trauma. |
From 2005 to 2009, there were a total of 159 patients who underwent cervical arterial imaging at the 2 participating institutions for the indication of cervical trauma with concern for arterial injury. Thirty-six (22.64%) were found to have an injury after arterial imaging. There was a statistically significant correlation with displaced cervical injuries (P < 0.0153), which were defined as cervical dissociations or perched and/or jumped facets. The other statistically significant correlation was the presence of a neurological deficit (P < 0.001), defined as any presenting deficit on sensory or motor examination. Level of injury defined as axial (O-C2) versus subaxial (C3-C7), age, body mass index, and history of cigarette smoking were not statistically related to vascular injury. |
3 |
| 77. Geddes AE, Burlew CC, Wagenaar AE, et al. Expanded screening criteria for blunt cerebrovascular injury: a bigger impact than anticipated. Am J Surg. 212(6):1167-1174, 2016 Dec. |
Review/Other-Dx |
386 patients |
To capture the remaining 20% of patients not historically identified with earlier protocols and to hypothesize that these expanded criteria would capture the additional 20% of blunt cerebrovascular injuries (BCVIs) patients not previously identified |
BCVIs were identified in 386 patients: 150 during the classic period (2.36% incidence) and 236 in the expanded period (2.99% incidence). In the expanded period, 155 patients were imaged based on classic screening criteria, 62 on expanded criteria (21 complex skull fractures, 20 upper rib fractures, 6 mandible fractures, 2 scalp degloving, 1 great vessel injury, and 12 combination), and 19 for other injuries and symptoms. |
4 |
| 78. Lebl DR, Bono CM, Velmahos G, Metkar U, Nguyen J, Harris MB. Vertebral artery injury associated with blunt cervical spine trauma: a multivariate regression analysis. Spine. 38(16):1352-61, 2013 Jul 15. |
Observational-Dx |
1204 patients |
To determine the patient characteristics, risk factors, and fracture patterns associated with vertebral artery injury (VAI) in patients with blunt cervical spine injury. |
Twenty-one percent of 1204 patients with cervical injuries (n = 253) underwent screening for VAI by multidetector computed tomography angiogram. VAI was diagnosed in 17% (42 of 253), unilateral in 15% (38 of 253), and bilateral in 1.6% (4 of 253) and was associated with a lower Glasgow coma scale (P< 0.001), a higher injury severity score (P < 0.01), and a higher mortality (P < 0.001). VAI was associated with ankylosing spondylitis/diffuse idiopathic skeletal hyperosteosis (crude odds ratio [OR] = 8.04; 95% confidence interval [CI], 1.30–49.68; P= 0.034), and occipitocervical dissociation (P < 0.001) by univariate analysis and fracture displacement into the transverse foramen 1 mm or more (adjusted OR = 3.29; 95% CI, 1.15–9.41; P= 0.026), and basilar skull fracture (adjusted OR = 4.25; 95% CI, 1.25–14.47; P= 0.021), by multivariate regression model. Subgroup analyses of neurological events secondary to VAI occurred in 14% (6 of 42) and the stroke-related mortality rate was 4.8% (2 of 42). Neurological events were associated with male sex (P= 0.024), facet subluxation/dislocation (crude OR = 9.00; 95% CI, 1.51–53.74; P= 0.004) and the diagnosis of ankylosing spondylitis/diffuse idiopathic skeletal hyperosteosis (OR = 40.67; 95% CI, 5.27–313.96; P < 0.001). |
2 |
| 79. Carrillo EH, Osborne DL, Spain DA, Miller FB, Senler SO, Richardson JD. Blunt carotid artery injuries: difficulties with the diagnosis prior to neurologic event. Journal of Trauma-Injury Infection & Critical Care. 46(6):1120-5, 1999 Jun. |
Review/Other-Dx |
30 Patients |
To evaluate the incidence, timing of diagnosis, clinical factors for adverse outcome, and role of anticoagulant, surgical therapy, or endovascular intervention for patients with blunt carotid artery injury (BCAI). |
There were 18 men and 12 women, with an average age of 29 years. The diagnosis of BCAI was initially suspected in 15 patients after a major or new neurologic event, and in 15 patients after changes were shown by computed tomography. BCAI was confirmed by arteriography in 29 patients and by magnetic resonance angiography in 1 patient. Treatment consisted of antiplatelet therapy (n = 9), anticoagulation (n = 8), surgical repair (n = 6), observation (n = 4), and endovascular embolization (n = 3). With some type of treatment, 14 patients with no neurologic deficits remained stable; however, treatment improved the final neurologic outcome in 8 patients (20%). Three patients remained with severe deficits, and five patients died. |
4 |
| 80. Parikh AA, Luchette FA, Valente JF, et al. Blunt carotid artery injuries. Journal of the American College of Surgeons. 185(1):80-6, 1997 Jul. |
Review/Other-Dx |
20 patients |
To identify patients sustaining blunt carotid injuries at a regional trauma center and report on the incidence, demographics, diagnostic workup, management, and outcome. |
Twenty patients were identified during the 7-year period. All patients suffered blunt trauma, with motor vehicle accidents being the most common mechanism, and the internal carotid the most frequently injured vessel. Associated injuries were present in all patients, with head (65%) or chest (65%) injuries being the most common. The combination of head and chest trauma (45%) was found to be associated with a 14-fold increase in the likelihood of carotid injury. Cerebral angiography was diagnostic in all patients and the majority were treated nonoperatively with anticoagulation. Twenty percent of patients were discharged with a normal neurologic exam, while 45% left with a significant neurologic deficit. Overall mortality was 5% |
4 |
| 81. Biffl WL, Moore EE, Elliott JP, et al. The devastating potential of blunt vertebral arterial injuries. Annals of Surgery. 231(5):672-81, 2000 May. |
Observational-Dx |
38 patients |
To formulate management guidelines for blunt vertebral arterial injury (BVI). |
Thirty-eight patients (0.53% of blunt trauma admissions) were diagnosed with 47 BVIs during a 3.5-year period. Motor vehicle crash was the most common mechanism, and associated injuries were common. Cervical spine injuries were present in 71% of patients, but there was no predilection for cervical vertebral level or fracture pattern. The incidence of posterior circulation stroke was 24%, and the BVI-attributable death rate was 8%. Stroke incidence and neurologic outcome were independent of BVI injury grade. In patients treated with systemic heparin, fewer overall had a poor neurologic outcome, and fewer had a poor outcome after stroke. Trends associated with heparin therapy included fewer injuries progressing to a higher injury grade, fewer patients in whom stroke developed, and fewer patients deteriorating neurologically from diagnosis to discharge. |
2 |
| 82. Burlew CC, Sumislawski JJ, Behnfield CD, et al. Time to stroke: A Western Trauma Association multicenter study of blunt cerebrovascular injuries. The Journal of Trauma and Acute Care Surgery. 85(5):858-866, 2018 11. |
Observational-Dx |
492 patients |
To determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury. |
During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred. |
2 |
| 83. Anaya C, Munera F, Bloomer CW, Danton GH, Caban K. Screening multidetector computed tomography angiography in the evaluation on blunt neck injuries: an evidence-based approach. Seminars in Ultrasound, CT & MR. 30(3):205-14, 2009 Jun. |
Review/Other-Dx |
NA |
To discuss an evidence based approach of screening multidetector computed tomography angiography in the evaluation on blunt neck injuries |
No results stated in the abstract. |
4 |
| 84. Cothren CC, Moore EE, Ray CE Jr, Johnson JL, Moore JB, Burch JM. Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury. Surgery. 141(1):76-82, 2007 Jan. |
Observational-Dx |
23 patients |
To hypothesize that specific cervical spine fracture patterns that warrant screening evaluation exist, hence limiting unwarranted diagnostic imaging. |
During the study period from January 1996 to January 2005, there were 17,007 blunt trauma admissions. Twenty-three patients presented with symptoms of BCVI. Screening angiography was performed in 766 patients (4.5%), and diagnosed 258 (34%) patients with BCVI. One hundred twenty-five patients with BCVI had cervical spine fractures; 18 patients had isolated CAI; 84 had isolated VAI, and 23 had combined CAI and VAI. Eight patients with VAI had minor cervical fractures but underwent screening for other injury patterns. Fractures in the remaining patients with BCVI were 1 of 3 patterns. Subluxations in 56 (48%) patients, C1 to C3 cervical spine fractures in 42 (36%), or extension of the fracture through the foramen transversarium in 19 (16%). Cervical spine fractures were the sole indication for screening in 90% of the study population. Screening yield of all patients admitted with 1 of these 3 fracture patterns was 37%. |
2 |
| 85. Kopelman TR, Leeds S, Berardoni NE, et al. Incidence of blunt cerebrovascular injury in low-risk cervical spine fractures. American Journal of Surgery. 202(6):684-8; discussion 688-9, 2011 Dec. |
Review/Other-Dx |
260 patients |
To determine the incidence of BCVI with CSfx in the absence of high-risk injury patterns. |
A total of 260 patients had CSfx. When screened for high-risk pattern of injury for BCVI, 168 patients were identified and 13 had a BCVI (8%). The remaining 92 patients had isolated low CSfx (C4-C7) without other risk factors for BCVI. In this group, 2 patients were diagnosed with BCVI (2%). Failure to screen all patients with CSfx would have missed 2 of 15 BCVIs (13%). |
4 |
| 86. McKinney A, Ott F, Short J, McKinney Z, Truwit C. Angiographic frequency of blunt cerebrovascular injury in patients with carotid canal or vertebral foramen fractures on multidetector CT. European Journal of Radiology. 62(3):385-93, 2007 Jun. |
Observational-Dx |
71 patients |
To evaluate the rate of occurrence of BCI/BVI in patients screened purely by the radiologic criteria of fracture through the carotid canal or vertebral transverse foramina, or significant cervical subluxation, noted by multidetector CT. |
Two thousand and seventy-three total blunt trauma admissions occurred during the time period, with a BCVI rate of 0.92-1.0% (depending on the reviewer), similar to previous studies. Mean time to catheter angiography was 16.6 h. Of the 71 included patients, there were 11-12 BCI's and 10-12 BVI's, an overall rate of 27-30% of BCVI in the patients with foraminal fractures. Interobserver agreement in reviewing the catheter angiograms was excellent (Kappa 0.795). Of note, three internal carotid pseudoaneurysms resolved spontaneously after anticoagulation or aspirin. |
2 |
| 87. Paulus EM, Fabian TC, Savage SA, et al. Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it. J Trauma Acute Care Surg. 76(2):279-83; discussion 284-5, 2014 Feb. |
Observational-Dx |
594 patients |
To determine the diagnostic accuracy of the 64-channel multidetector computed tomographic angiography (CTA) for trauma patients with blunt cerebrovascular injury (BCVI). |
A total of 594 patients met criteria for BCVI screening and underwent both CTA and Digital subtraction angiography (DSA). One hundred twenty-eight patients (22% of those screened) had 163 injured vessels: 99 (61%) carotid artery injuries and 64 (39%) vertebral artery injuries. Sixty-four-channel CTA demonstrated an overall sensitivity per vessel of 68% and specificity of 92%. The 52 false-negative findings on CTA were composed of 34 carotid artery injuries and 18 vertebral artery injuries; 32 (62%) were Grade I injuries. Overall, positive predictive value was 36.2%, and negative predictive value was 97.5%. Six procedure-related complications (1%) occurred with DSA, including two iatrogenic dissections and one stroke. |
3 |
| 88. Malhotra AK, Camacho M, Ivatury RR, et al. Computed tomographic angiography for the diagnosis of blunt carotid/vertebral artery injury: a note of caution. Annals of Surgery. 246(4):632-42; discussion 642-3, 2007 Oct. |
Observational-Dx |
119 consecutive patients |
Prospective study to validate the accuracy of CTA in replacing DSA for diagnosing or excluding blunt carotid/vertebral injuries. |
DSA identified 26 blunt carotid/vertebral injuries; CTA identified 19 and failed to identify 7 injuries. Excluding the 3 nonevaluable CTA, the sensitivity, specificity, PPV and NPV values of CTA were 74%, 86%, 65%, and 90%, respectively. Recommend CTA not be used to screen for blunt carotid/vertebral injuries until more data are available. |
2 |
| 89. Sawiris N, Venizelos A, Ouyang B, Lopes D, Chen M. Current utility of diagnostic catheter cerebral angiography. Journal of Stroke & Cerebrovascular Diseases. 23(3):e145-50, 2014 Mar. |
Review/Other-Dx |
200 studies |
To perform an observational cross-sectional study of consecutive patients undergoing diagnostic cerebral angiography at an urban tertiary care center |
Of the 200 consecutive studies over 8 months, 55% were for purely diagnostic purposes, whereas the remaining were for surveillance. The most common indications were subarachnoid hemorrhage, ischemic stroke, intracerebral hemorrhage, cerebral aneurysm, and arteriovenous malformation. New findings were detected in 43% of purely diagnostic angiograms and 32% of surveillance studies. We found false-negative rates of 9.9% and false-positive rates of 11.7%. In 23.4% of cases, more precise anatomic information was found that was subjectively deemed clinically meaningful. |
4 |
| 90. Biffl WL, Ray CE Jr, Moore EE, et al. Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Annals of Surgery. 235(5):699-706; discussion 706-7, 2002 May. |
Observational-Dx |
171 patients |
To assess the impact of routine follow-up arteriography on the management and outcome of patients with acute blunt cerebrovascular injuries (BCVI). |
From June 1990 to October 2001, 171 patients (115 male, age 36 +/- 1 years) were diagnosed with BCVI. Mean injury severity score was 28 +/- 1; associated injuries included brain (57%), spine (44%), chest (43%), and face (34%). Mechanism was motor vehicle crash in 50%, fall in 11%, pedestrian struck in 11%, and other in 29%. One hundred fourteen patients had 157 carotid artery injuries (43 bilateral), and 79 patients had 97 vertebral artery injuries (18 bilateral). The breakdown of injury grades was 137 grade I, 52 grade II, 32 grade III, 25 grade IV, and 8 grade V. One hundred fourteen (73%) carotid and 65 (67%) vertebral arteries were restudied with arteriography 7 to 10 days after the injury. Eight-two percent of grade IV and 93% of grade III injuries were unchanged. However, grade I and II lesions changed frequently. Fifty-seven percent of grade I and 8% of grade II injuries healed, allowing cessation of therapy, whereas 8% of grade I and 43% of grade II lesions progressed to pseudoaneurysm formation, prompting interventional treatment. There was no significant difference in healing or in progression of injuries whether treated with heparin or antiplatelet therapy or untreated. However, heparin may improve the neurologic outcome in patients with ischemic deficits and may prevent stroke in asymptomatic patients. |
2 |
| 91. Biffl WL, Ray CE Jr, Moore EE, Mestek M, Johnson JL, Burch JM. Noninvasive diagnosis of blunt cerebrovascular injuries: a preliminary report. J Trauma. 53(5):850-6, 2002 Nov. |
Observational-Dx |
46 patients |
To determine the accuracy of CTA and MRA in identifying blunt cerebrovascular injuries in asymptomatic patients. Studies evaluated in a blinded manner. |
CTA had sensitivity of 68%, specificity 67%, PPV 65%, NPV of 70%. CTA missed 55% of grade I injuries, 14% of grade II injuries, and 13% of grade III injuries. 16 patients had both MRA and arteriography. One (11%) had a false-negative MRA result, and 4 (57%) had false-positive MRA results (75% sensitivity, 67% specificity, 43% PPV, 89% NPV). Arteriography remains the gold standard but CTA should be used if not available for screening purposes. |
1 |
| 92. Payabvash S, McKinney AM, McKinney ZJ, Palmer CS, Truwit CL. Screening and detection of blunt vertebral artery injury in patients with upper cervical fractures: the role of cervical CT and CT angiography. Eur J Radiol. 83(3):571-7, 2014 Mar. |
Observational-Dx |
210 patients |
To evaluate the clinical utility of nonenhanced CT (NECT)-based screening criteria and CTA in detection of blunt vertebral artery injury (BVAI) in trauma patients with C1 and/or C2 fractures. |
210 patients were included; of these, 124 underwent CTA (21/124 with digital subtraction angiography, DSA), and 2 underwent DSA only. Overall, 30/126 suffered BVAI. Among 21 patients who underwent both CTA and DSA, there was 1 false negative and 1 false positive (both grade 1). There was strong interobserver agreement regarding CTA-based BVAI detection (kappa=0.93, p<0.001) and grading (kappa=0.90, p<0001). Only 3/30 BVAI patients suffered a posterior circulation stroke; none of the patients who had a negative CTA or were not selected for CTA, based on NECT screening criteria, suffered symptomatic stroke. While C1/C2 comminuted fracture was more common in patients with high grade BVAI (p=0.039), simultaneous C3-C7 comminuted fracture increased the overall BVAI risk (p=0.011). |
3 |
| 93. Wang AC, Charters MA, Thawani JP, Than KD, Sullivan SE, Graziano GP. Evaluating the use and utility of noninvasive angiography in diagnosing traumatic blunt cerebrovascular injury. J Trauma Acute Care Surg. 72(6):1601-10, 2012 Jun. |
Observational-Dx |
38 patients |
To explore the utility, effectiveness, and cost of noninvasive computed tomography angiography (CTA) and magnetic resonance angiography (MRA) screening for blunt cerebrovascular injury (BCVI). |
Of reviewed patients, 196 received CTA or MRA. Thirty-eight patients (19.4%) were diagnosed with BCVI. Screening yield in patients symptomatic at presentation was 48.8%. Large-vessel internal carotid, vertebral, anterior spinal, and basilar artery occlusion were associated with a positive screen, as were concurrent stroke and spinal cord injury (p < 0.01). Of patients with injuries found with noninvasive imaging, 50.0% of BCVI involved C1-3 fracture, 34.2% involved subluxation, and 65.8% involved foramina transversaria. In both symptomatic and asymptomatic patients, CTA screening was more cost effective than Digital subtraction angiography (DSA) . |
3 |
| 94. Kik CC, Slooff WM, Moayeri N, de Jong PA, Muijs SPJ, Oner FC. Diagnostic accuracy of computed tomography angiography (CTA) for diagnosing blunt cerebrovascular injury in trauma patients: a systematic review and meta-analysis. [Review]. European Radiology. 32(4):2727-2738, 2022 Apr. |
Review/Other-Dx |
3293 studies |
To investigate the diagnostic accuracy of CTA in detecting BCVI in comparison with DSA in trauma patients |
Of the 3293 studies identified, 9 met the inclusion criteria. Pooled sensitivity was 64% (95% CI, 53-74%) and specificity 95% (95% CI, 87-99%) The estimated positive likelihood ratio was 11.8 (95%, 5.6-24.9), with a negative likelihood ratio of 0.38 (95%, 0.30-0.49) and a diagnostic odds ratio of 31 (95%, 17-56). |
4 |
| 95. Eastman AL, Chason DP, Perez CL, McAnulty AL, Minei JP. Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma. 2006;60(5):925-929; discussion 929. |
Observational-Dx |
162 patients |
To determine the sensitivity of CTA for the diagnosis of BCVI. The authors hypothesized that advances in CT technology have improved the diagnostic sensitivity of CTA at least to that of invasive catheter angiography. |
Over 11 months, 162 patients were at risk for BCVI. In all, 146 patients received both CTA and CA. 46 BCVIs were identified among 43 patients. In 45/46 cases (98%), the results of CTA and catheter angiography were concordant. There was a single false-negative CTA in a patient with a grade I vertebral artery injury. The remaining 103 patients had normal CTAs confirmed by a normal catheter angiography. The overall sensitivity, specificity, PPV, NPV, and accuracy of CTA for the diagnosis of BCVI were 97.7%, 100%, 100%, 99.3%, and 99.3%, respectively. |
3 |
| 96. Scott WW, Sharp S, Figueroa SA, et al. Clinical and radiographic outcomes following traumatic Grade 1 and 2 carotid artery injuries: a 10-year retrospective analysis from a Level I trauma center. The Parkland Carotid and Vertebral Artery Injury Survey. J Neurosurg. 122(5):1196-201, 2015 May. |
Observational-Dx |
100 patients |
To define their natural history and establish a rational management plan based on lesion progression and cerebral infarction. |
One hundred seventeen Grade 1 and 2 BCIs in 100 patients were identified and available for follow-up. The mean follow-up duration was 60 days. Final imaging of Grade 1 and 2 BCIs demonstrated that 64% of cases had resolved, 13% of cases were radiographically stable, and 9% were improved, whereas 14% radiographically worsened. Of the treatments received, 54% of cases were treated with acetylsalicylic acid (ASA), 31% received no treatment, and 15% received various medications and treatments, including endovascular stenting. There was 1 cerebral infarction that was thought to be related to bilateral Grade 2 BCI, which developed soon after hospital admission. |
2 |
| 97. Grandhi R, Weiner GM, Agarwal N, et al. Limitations of multidetector computed tomography angiography for the diagnosis of blunt cerebrovascular injury. Journal of Neurosurgery. 128(6):1642-1647, 2018 06. |
Observational-Dx |
140 patients |
To perform a retrospective analysis of patients who experienced BCVI between 2013 and 2015 at 2 Level I trauma centers. |
A total of 140 patients (64% males, mean age 50 years) with 156 cerebrovascular blunt injuries to the carotid and/or vertebral arteries were identified. After comparison with DSA findings, CTA findings were incorrect in 61.5% of vessels studied, and the overall CTA false-positive rates were 47.4% of vessels studied and 47.9% of patients screened. The positive predictive value (PPV) for CTA was higher among worse BCVI subtypes on initial imaging (PPV 76% and 97%, for BCVI Grades II and IV, respectively) compared with Grade I injuries (PPV 30%, p < 0.001). CONCLUSIONS In the current series, multidetector CTA as a screening test for blunt cerebrovascular injury had a high-false positive rate, especially in patients with Grade I BCVI. Given a false-positive rate of 47.9% with an estimated average of 132 patients per year screening positive for BCVI with CTA, approximately 63 patients per year would potentially be treated unnecessarily with antithrombotic therapy at a busy United States Level I trauma center. The authors' data support the use of DSA after positive findings on CTA in patients with suspected BCVI. DSA as an adjunctive test in patients with positive CTA findings allows for increased diagnostic accuracy in correctly diagnosing BCVI while minimizing risk from unnecessary antithrombotic therapy in polytrauma patients. |
2 |
| 98. Shahan CP, Magnotti LJ, Stickley SM, et al. A safe and effective management strategy for blunt cerebrovascular injury: Avoiding unnecessary anticoagulation and eliminating stroke. The Journal of Trauma and Acute Care Surgery. 80(6):915-22, 2016 06. |
Observational-Dx |
228 patients |
To perform to evaluate outcomes, including the potential for missed clinically significant BCVI, since this new management algorithm was adopted. |
A total of 228 patients underwent DSA: 64% were male, with mean age and Injury Severity Score (ISS) of 43 years and 22, respectively. A total of 189 patients (83%) had a positive screening CTA result. Of these, DSA confirmed injury in 104 patients (55%); the remaining 85 patients (45%) (false-positive results) were found to have no injury on DSA. Five patients (4.8%) experienced BCVI-related strokes, unchanged from the previous study (3.9%, p = 0.756); two were symptomatic at trauma center presentation, and three occurred while receiving appropriate therapy. No patient with a negative screening CTA result experienced a stroke. |
2 |
| 99. Wagner MJ, Hussein I, Low G, Samji KB. Comparing the Denver criteria sets for blunt trauma: a retrospective study of cases in Edmonton, Alberta. British Journal of Radiology. 96(1148):20221116, 2023 Aug. |
Observational-Dx |
447 patients |
To determine whether a more conservative Denver criterion set could reduce unnecessary CT angiography (CTA) studies when screening for blunt cerebrovascular injury (BCVI) following blunt trauma. |
The specificities of the Original, Modified, and Expanded Denver criteria were 43.58%, 34.32%, and 24.85%, respectively. Positive-predictive values (PPV) followed a different trend, with respective values of 2.77%, 3.06%, and 2.78%. Sensitivity and negative-predictive values (NPV) were found to be 100% for each criterion set. Being positive for a criterion set, and the presence of BCVI, was statistically significant for the original Denver criteria (p = 0.021, n = 443), but not the modified (p = 0.100, n = 345) or expanded Denver criteria (p = 0.202, n = 333). |
2 |
| 100. Karagiorgas GP, Brotis AG, Giannis T, et al. The diagnostic accuracy of magnetic resonance angiography for blunt vertebral artery injury detection in trauma patients: A systematic review and meta-analysis. [Review]. Clin Neurol Neurosurg. 160:152-163, 2017 Sep. |
Review/Other-Dx |
91 studies |
To define the diagnostic accuracy of MRA in comparison to digital subtraction angiography (DSA) for the detection of blunt vertebral artery injury in trauma patients. |
Five studies fulfilled our eligibility criteria. Two authors assessed the risk of bias and applicability concerns using QUADAS-2. Two-by-two contingency tables were constructed on a per-vessel level. Heterogeneity was tested by the statistical significance of Cochran's Q, and was quantified by the Higgins's I2 metric. The pooled estimates of sensitivity and specificity for blunt vertebral artery injury detection with MRA in comparison to DSA were calculated based on the bivariate model. The meta-analysis was supplemented by subgroup and sensitivity analysis, as well as analysis for publication bias. There was significant clinical heterogeneity in the targeted population, inclusion criteria, and MRA related parameters. The reporting bias and applicability concerns were moderate and low, respectively. In the overall analysis, the sensitivity ranged from 25% to 85%, while the specificity varied from 65% to 99%, across studies. According to the bivariate model, the pooled sensitivity and specificity of MRA in the evaluation of patients with blunt vertebral artery was as high as 55% (95% CI 32.1%-76.7%), and 91% (95% CI 66.3%-98.2%), respectively. Subgroup analysis in terms of MRA sequence sensitivity of phase, the contrasted MRA (75% [95% CI 43%-92%]) seemed to be superior to the TOF MRA (46% [95%CI 20%-74%]). The addition of contrast enhancement did not seem to improve the diagnostic yield of MRA. The Egger's test did not identify any significant publication bias (p=0.2). An important limitation of the current meta-analysis is the small number of eligible studies, as well as the lack of studies on newer, high-field MR scanners. We concluded that MRA has a moderate diagnostic accuracy in the diagnosis of blunt vertebral artery injuries. Further studies on high-field magnetic resonance scanners are recommended. |
4 |
| 101. Friedman D, Flanders A, Thomas C, Millar W. Vertebral artery injury after acute cervical spine trauma: rate of occurrence as detected by MR angiography and assessment of clinical consequences. AJR Am J Roentgenol. 164(2):443-7; discussion 448-9, 1995 Feb. |
Observational-Dx |
37 patients |
To assess prospectively the frequency of vertebral artery injuries after major acute cervical spine trauma as determined by MR angiography and to assess the clinical consequences of these injuries. |
Findings on MR angiograms were abnormal in nine patients (24%). In seven cases, one vertebral artery was diagnosed as nonvisualized (occluded) or focally narrowed; one patient had bilateral vertebral artery injuries; and one patient had nonvisualization of the left common carotid and left vertebral arteries. In all 37 control subjects, both vertebral arteries were identified on MR angiograms. A significant difference in the frequency of vertebral artery nonvisualization (occlusion) was found between the trauma and control populations. The patient with bilateral vertebral artery injuries died 2 days after hospital admission of a massive infarction of the right cerebellar hemisphere. The other eight patients with vertebral artery injuries, and the remaining 28 patients with normal findings on MR angiograms, had no intracranial neurologic deficits that could be ascribed to a major arterial injury. |
2 |
| 102. Liang T, Plaa N, Tashakkor AY, Nicolaou S. Imaging of blunt cerebrovascular injuries. Semin Roentgenol 2012;47:306-19. |
Review/Other-Dx |
N/A |
To discuss the imaging of blunt cerebrovascular injuries |
No results stated in the abstract. |
4 |
| 103. Vertinsky AT, Schwartz NE, Fischbein NJ, Rosenberg J, Albers GW, Zaharchuk G. Comparison of multidetector CT angiography and MR imaging of cervical artery dissection. AJNR Am J Neuroradiol. 2008;29(9):1753-1760. |
Observational-Dx |
18 patients |
To compare the ability of multidetector CT/CTA and MR imaging/MRA to detect common imaging findings of dissection. |
Eighteen patients with 25 dissected vessels (15 internal carotid arteries [ICA] and 10 vertebral arteries [VA]) met the inclusion criteria. CT/CTA identified more intimal flaps, pseudoaneurysms, and high-grade stenoses than MR imaging/MRA. CT/CTA was preferred for diagnosis in 13 vessels (5 ICA, 8 VA), whereas MR imaging/MRA was preferred in 1 vessel (ICA). The 2 techniques were deemed equal in the remaining 11 vessels (9 ICA, 2 VA). A significant preference for CT/CTA was noted for VA dissections (P < .05), but not for ICA dissections. |
2 |
| 104. Sliker CW, Mirvis SE, Shanmuganathan K. Assessing cervical spine stability in obtunded blunt trauma patients: review of medical literature. [Review] [34 refs]. Radiology. 234(3):733-9, 2005 Mar. |
Review/Other-Dx |
1,161 patients |
To review the medical literature on dynamic fluoroscopic and MRI assessment of cervical spine stability in obtunded blunt trauma patients. |
No statistical evidence of the diagnostic superiority of either modality in the diagnosis of unstable cervical injuries. MRI routinely depicts the entire cervical spine and does not carry the safety risk that fluoroscopy has. For these reasons, MRI should be the preferred technique for assessing cervical spine stability in obtunded blunt trauma patients. |
4 |
| 105. Schuster R, Waxman K, Sanchez B, et al. Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits. Archives of Surgery. 140(8):762-6, 2005 Aug. |
Observational-Dx |
2854 patients |
To review the registry data for blunt trauma patients with normal computed tomographic results and no motor deficits. |
During the study period, 2854 trauma patients were admitted, of whom 91.2% had blunt trauma. Of these patients, 56.2% had a closed head injury. One hundred patients had cervical spine and/or spinal cord injuries. Eighty-five patients had a cervical spine injury diagnosed by CT. Fifteen patients had admission neurologic deficits not seen on CT, and 7 of these patients had non-bony abnormalities on MRI. Ninety-three patients had a normal admission motor examination result, a CT result negative for trauma, and persistent cervical spine pain, and were examined with MRI. All MRI examination results were negative for clinically significant injury. Seventeen patients had MRIs that showed degenerative disc disease, and 6 had spinal canal stenosis secondary to ossification. Twelve comatose patients (Glasgow Coma Scale score, <9), moving all 4 extremities on arrival, with normal CT results of the cervical spine, were examined with MRI. All of these MRI examination results were negative for injury. None of the patients experienced neurologic deterioration. No patient required operative management of spinal injury. |
4 |
| 106. Shen HX, Li M. Cervical spine clearance in obtunded patients after severe polytrauma. [Review] [20 refs]. Chin J Traumatol. 12(3):157-61, 2009 Jun. |
Review/Other-Dx |
N/A |
To provide clinicians with data supporting three different clearance techniques in the obtunded patients after severe polytrauma. |
Currently, there were three accepted techniques for clearance of the cervical spine in obtunded patients after severe polytrauma. Each of these methods has advantages and disadvantages to both of the patients and the clinicians. |
4 |
| 107. Saltzherr TP, Fung Kon Jin PH, Beenen LF, Vandertop WP, Goslings JC. Diagnostic imaging of cervical spine injuries following blunt trauma: a review of the literature and practical guideline. [Review] [79 refs]. Injury. 40(8):795-800, 2009 Aug. |
Review/Other-Dx |
N/A |
To review the literature and practice guideline of the diagnostic imaging of cervical spine injuries following blunt trauma: |
No results stated in the abstract |
4 |
| 108. Plumb JO, Morris CG. Clinical review: Spinal imaging for the adult obtunded blunt trauma patient: update from 2004. [Review]. Intensive Care Med. 38(5):752-71, 2012 May. |
Review/Other-Dx |
N/A |
To provide a clinically relevant update of the available evidence since our last review and practice recommendations in 2004. |
Plain radiography has low sensitivity for detecting unstable spinal injuries in OBTPs whereas multidetector-row computerised tomography (MDCT) approaches 100%. Magnetic resonance imaging (MRI) is inferior to MDCT for detecting bony injury but superior for detecting soft tissue injury with a sensitivity approaching 100%, although 40% of such injuries may be stable and 'false positive'. For studies comparing MDCT with MRI for OBTPs; MRI following 'normal' CT may detect up to 7.5% missed injuries with an operative fixation in 0.29% and prolonged collar application in 4.3%. Increasing data is available on the complications associated with prolonged spinal immobilisation among a population where a minority have an actual injury. |
4 |
| 109. Ackland HM, Cameron PA, Wolfe R, et al. Outcomes at 12 months after early magnetic resonance imaging in acute trauma patients with persistent midline cervical tenderness and negative computed tomography. Spine. 38(13):1068-81, 2013 Jun 01. |
Observational-Dx |
178 patients |
To determine the association of acute findings and demographic characteristics with any long-term neck disability, and with time to return to work in such patients. |
There were 162 of 178 patients available for follow-up at 12 months (91%). Of these, 46% had MRI-identified cervical spine injury at their initial examination, and 22% had required clinical management, including 2.5% with operative stabilization. Neck disability was present in 43% of patients and was associated with depressive symptoms, workers' compensation, and low annual income. Delay in return to work was associated with the presence of minor limb/other fractures and depressive symptoms, whereas patients on high annual incomes were found to return to work more quickly. |
2 |
| 110. Kaiser ML, Whealon MD, Barrios C, Kong AP, Lekawa ME, Dolich MO. The current role of magnetic resonance imaging for diagnosing cervical spine injury in blunt trauma patients with negative computed tomography scan. American Surgeon. 78(10):1156-60, 2012 Oct. |
Observational-Dx |
114 patients |
1) to establish the incidence of CS injury identified through MRI in altered patients with negative CS CT; 2) characterize the demographics and outcomes of patients with such injuries; and 3) identify any risk factors, including CT resolution, associated with injuries missed on CT. |
One hundred fourteen patients met inclusion criteria, of which 23 had MRI findings. Seven (6%) of these had neurologic deficits and/or a change in management on the basis of MRI findings. Although use of the single-slice scanner was significantly associated with MRI findings (odds ratio, 2.62; P=0.023), no significant clinical risk factors were identified. Patients with MRI findings were heterogeneous in terms of age, mechanism, and Injury Severity Score. |
3 |
| 111. Tan LA, Kasliwal MK, Traynelis VC. Comparison of CT and MRI findings for cervical spine clearance in obtunded patients without high impact trauma. Clin Neurol Neurosurg. 120:23-6, 2014 May. |
Observational-Dx |
83 patients |
To evaluate and compare cervical spinal computed tomography (CT) and magnetic resonance imaging (MRI) findings in this particular group of patients. |
Eighty-three patients were identified from the computer database. Twenty-eight of these patients had positive findings on both CT and MRI (33.73% - Group I); four patients had a negative CT but had positive findings on follow-up MRI (4.82% - Group II); fifty-one patients had both negative CT and MRI (61.44% - Group III). All patients in Group I required either surgical stabilization or continuation of rigid cervical orthosis. All four patients in Group II had intramedullary T2 hyper intensity consistent with possible spinal cord injury on MRI, but did not have any signs of fracture or ligamentous injury to suggest instability. They eventually underwent surgical decompression of the spinal cord during the same hospital stay. Cervical collars were safely removed in all patients in Group III. In our retrospective study, CT had a sensitivity of 0.875 [0.719-0.950, 95% CI] and a specificity of 1.000 [0.930-1.000, 95% CI] in detecting all cervical spine injuries compared to MRI. However, all patients with missed injuries had intramedullary T2 hyper intensity consistent with possible spinal cord injury on MRI and were not unstable precluding cervical spine clearance. If only unstable injuries are considered, CT had a sensitivity of 1.00 [0.879-1.000, 95% CI] and a specificity is 1.000 [0.935-1.000, 95% CI] compared to MRI in this particular group of patients. |
3 |
| 112. Craxford S, Bayley E, Walsh M, Clamp J, Boszczyk BM, Stokes OM. Missed cervical spine injuries: a national survey of the practice of evaluation of the cervical spine in confused and comatose patients. Bone Joint J. 98-B(6):825-8, 2016 Jun. |
Observational-Dx |
N/A |
To investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals. |
Written guidelines were used in 138 hospitals (85%). CT scanning was the first-line investigation in 122 (75%). A normal CT scan was sufficient to clear the cervical spine in 73 (45%). However, 40 (25%) would continue precautions until the patient regained full consciousness. MRI was performed in all confused or comatose patients with a possible cervical spinal injury in 15 (9%). There were variations in the grade and speciality of the clinician who had responsibility for deciding when to discontinue precautions. A total of 31 (19%) reported at least one missed cervical spinal injury following discontinuation of spinal precautions within the last five years. Only 93 (57%) had a formal mechanism for reviewing missed injuries. |
4 |
| 113. Malhotra A, Durand D, Wu X, et al. Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT. European Radiology. 28(7):2823-2829, 2018 Jul. |
Review/Other-Dx |
1,271 patient |
To determine the utility of cervical spine MRI in blunt trauma evaluation for instability after a negative non-contrast cervical spine CT. |
A total of 1,271 patients with blunt cervical spine trauma underwent both cervical spine CT and MRI within 48 h; 1,080 patients were included in the study analysis. Sixty-six percent of patients with a CT cervical spine study had a negative study. Of these, the subsequent cervical spine MRI had positive findings in 20.9%; 92.6% had stable ligamentous or osseous injuries, 6.0% had unstable injuries and 1.3% had potentially unstable injuries. For unstable injury, the NPV for CT was 98.5%. In all 712 patients undergoing both CT and MRI, only 1.5% had unstable injuries, and only 0.42% had significant change in management. |
4 |
| 114. Chilvers G, Janjua U, Choudhary S. Blunt cervical spine injury in adult polytrauma: incidence, injury patterns and predictors of significant ligament injury on CT. Clinical Radiology. 72(11):907-914, 2017 Nov. |
Review/Other-Dx |
N/A |
To describe the pattern of cervical spine fractures in adult major trauma and identify computed tomography (CT) parameters that can predict significant ligament injury when fractures are absent; to define the normal range for parameters used; and identify common variations due to position of cervical immobilisation in a trauma patient. |
Significant ligament injury on MRI was detected at the craniocervical junction, when CT showed a basion dens interval of >10 mm, widened incongruous C0/C1 facet joint space of >3 mm, and widened C1/2 facet joint space of >6 mm. In the subaxial cervical spine, facet subluxation >50% and obscured posterior paraspinal fat pad were the only reliable predictors of ligament injury, as confirmed on subsequent MRI. |
4 |
| 115. Wu X, Malhotra A, Geng B, et al. Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma. Annals of Emergency Medicine. 71(1):64-73, 2018 Jan. |
Observational-Dx |
1 patient |
To evaluate the utility and cost-effectiveness of using MRI versus no follow-up in this patient population. |
The cost of MRI follow-up was $11,477, with a health benefit of 24.03 quality-adjusted life-years; the cost of no follow-up was $6,432, with a health benefit of 24.08 quality-adjusted life-years. No follow-up was the dominant strategy, with a lower cost and a higher utility. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10,000 iterations. No follow-up was the better strategy irrespective of the negative predictive value of initial CT result, and it remained the better strategy when the incidence of missed unstable injury resulting in permanent neurologic deficits was less than 64.2% and the incidence of patients immobilized with a hard collar who still received cord injury was greater than 19.7%. Multiple 3-way sensitivity analyses were performed. |
3 |
| 116. Chilvers G, Porter K, Choudhary S. Cervical spine clearance in adults following blunt trauma: a national survey across major trauma centres in England. Clinical Radiology. 73(4):410.e1-410.e8, 2018 04. |
Review/Other-Dx |
N/A |
To assess current practice in cervical spine clearance across major trauma centres in England and review current guidelines. |
Eighteen out of the 22 (82%) centres responded by completing the survey. Most (71%) centres used the Canadian C-Spine Rule for clearing the cervical spine clinically. Seventy-two percent of centres preferred computed tomography (CT) as the first-line imaging technique, the choice based on age of patient and mechanism of injury. If the initial CT imaging was normal, magnetic resonance imaging (MRI) was performed in 52% of centres to clear the cervical spine, with half of these centres stating that they would discuss further imaging with a radiologist first. The practice across centres was highly variable for the obtunded patient, with most centres preferring continuing immobilisation or MRI to clear the cervical spine, with a small minority removing spinal precautions when a high-quality multidetector CT was normal. |
4 |
| 117. Malhotra A, Wu X, Kalra VB, et al. Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis. [Review]. European Radiology. 27(3):1148-1160, 2017 Mar. |
Review/Other-Dx |
23 articles |
To quantify the rate of unstable injuries detected by MRI missed on CT in blunt cervical spine (CS) trauma patients and assess the utility of MRI in CS clearance. |
Of 428 unique citations, 23 proved eligible, with 5,286 patients found, and 16 unstable injuries reported in five studies. The overall pooled incidence is 0.0029 %. Among studies reporting only obtunded patients, the pooled incidence is 0.017 %. In alert patients, the incidence is 0.011 %. All reported positive findings were critically reviewed, and only 11 could be considered truly unstable. |
4 |
| 118. Novick D, Wallace R, DiGiacomo JC, Kumar A, Lev S, George Angus LD. The cervical spine can be cleared without MRI after blunt trauma:A retrospective review of a single level 1 trauma center experience over 8 years. American Journal of Surgery. 216(3):427-430, 2018 09. |
Observational-Dx |
241 patients |
To identify 241 patients who underwent CT scan and MRI of the cervical spine. |
The CT scans were normal in 153 patients, and abnormal in 88. Of the 88 abnormal CT scans, the MRIs were abnormal in 65, and normal in the other 23. The indications for MRI in patients with normal CT scans were neck pain, an abnormal neurologic examination, and/or altered mental status. Of the 13 patients with abnormal MRIs, none were pain free with a normal clinical examination. |
2 |
| 119. Minja FJ, Mehta KY, Mian AY. Current Challenges in the Use of Computed Tomography and MR Imaging in Suspected Cervical Spine Trauma. [Review]. Neuroimaging Clin N Am. 28(3):483-493, 2018 Aug. |
Review/Other-Dx |
N/A |
To discuss the current challenges in the use of computed tomography and MR Imaging in Suspected Cervical Spine Trauma. |
No results stated in the abstract. |
4 |
| 120. Izzo R, Popolizio T, Balzano RF, et al. Imaging of cranio-cervical junction traumas. [Review]. Eur J Radiol. 127:108960, 2020 Jun. |
Review/Other-Dx |
N/A |
To identify which patients can benefit of surgical stabilization and prevent secondary neurologic damage. |
No results stated in the abstract |
4 |
| 121. Lee JY, Vaccaro AR, Lim MR, et al. Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma. Journal of Orthopaedic Science. 10(6):671-5, 2005 Nov. |
Review/Other-Dx |
N/A |
To identify similarities in treatment algorithms for common thoracolumbar injuries, as well as to identify characteristics of injury that played a key role in the decision-making process. |
Based on the survey, the Spine Trauma Group has developed a classification system and an injury severity score (thoracolumbar injury classification and severity score, or TLICS), which may facilitate communication between physicians and serve as a guideline for treating these injuries. The classification system is based on the morphology of the injury, integrity of the posterior ligamentous complex, and neurological status of the patient. Points are assigned for each category, and the final total points suggest a possible treatment option. |
4 |
| 122. Krakenes J, Kaale BR. Magnetic resonance imaging assessment of craniovertebral ligaments and membranes after whiplash trauma. Spine (Phila Pa 1976). 2006;31(24):2820-2826. |
Review/Other-Dx |
N/A |
To determine the role of MRI for soft tissue abnormalities in patients with a history of whiplash trauma. |
MRI shows structural changes in ligaments and membranes after whiplash injury, and such lesions can be assessed with reasonable reliability. Lesions to specific structures can be linked with specific trauma mechanisms. There is a correlation between clinical impairment and morphologic findings. |
4 |
| 123. Awad BI, Carmody MA, Lubelski D, et al. Adjacent Level Ligamentous Injury Associated with Traumatic Cervical Spine Fractures: Indications for Imaging and Implications for Treatment. World Neurosurgery. 84(1):69-75, 2015 Jul. |
Observational-Dx |
787 patients |
To develop guidelines for when magnetic resonance imaging (MRI) should be performed for initially evaluating and treating patients with cervical spine injury (CSI). |
MRI was performed in 240 of 787 patients. Evidence of soft tissue injury (STI) was identified in 54.6%. adjacent level ligamentous injury (ALLI) was the most common STI (80 of 240 patients); these injuries were subdivided into above, below, or both above and below the concurrent fracture level. Patients with ALLI were significantly more likely to have injured C3 (P < 0.01) and C5 (P < 0.03) levels, association with widened disc space (P = 0.03), and multiple CSIs (P = 0.008). The whole ALLI was included in the fixation strategy in 100% of patients with ALLI only above the concurrent fracture level and 87% of patients with ALLI only below the concurrent fracture level. |
3 |
| 124. Shah LM, Ross JS. Imaging of Spine Trauma. [Review]. Neurosurgery. 79(5):626-642, 2016 Nov. |
Review/Other-Dx |
N/A |
To focus on the complementary role of different radiologic modalities in the diagnosis of patients with traumatic injuries of the spine. |
No results stated in the abstract. |
4 |
| 125. Muto M, Giurazza F, Guarnieri G, Izzo R, Diano A. Neuroimaging of Spinal Instability. [Review]. Magn Reson Imaging Clin N Am. 24(3):485-94, 2016 Aug. |
Review/Other-Dx |
N/A |
To reviews the basic concepts of spinal instability and describes the role of different imaging techniques in its assessment. |
No results stated in the abstract. |
4 |
| 126. Cloney M, Kim H, Riestenberg R, Dahdaleh NS. Risk Factors for Transverse Ligament Disruption and Vertebral Artery Injury Following an Atlas Fracture. World Neurosurgery. 146:e1345-e1350, 2021 02. |
Observational-Dx |
97 patients |
To analyze demographic and clinic characteristics, including mechanism of injury, fracture type, and associated injuries. We identified factors independently associated with vertebral artery injury and/or transverse ligament disruption. |
On multivariable analysis, vertebral artery injury was independently, positively associated with injury to the transverse ligament (odds ratio [OR], 8.51 [1.17, 61.72], P = 0.034), associated facial injury (OR, 7.78 [1.05, 57.50]; P = 0.045), intoxication at presentation (OR, 51.42 [1.10, 2408.82]; P = 0.045), and negatively associated with type 3 fractures (OR, 0.081 [0.0081, 0.814]; P = 0.033). There was a trend toward a positive association with a violence mechanism of injury (OR, 33.47 [0.75, 1487.89]; P = 0.070). Transverse ligament injury was independently associated with other injuries to the spine (OR, 13.07362 [2.43, 70.28]; P = 0.003), atlantodental interval (OR, 2.63 [1.02, 6.75]; P = 0.045), lateral mass displacement (OR, 1.78 [1.32, 2.39]; P < 0.001), and male sex (OR, 7.07 [1.47, 34.06]; P = 0.015). There was a trend toward a positive association with injury to the vertebral artery (OR, 5.13 [0.96, 27.35]; P = 0.056). |
2 |
| 127. Guo Z, Shi S, Liu F, et al. Imaging parameters and clinical significance of posterior ligament complex injury in thoracolumbar fracture. Medicine (Baltimore). 102(4):e32721, 2023 Jan 27. |
Observational-Dx |
150 patients |
To investigate whether the combination of radiographs and computed tomography (CT) images can be used as an alternative means of magnetic resonance imaging examination or a preliminary screening method before examination, so as to improve the accuracy of determining the degree of posterior ligament complex injury in thoracolumbar fracture patients. |
No result stated the abstract |
2 |
| 128. Bozzo A, Marcoux J, Radhakrishna M, Pelletier J, Goulet B. The role of magnetic resonance imaging in the management of acute spinal cord injury. [Review]. J Neurotrauma. 28(8):1401-11, 2011 Aug. |
Review/Other-Dx |
N/A |
To review the role of magnetic resonance imaging in the management of acute spinal cord injury |
No results stated in abstract. |
4 |
| 129. Freund P, Seif M, Weiskopf N, et al. MRI in traumatic spinal cord injury: from clinical assessment to neuroimaging biomarkers. [Review]. Lancet Neurology. 18(12):1123-1135, 2019 12. |
Review/Other-Dx |
N/A |
To discuss the MRI in traumatic spinal cord injury from clinical assessment to neuroimaging biomarkers. |
No results stated in the abstract. |
4 |
| 130. Rutsch N, Amrein P, Exadaktylos AK, et al. Cervical spine trauma - Evaluating the diagnostic power of CT, MRI, X-Ray and LODOX. Injury. 54(7):110771, 2023 Jul. |
Observational-Dx |
4996 patients |
To evaluate the sensitivity and specificity of CT, MRI, X-Ray, and, for the first time, LODOX-Statscan in identifying c-spine injuries in patients with blunt trauma and neck pain. |
We identified 4996 patients, of which 2321 met the inclusion criteria. 91.3% (n = 2120) patients received a CT scan, 8.9% (n = 206) a MRI, 9.3% (n = 215) an X-ray, and 21.5% (n = 498) a LODOX scan. By retrospective case review, 186 participants were classified as injured. The sensitivity of CT was 88.6% (specificity 99%), and 89.8% (specificity 99.2%) with orthopedic surgeon consultation. MRI had a sensitivity of 88.5% (specificity of 96.9%); highlighting 14 cases correctly diagnosed as injured by MRI and misdiagnosed by CT. Projection radiography (36.4% sensitivity, 95.1% specificity) and LODOX (5.3% sensitivity, 100% specificity) were unsuitable for ruling out spinal injury. |
2 |
| 131. Miller CP, Brubacher JW, Biswas D, Lawrence BD, Whang PG, Grauer JN. The incidence of noncontiguous spinal fractures and other traumatic injuries associated with cervical spine fractures: a 10-year experience at an academic medical center. Spine. 36(19):1532-40, 2011 Sep 01. |
Review/Other-Dx |
N/A |
To review the incidence of noncontiguous spinal fractures and other traumatic injuries associated with cervical spine fractures |
No results stated in abstract. |
4 |
| 132. Kim S, Yoon CS, Ryu JA, et al. A comparison of the diagnostic performances of visceral organ-targeted versus spine-targeted protocols for the evaluation of spinal fractures using sixteen-channel multidetector row computed tomography: is additional spine-targeted computed tomography necessary to evaluate thoracolumbar spinal fractures in blunt trauma victims? J Trauma 2010;69:437-46. |
Observational-Dx |
72 patients |
To assess retrospectively whether the visceral organ-targeted images obtained from “AP-CT protocol” are comparable with spine-targeted images obtained from “TL spine CT protocol” when accompanied with MPR images obtained from the AP-CT protocol in the evaluation of TL spinal fractures. |
The overall areas under the curves for sets S and A for fracture detection were 0.996 and 0.995, respectively; no significant difference was found between the two sets. Concordance rates for typing performance also showed no statistical significance between the two sets for any of the three observers. |
3 |
| 133. Karul M, Bannas P, Schoennagel BP, et al. Fractures of the thoracic spine in patients with minor trauma: comparison of diagnostic accuracy and dose of biplane radiography and MDCT. European Journal of Radiology. 82(8):1273-7, 2013 Aug. |
Observational-Dx |
107 patients |
To investigate the accuracy of biplane radiography in the detection of fractures of the thoracic spine in patients with minor trauma using multidetector computed tomography (MDCT) as the reference and to compare the dose of both techniques. |
MDCT revealed 77 fractures in 65/107 patients (60.7%). Biplane radiography was true positive in 32/107 patients (29.9%), false positive in 19/107 patients (17.8%), true negative in 23/107 (21.5%) and false negative in 33/107 patients (30.8%), showing a sensitivity of 49.2%, a specificity of 54.7%, a positive predictive value (PPV) of 62.7%, a negative predictive value (NPV) of 41.1%, and an accuracy of 51.4%. The presence of a fracture on biplane radiography was highly statistical significant, if this was simultaneously proven by MDCT (?(2)=7.6; p=0.01). None of the fractures missed on biplane radiography was unstable. The mean DLP on biplane radiography was 14.5mGycm (range 1.9-97.8) and on MDCT 374.6mGycm (range 80.2-871). |
2 |
| 134. Rozenberg A, Weinstein JC, Flanders AE, Sharma P. Imaging of the thoracic and lumbar spine in a high volume level 1 trauma center: are reformatted images of the spine essential for screening in blunt trauma?. Emergency Radiology. 24(1):55-59, 2017 Feb. |
Observational-Dx |
250 patients |
To determine whether there was a difference in the rate of detection of spinal fractures on CTs of the body compared to the reformatted T/L spine. Secondary endpoint to evaluate whether cases dictated by trainees improved fracture detection rate. |
Each report was reviewed to determine if there was a thoracolumbar fracture and whether a trainee had been involved in interpreting the CT body. If a fracture was identified on either report, then the number, type, and location of each fracture was documented. Sixty-nine fractures, from a total of 38 patients, were identified on either the CT of the body or the CT T/L. Sensitivity for CT body interpretations was 94 % (95 % CI: 86-98 %) compared to a 97 % (95 % CI: 89-100 %) sensitivity for the CT T/L (p > 0.5). Although the sensitivity was 97 % (95 % CI: 88-100 %) when a trainee was involved in interpreting the body CT, there was no statistically significant improvement. The results suggest that with careful scrutiny most spine fractures can be diagnosed on body CT images without the addition of spine reformats. |
2 |
| 135. Sheridan R, Peralta R, Rhea J, Ptak T, Novelline R. Reformatted visceral protocol helical computed tomographic scanning allows conventional radiographs of the thoracic and lumbar spine to be eliminated in the evaluation of blunt trauma patients. J Trauma. 55(4):665-9, 2003 Oct. |
Observational-Dx |
1,915 patients |
Prospective study to determine if reformatted CT images of the thoracic and lumbar spine were effective in diagnosing thoracic and lumbar fractures and they could replace radiography. |
Of 1,915 patients, 78 (4.1%), with an average Injury Severity Score of 21.3 +/- 1.2, sustained one or more thoracic (n=35 patients) or lumbar (n=43 patients) spine fractures. Reformatted CT images identified 97% of thoracic and 95% of lumbar fractures as opposed to 62% and 86% respectively for radiographs. Study concludes that reformatted images provide accurate screening, eliminating the time, expense, and radiation exposure associated with conventional radiography. |
2 |
| 136. Rhea JT, Sheridan RL, Mullins ME, Novelline RA. Can chest and abdominal trauma CT eliminate the need for plain films of the spine? – Experience with 329 multiple trauma patients. Emergency Radiology. 2001;8(2):99-104. |
Observational-Dx |
329 patients |
To compare the accuracy of spine plain films with chest and abdominal trauma computed tomography (CT) in detection of spine fractures. |
Of the fractures visible at either chest trauma CT or thoracic spine plain film examination, all were diagnosed on CT and 62 % on plain films. Of fractures visible at either abdominal trauma CT or lumbar spine plain films, 94 % were diagnosed on CT and 67 % on plain films. The one false negative CT involved an articular process fracture, which was visible but not mentioned, in a patient with a sacral fracture. |
3 |
| 137. Martin MJ, Bush LD, Inaba K, et al. Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey. The Journal of Trauma and Acute Care Surgery. 83(6):1032-1040, 2017 12. |
Observational-Dx |
10,191 patients |
To evaluate the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice. |
Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p < 0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p < 0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p < 0.01), and prolonged immobilization (>12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data. |
1 |
| 138. Khanna P, Chau C, Dublin A, Kim K, Wisner D. The value of cervical magnetic resonance imaging in the evaluation of the obtunded or comatose patient with cervical trauma, no other abnormal neurological findings, and a normal cervical computed tomography. J Trauma Acute Care Surg. 72(3):699-702, 2012 Mar. |
Observational-Dx |
150 patients |
To evaluate the utility of MRI in the evaluation of obtunded and comatose patients in the acute setting, and to confirm the usefulness of multidetector CT for the identification of patients in need of operative management. |
Among the 150 obtunded or comatose patients with a negative CT, the majority (51%) had a normal MRI. Among the patients with a positive MRI, the most common MRI-positive findings were ligamentous and soft tissue injury (81%). However, no MRI findings were deemed unstable, and no surgical intervention or change in the clinical management aside from collar immobilization of these individuals occurred after MRI. |
3 |
| 139. Lau BPH, Hey HWD, Lau ET, Nee PY, Tan KA, Tan WT. The utility of magnetic resonance imaging in addition to computed tomography scans in the evaluation of cervical spine injuries: a study of obtunded blunt trauma patients. European Spine Journal. 27(5):1028-1033, 2018 05. |
Review/Other-Dx |
63 patients |
To determine and predict if computed tomography (CT) scans alone can be performed without risking oversight of substantial injuries found on follow-up magnetic resonance imaging (MRI). |
The mean age of patients was 42.3 years and 90.5% were males. CT scans had a high specificity of 100% and sensitivity of 87.2%. Predictors of MRI abnormalities include females, patients with relatively milder mechanisms of injury, patients with suspected thoracic spine injury, and CT scan findings of facet dislocation and intracranial haemorrhage. There was no predictor for spinal cord oedema. |
4 |
| 140. Resnick S, Inaba K, Karamanos E, et al. Clinical relevance of magnetic resonance imaging in cervical spine clearance: a prospective study. JAMA Surg. 149(9):934-9, 2014 Sep. |
Observational-Dx |
830 adults |
To investigate the accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) for CS clearance. |
Overall, 164 CS injuries (19.8%) were diagnosed, and 23 of these (2.8%) were clinically significant. All clinically significant injuries were detected by CT. Fifteen of 681 patients (2.2%) with a normal CT scan had a newly identified finding on MRI; however, none of the injuries required surgical intervention or halo placement. There was no change in management on the basis of MRI findings. The sensitivity and specificity of CT for detecting CS injury was 90.9% and 100%, respectively. For clinically significant CS injuries, the sensitivity was 100% and specificity was 100%. |
3 |
| 141. Badhiwala JH, Lai CK, Alhazzani W, et al. Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review. [Review]. Annals of Internal Medicine. 162(6):429-37, 2015 Mar 17. |
Review/Other-Dx |
3627 patients |
To review evidence about the utility of different cervical spine clearance protocols in excluding significant cervical spine injury after negative CT results in obtunded adults with blunt traumatic injury. |
Of 28 observational studies (3627 patients) that met eligibility criteria, 7 were prospective studies (1686 patients) with low risk of bias and well-interpreted, high-quality CT scans. These 7 studies showed that 0% of significant injuries were missed after negative CT results. The overall studies using confirmatory routine testing with MRI showed incidence rates of 0% to 1.5% for cervical spine instability (16 studies; 1799 patients), 0% to 7.3% for need for operative fixation (17 studies; 1555 patients), and 0% to 29.5% for prolonged collar use (16 studies; 1453 patients). |
4 |
| 142. Bush L, Brookshire R, Roche B, et al. Evaluation of Cervical Spine Clearance by Computed Tomographic Scan Alone in Intoxicated Patients With Blunt Trauma. JAMA Surgery. 151(9):807-13, 2016 09 01. |
Observational-Dx |
1668 patients |
To analyze cervical spine clearance practices and the utility of CT scans of the cervical spine in intoxicated patients with blunt trauma. |
Of 1668 patients, 1103 (66.1%) were male, with a mean (SD) age of 49 (20) years and a mean (SD) Injury Severity Score of 10 (9). Vehicular (734 [44.0%]) and falls (579 [34.7%]) were the most common mechanisms for hospitalization. Intoxication was identified in 632 of 1429 of patients tested (44.2%; 425 [29.7%] by serum alcohol levels and 350 [24.5%] by urine drug screens). Half (316 [50.0%]) were admitted with cervical spine immobilization, and 38 (12%) of these were solely owing to the presence of intoxication. There were 65 abnormal CT scans (10.3%) in the intoxicated group. Among 567 normal CT scans, 4 (0.7%) had central cord syndrome found on initial physical examination, and 1 (0.2%) had a symptomatic unstable ligament injury that was misread as normal on CT scan but was abnormal on magnetic resonance imaging. The 316 patients kept in a cervical collar for intoxication had no missed CSIs but were kept immobilized for a mean (SD) of 12 (19) hours. Computed tomographic scans had an overall negative predictive value of 99.2% for patients with CSIs and a negative predictive value of 99.8% for ruling out CSIs that required immobilization or stabilization. |
2 |
| 143. Raza M, Elkhodair S, Zaheer A, Yousaf S. Safe cervical spine clearance in adult obtunded blunt trauma patients on the basis of a normal multidetector CT scan--a meta-analysis and cohort study. [Review]. Injury. 44(11):1589-95, 2013 Nov. |
Meta-analysis |
10 studies |
To determine whether in obtunded adult patients with blunt trauma, a clinically significant injury to the cervical spine be ruled out on the basis of a normal multidetector cervical spine computed tomography. |
A total of 10 studies involving 1850 obtunded blunt trauma patients with initial cervical spine CT scan reported as normal were included in the final meta-analysis. The cumulative negative predictive value and specificity of cervical spine CT of the ten studies was 99.7% (99.4-99.9%, 95% confidence interval). The positive predictive value and sensitivity was 93.7% (84.0-97.7%, 95% confidence interval). In the retrospective review of our obtunded blunt trauma patients, none was later diagnosed to have significant cervical spine injury that required a change in clinical management. |
M |
| 144. Stelfox HT, Velmahos GC, Gettings E, Bigatello LM, Schmidt U. Computed tomography for early and safe discontinuation of cervical spine immobilization in obtunded multiply injured patients. J Trauma. 63(3):630-6, 2007 Sep. |
Observational-Dx |
215 patients |
Prospective study to compare two different protocols for clearing the cervical spine in obtunded patients. Group 1 was 140 patients who underwent CT plus MRI for clearance; group 2 (75 patients) was CT only. |
CT alone was just as effective as MRI for clearing the spine and decreased the duration of cervical immobilization. |
2 |
| 145. National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. Measuring Sex, Gender Identity, and Sexual Orientation. In: Becker T, Chin M, Bates N, eds. Measuring Sex, Gender Identity, and Sexual Orientation. Washington (DC): National Academies Press (US) Copyright 2022 by the National Academy of Sciences. All rights reserved.; 2022. |
Review/Other-Dx |
N/A |
Sex and gender are often conflated under the assumptions that they are mutually determined and do not differ from each other; however, the growing visibility of transgender and intersex populations, as well as efforts to improve the measurement of sex and gender across many scientific fields, has demonstrated the need to reconsider how sex, gender, and the relationship between them are conceptualized. |
No abstract available. |
4 |
| 146. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. |
Review/Other-Dx |
N/A |
To provide evidence-based guidelines on exposure of patients to ionizing radiation. |
No abstract available. |
4 |
