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Study Quality
1. Mirvis SE, Diaconis JN, Chirico PA, Reiner BI, Joslyn JN, Militello P. Protocol-driven radiologic evaluation of suspected cervical spine injury: efficacy study. Radiology. 170(3 Pt 1):831-4, 1989 Mar. Review/Other-Dx 408 patients Prospective study to compare the results of physicians’ bedside assessments of the cervical spine with the results of radiography and CT performed on patients with history of major blunt trauma. 138 (34%) were judged as mentally alert and without symptoms referable to CSI. CT was performed after cervical radiography to adequately visualize the lower cervical spine (132 patients) or to clarify uncertain radiographic findings (6 patients). One nondisplaced transverse process fracture of C-7 was detected. The combined cost of cervical radiography and CT for the 138 asymptomatic patients was $59,202. Study recommends careful bedside clinical assessment of the cervical spine in mentally alert blunt-trauma victims. 4
2. Ross SE, O'Malley KF, DeLong WG, Born CT, Schwab CW. Clinical predictors of unstable cervical spinal injury in multiply injured patients. Injury. 1992; 23(5):317-319. Review/Other-Dx 410 patients 13 patients with unstable cervical spines Prospective study of clinical predictors of unstable cervical spinal injury in multi-trauma. Loss or defect of consciousness, neurologic deficit consistent with cervical cord or nerve root injury and neck tenderness. Without these signs, examination is not mandatory. 4
3. Silberstein M, Tress BM, Hennessy O. Prevertebral swelling in cervical spine injury: identification of ligament injury with magnetic resonance imaging. Clin Radiol. 1992; 46(5):318-323. Review/Other-Dx 27 consecutive patients Retrospective analysis of patients with acute CSI who had MRI. Cervical prevertebral swelling after trauma was indicative of ligament injury in nearly half the patients. This finding should prompt clinical and radiographic follow-up to exclude spinal instability. 4
4. Vandemark RM. Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficiency and communication. AJR. 1990; 155(3):465-472. Review/Other-Dx N/A To present a risk–tailored approach of using cervical spine radiographs to improve efficiency. Tailored approach necessary. Detracts myth of the painless CSI. Examine in accordance with risk level. 4
5. Berne JD, Velmahos GC, El-Tawil Q, et al. Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study. J Trauma. 1999; 47(5):896-902; discussion 902-893. Observational-Dx 58 patients Prospective blinded study to evaluate the role of routine helical CT of the cervical spine in high-risk patients. Patients had standard cervical spine radiography. Radiography missed 8 injuries (three unstable) and its sensitivity was 60%, specificity 100%, PPV 100%, and NPV 85.1%. Helical CT scan missed two spinal injuries (both stable) and its sensitivity was 90%, specificity was 100%, PPV 100%, NPV 95%. Spiral CT is superior to radiography in identifying injuries. However, authors recommend that radiography and CT be performed together in high-risk patients. 2
6. Blackmore CC, Emerson SS, Mann FA, Koepsell TD. Cervical spine imaging in patients with trauma: determination of fracture risk to optimize use. Radiology. 1999; 211(3):759-765. Observational-Dx 472 (168 with fractures, 304 control patients) Retrospective case-control study. To develop a method using clinically apparent factors to determine cervical fracture risk helping in the selection of optimal imaging strategies. High-risk established if any of the following are present: Severe head injury, High energy mechanism, Age over 50 years, and Focal neurologic deficits. 4
7. Blackmore CC, Ramsey SD, Mann FA, Deyo RA. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology. 1999; 212(1):117-125. Review/Other-Dx N/A Retrospective study to assess the cost-effectiveness of CT relative to radiography for cervical spine trauma screening. CT is the preferred screening method for patients with high and moderate risk of injury. 4
8. Daffner RH. Cervical radiography for trauma patients: a time-effective technique? AJR. 2000; 175(5):1309-1311. Review/Other-Dx 127 patients Prospective study to determine the time needed to perform a 6-view radiographic examination of the cervical spine in trauma patients. Also compared the added examination times for 30 patients who had an additional helical CT of the cervical region immediately after cranial CT. Cervical radiography is a time-consuming process. A more efficient method (spiral CT) needs to be adopted. 4
9. Daffner RH. Helical CT of the cervical spine for trauma patients: a time study. AJR. 2001; 177(3):677-679. Review/Other-Dx 156 patients 100 had CT plus cranial examination 56 had primary cervical examination Prospective study to determine the time needed to perform a helical CT examination in trauma patients. Cervical CT plus cranial CT added an average of 12 minutes to the overall study time. Primary cervical examination was 11 minutes on average. This compares favorably with the 6-view radiographic study, which takes 22 minutes. 4
10. D'Alise MD, Benzel EC, Hart BL. Magnetic resonance imaging evaluation of the cervical spine in the comatose or obtunded trauma patient. J Neurosurg. 1999; 91(1 Suppl):54-59. Review/Other-Dx 121 patients To investigate whether MRI is useful for determining spinal stability in comatose or obtunded patients. 31 patients (26%) had damage detected by MRI that was undetected on radiographs. MRI is a safe and reliable procedure for assessing stability in comatose and obtunded patients. 4
11. Dwek JR, Chung CB. Radiography of cervical spine injury in children: are flexion/extensionradiographs useful for acute trauma? AJR. 2000; 174(6):1617-1619. Observational-Dx 247 patients Retrospective review during a 22-month period to assess the role of cervical flexion/extension radiographs in the acute evaluation of pediatric trauma patients. Patients had static cervical spine radiographs followed by flexion/extension radiographs. Static cervical spine radiographs showed normal findings in 224 patients (91%). Flexion/extension radiographs showed normal findings for all patients on cervical spine radiographs. 224 had normal static radiographs; 23 had abnormal static radiographs. 7/23 had congenital anomalies; 10 patients had fractures on static radiographs; 2 had instability; 6 had questionable abnormalities. Study concludes that use of flexion/extension radiographs is questionable. 3
12. Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CT screening. AJR. 2000; 174(3):713-717. Observational-Dx 4,285 patients; 601 had CT 3,684 had radiographic examination Retrospective study to validate a clinical decision rule to direct cervical spine imaging in high-risk trauma patients. The clinical decision rule is valid. It can differentiate patients at high and low-risk of CSI. 3
13. 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
14. Katzberg RW, Benedetti PF, Drake CM, et al. Acute cervical spine injuries: prospective MR imaging assessment at a level 1 trauma center. Radiology. 1999; 213(1):203-212. Observational-Dx 199 patients To determine the sensitivity of MRI for prospective detection of acute neck injuries and to compare findings with comprehensive conventional radiographic assessment. 58 patients had 172 injuries. MRI found 136 (79%); radiography found 39 (23%). For acute fractures, MRI (weighted average sensitivity, 43%; CI: 21%-66%) were comparable to conventional radiographs (weighted average sensitivity, 48%; CI: 30%-65%). Study concludes MRI is more sensitive than radiography but more study is needed. 1
15. LeBlang SD, Nunez DB, Jr. Helical CT of cervical spine and soft tissue injuries of the neck. Radiol Clin North Am. 1999; 37(3):515-532, v-vi. Review/Other-Dx N/A Review of current concepts in the use of helical CT for neck trauma. Spiral CT is faster and more efficient. 4
16. Patton JH, Kralovich KA, Cuschieri J, Gasparri M. Clearing the cervical spine in victims of blunt assault to the head and neck: what is necessary?. Am Surg. 66(4):326-30; discussion 330-1, 2000 Apr. Review/Other-Dx 102 patients; 8 patients met criteria for clinical clearance of the c-spine To determine the incidence of cervical injury in patients with blunt assault to the head and neck and to determine the extent of radiographic workup needed. Incidence of CSI in this mechanism is so low that nothing other than radiographs are needed. 4
17. Saifuddin A. MRI of acute spinal trauma. Skeletal Radiol. 2001; 30(5):237-246. Review/Other-Dx N/A Review the current status of MRI in the assessment of acute spine trauma. MRI has a role in assessment of acute spinal injury, showing the status of the bones, ligaments, spinal cord, and discs. 4
18. Stiell IG, Wells GA, Vandemheen K, et al. Variation in emergency department use of cervical spine radiography for alert, stable trauma patients. Cmaj. 1997; 156(11):1537-1544. Observational-Dx 6,855 patients; 60 patients had acute CSI Retrospectively survey health records to assess the emergency department utilization of cervical spine radiographs in alert, stable adult trauma patients. 98.5% of radiographs were negative for significant abnormalities. Findings suggest cervical radiography could be used more efficiently. 4
19. 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
20. Vaccaro AR, Kreidl KO, Pan W, Cotler JM, Schweitzer ME. Usefulness of MRI in isolated upper cervical spine fractures in adults. J Spinal Disord. 1998; 11(4):289-293; discussion 294. Review/Other-Dx 55 patients Prospective study to assess the value of MRI performed within 48 hours of inciting trauma. Only 4/55 patients had neurologic findings. MRI changed management in one patient. Therefore, MRI not indicated in patients with no neurologic findings. 4
21. Zabel DD, Tinkoff G, Wittenborn W, Ballard K, Fulda G. Adequacy and efficacy of lateral cervical spine radiography in alert, high-risk blunt trauma patient. J Trauma. 43(6):952-6; discussion 957-8, 1997 Dec. Observational-Dx 353 patients Retrospective study to determine the adequacy and accuracy of lateral cervical radiographs in alert, but high-risk trauma patients. Lateral cervical spine radiography had; sensitivity 67%, specificity 58%, negative predictive probability of 1.4% and for absence of cervical symptoms; sensitivity 89%, specificity 81%, and negative predictive probability 0.32%.The high accuracy and lower negative predictive probability make absence of cervical symptoms a better screening tool. Study suggests alert patients without signs and symptoms do not need radiography. 3
22. 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
23. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma. 2009; 67(3):651-659. Review/Other-Dx 52 articles Updated practice management guidelines for identification of cervical spine injuries following trauma from the eastern association for the surgery of trauma practice management guidelines committee. There have been significant changes in practice since the previous CSI guidelines. Most significantly, CT has supplanted plain radiography as the primary screening modality in those who require imaging. Clinical clearance remains the standard in awake, alert patients with trauma without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion. Cervical collars should be removed as soon as feasible. Controversy persists regarding cervical spine clearance in the obtunded patient without gross neurologic deficit. 4
24. Como JJ, Leukhardt WH, Anderson JS, Wilczewski PA, Samia H, Claridge JA. Computed tomography alone may clear the cervical spine in obtunded blunt trauma patients: a prospective evaluation of a revised protocol. J Trauma. 2011; 70(2):345-349; discussion 349-351. Review/Other-Dx 197 patients To prospectively evaluate the safety of a protocol to discontinue the cervical collar in obtunded blunt trauma patients based on CT scan alone. Removal of cervical spine precautions in obtunded blunt trauma patients with gross movement of all extremities is safe and efficacious if CT cervical spine is negative for injury. Supplemental MRI cervical spine is not needed in this patient population. 4
25. 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
26. 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
27. Hennessy D, Connolly S, Lennon G, Quinlan D, Mulvin D. Out-patient management and non-attendance in the current economic climate. How best to manage our resources? Ir Med J. 2010; 103(3):80-82. Review/Other-Dx 737 appointments Prospective audit over a 2-month period to a tertiary-referral Urological service was performed to determine the clinical and demographic profile of non-attendees. The aim of the study was to analyze outpatient non-attendance and determine what factors influence attendance. Of 737 appointments, 148 (20%) patients did not attend. A benign urological condition was evident in 116 cases (78%). This group of patients also accounted for the majority of new patients not attending 40/47, returning patients not attending 101/148 and the majority of patients who missed multiple appointments 43/49. Patients with benign conditions make up the majority of clinic non-attendance. Consideration may be given to discharging such patients back to their general practitioner after one unexplained non-attendance until other alternatives of follow up are available. 4
28. Mancini DJ, Burchard KW, Pekala JS. Optimal thoracic and lumbar spine imaging for trauma: are thoracic and lumbar spine reformats always indicated?. J Trauma. 69(1):119-21, 2010 Jul. Observational-Dx “fracture” group (n=35) and a “no fracture” group (n=57) To directly compare CAP CT with CT with thoracic and lumbar reformats for the identification of thoracic and lumbar spine fractures. The CAP CT correctly identified all 35 patients with a thoracolumbar fracture (100% sensitivity; 95% CI: 88%-100%). A total of 80 separate fracture sites were present in the 35 patients. The CAP CT accurately identified 78 of those fractures (97.5% sensitivity; 95% CI: 90.4%-99.6%). The two fractures not identified on the CAP CT were both the transverse process fractures in patients with multiple fractures at different levels. Patients who have a CAP CT do not require reformats for clearance of the thoracic and lumbar spine. 3
29. 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
30. Pieretti-Vanmarcke R, Velmahos GC, Nance ML, et al. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma. J Trauma. 2009; 67(3):543-549; discussion 549-550. Observational-Dx 12,537 patients <3 years of age; 83 with cervical spine injuries Multicenter retrospective study to determine whether simple clinical criteria can be used to safely rule out cervical spine injuries in patients younger than 3 years. Of 12,537 patients younger than 3 years, cervical spine injuries were identified in 83 patients (0.66%), 8 had spinal cord injury. Four independent predictors of cervical spine injuries were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a NPV of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed cervical spine injuries in this study. Cervical spine injuries in patients younger than 3 years are uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population. 4
31. 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
32. Silva CT, Doria AS, Traubici J, Moineddin R, Davila J, Shroff M. Do additional views improve the diagnostic performance of cervical spine radiography in pediatric trauma? AJR. 2010; 194(2):500-508. Observational-Dx 234 patients Retrospective analysis of cervical spine radiographs of pediatric patients to measure the diagnostic performances of lateral views alone and multiple radiographic views of the cervical spine in comparison with MDCT scans in pediatric trauma and to determine whether evaluation of additional views, in relation to lateral views alone, improves the performance of radiography. 22 patients had positive findings on CT: Atlantooccipital subluxation/dislocation was seen in one patient; C1 ring fracture, in three patients; C1-C2 rotatory subluxation, in one; C1-C2 subluxation/dislocation, in one; odontoid fracture, in two; vertebral body wedge fracture, in six; posterior arch fracture dislocation, in 10; and spinous process fracture, in none. The lateral view radiograph alone had 73% sensitivity (95% CI, 50%-89%) and 92% specificity (95% CI, 87%-95%) for cervical spine abnormalities compared with MDCT. The addition of other views did not change the sensitivity of radiography but rather marginally decreased its specificity to 91% (95% CI, 86%-94%). Lateral view radiographs had a borderline acceptable sensitivity to cervical spine abnormalities in pediatric patients compared with MDCT. The addition of other radiographic views did not seem to improve the diagnostic performance of radiography. 2
33. Smith MW, Reed JD, Facco R, et al. The reliability of nonreconstructed computerized tomographic scans of the abdomen and pelvis in detecting thoracolumbar spine injuries in blunt trauma patients with altered mental status. J Bone Joint Surg Am. 91(10):2342-9, 2009 Oct. Observational-Dx 59 consecutive patients To test the reliability of nonreconstructed CT of the abdomen and pelvis as a screening tool for thoracolumbar spine injuries in blunt trauma patients with altered mental status. Radiographic abnormalities were correlated to findings on MDCT, which was used as the reference standard. Reconstructions of the spine detected 72 thoracolumbar spine fractures, whereas nonreconstructed CT scans of the abdomen and pelvis detected 58 and those of the chest detected 16. With use of the reconstructions as the standard, CT of the CAP had a sensitivity of 89% (95% CI, 65% to 96%) and a specificity of 85% (95% CI, 65% to 96%) for the detection of all fractures, compared with 37% and 76% for plain radiographs, respectively. CT of the CAP was 100% sensitive and specific for the detection of whether a patient had any fracture at all, whereas radiographs were 54% sensitive and 86% specific. No fractures that were missed on nonreconstructed CT required surgery or other interventions. Nonreconstructed CT detected fractures of the thoracolumbar spine more accurately than plain radiographs did and is recommended for the diagnosis of thoracolumbar spine fractures in acute trauma patients with altered mental status. Reconstructions do not need to be ordered unless an abnormality that is found on the nonreconstructed CT needs additional elucidation. 2
34. Mower WR, Wolfson AB, Hoffman JR, Todd KH. The Canadian C-spine rule. N Engl J Med. 2004; 350(14):1467-1469; author reply 1467-1469. Review/Other-Dx N/A To critique Stiell, et al estimates of sensitivity of NEXUS. If Stiell estimates were correct, 1.000 serious blunt trauma injuries to cervical spine would be missed annually which is not the case. 4
35. 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
36. Brohi K, Healy M, Fotheringham T, et al. Helical computed tomographic scanning for the evaluation of the cervical spine in the unconscious, intubated trauma patient. J Trauma. 2005; 58(5):897-901. Observational-Dx 437 patients To determine whether CT is useful for the evaluation of the cervical spine as part of a spinal assessment and clearance protocol in unconscious patients. CT identified 61 patients with cervical injuries, of whom 31 were deemed unstable. CT had sensitivity 98.1%, specificity 98.8%, and NPV 99.7%. There were no missed unstable injuries. Rapid and safe evaluation of the cervical spine was realized with CT. 3
37. Brown CV, Antevil JL, Sise MJ, Sack DI. Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come. J Trauma. 2005; 58(5):890-895; discussion 895-896. Observational-Dx 3,537 patients Retrospective review to determine whether spiral CT could be used as the primary imaging modality for the diagnosis of cervical, thoracic, and lumbar spine fractures. Of 236 fractures sustained, CT identified all but two: one cervical and one thoracic. Study concludes CT is sensitive for the identification of spine fractures and that radiographs of the spine are not needed for the evaluation of the spine in blunt trauma patients. 3
38. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. [Review] [21 refs]. J Trauma. 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
39. Daffner RH, Sciulli RL, Rodriguez A, Protetch J. Imaging for evaluation of suspected cervical spine trauma: A 2-year analysis. Injury. 2006; 37(7):652-658. Observational-Dx 245 patients Review radiographs and CT and reports to determine if there was still a role for radiography in screening patients with suspected cervical injury. Cervical radiographs identified injuries in 108 patients (44.1%); CT detected injuries in 243 patients (99.2%). Of the two fractures CT missed, both were at C2; one was horizontal and the other was obscured by dental artifacts. Both fractures were clearly visible on lateral radiographs. The authors recommend CT for screening supplemented by a single lateral radiograph to demonstrate C2. 3
40. Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001; 108(2):E20. Observational-Dx 3,065 patients Prospective multicenter study to examine patterns of spine injury in children (<18 years of age) and to evaluate the efficacy of the NEXUS decision instrument for obtaining cervical spine radiography in pediatric trauma victims. 88 children were <2 years of age, 817 were between 2 and 8, and 2,160 were between 8 to 17 years of age. 30 patients had CSI with C5-C7 being most common site of injury. Decision rule had sensitivity of 100%; 95% CI: 99.4%-100.0% and correctly identified 603 patients as low risk for CSI (NPV: 100.0%; 95% CI: 99.4%-100.0%). NEXUS decision rule performed well in children and could reduce cervical spine imaging by 20 %. Results should not be applied to children <2 years of age because of small number of infants and toddlers in the study. 3
41. Anderson RC, Kan P, Hansen KW, Brockmeyer DL. Cervical spine clearance after trauma in children. Neurosurg Focus. 2006; 20(2):E3. Review/Other-Dx 2001 to 2003 936 cervical spines; 2004 to 2005 746 cervical spines To determine if a NEXUS based protocol could increase the number of pediatric cervical spines cleared of suspected injury without a neurosurgical consultation. Protocol used is effective in detection of CSI in children after trauma. It has increased by more than 60% the number of cervical spines cleared by non-neurosurgical staff. Protocol can reduce need for neurosurgical staff for clearance. 4
42. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery. 2002; 50(3 Suppl):S85-99. Review/Other-Dx N/A Examine usage of radiographs, CT and MRI in children with cervical spine and spinal cord injuries. Children with trauma and are alert, conversant, no neurologic deficit, no midline cervical tenderness, and no painful distracting injury cervical spine radiographs not recommended. Children (<9 years of age) with trauma and not alert or nonconversant, or have neurologic deficit, midline cervical tenderness, or painful distracting injury, AP and lateral cervical radiographs recommended. For children 9 years or older, CT to exclude occult fractures or to evaluate regions not seen adequately on radiographs recommended. Flexion/extension cervical radiographs or fluoroscopy may be considered to exclude gross ligamentous instability. MRI of the cervical spine may be considered to exclude cord or nerve root compression, evaluate ligamentous integrity, or provide information regarding neurological prognosis. 4
43. Chiu WC, Haan JM, Cushing BM, Kramer ME, Scalea TM. Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation, and outcome. J Trauma. 50(3):457-63; discussion 464, 2001 Mar. Review/Other-Dx 14,577 blunt trauma victims (614 have C-spine injury); 2,605 unreliable patients (143 have C-spine injury) Retrospective review to determine whether applying (post hoc) the practice management guidelines from the Eastern Association for the Surgery of Trauma (3 radiograph views plus CT scan of C1-C2) would have detected the ligamentous injuries in unstable patients. Ligamentous injuries without fracture of the C-spine are rare. Practice management guidelines are effective and should help early removal of the cervical collar in unreliable patients. 4
44. Davis JW, Kaups KL, Cunningham MA, et al. Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. J Trauma. 2001; 50(6):1044-1047. Observational-Dx 301 patients To evaluate the efficacy and safety of dynamic fluoroscopy flexion/extension examinations in identifying ligamentous CSI and clearing the cervical spine in patients with altered mental status after trauma. 297 true-negative examinations, 2 true-positive exams (stable injuries), 1 false-negative examination, and 1 false-positive examination. Incidence of ligamentous injury identified by fluoroscopy was 2/301. Unstable cervical spine ligamentous injuries were identified in 0.02% of all trauma patients. Study concludes that unstable cervical spine ligamentous injury without fracture is a rare occurrence. The cervical spine may be cleared after a normal cervical spine series (radiograph and CT) as recommended in the 1998 Eastern Association for the Surgery of Trauma guidelines. 3
45. Demetriades D, Charalambides K, Chahwan S, et al. Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. J Trauma. 2000; 48(4):724-727. Review/Other-Dx 14,755 admissions 292 had C-spine injuries Retrospective review to study the incidence and type of cervical spine trauma according to mechanism of injury; identify problems and pitfalls in the diagnosis of nonskeletal CSI. Isolated nonskeletal C-spine injuries are rare. In subluxations, the combination of an adequate lateral film and CT scan was reliable in diagnosing the injury but a large study is needed to confirm. In isolated cord injuries, the diagnosis was often missed because of associated severe head trauma and the low sensitivity of the radiographs and CT scans. 4
46. 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
47. Anglen J, Metzler M, Bunn P, Griffiths H. Flexion and extension views are not cost-effective in a cervical spine clearance protocol for obtunded trauma patients. J Trauma. 52(1):54-9, 2002 Jan. Review/Other-Dx 837 radiographs Review radiology reports and charts to determine efficiency and cost-effectiveness of flexion/extension cervical spine radiographs. About one-third of radiographs were inadequate to rule out instability. Only 4 patients were identified through flexion/extension of whom one was a false positive and the others were borderline. Study concludes that flexion/extension studies were not cost-effective. 4
48. Bolinger B, Shartz M, Marion D. Bedside fluoroscopic flexion and extension cervical spine radiographs for clearance of the cervical spine in comatose trauma patients. J Trauma. 2004; 56(1):132-136. Review/Other-Dx 56 consecutive comatose head-injured patients Review radiographic images to determine adequacy of bedside flexion and extension fluoroscopic examinations for identifying occult ligamentous instability. The bedside fluoroscopic flexion and extension studies were considered to be adequate (visualization to the C7-T1 motion segment) in 4% of the patients and should not be part of trauma center protocols. 4
49. Freedman I, van Gelderen D, Cooper DJ, et al. Cervical spine assessment in the unconscious trauma patient: a major trauma service's experience with passive flexion/extensionradiography. J Trauma. 2005; 58(6):1183-1188. Review/Other-Dx 123 patients To determine the usefulness of passive flexion/extension imaging of occult cervical injury in unconscious patient. 4/7 showed up as false negatives. Passive flexion/extension has inadequate sensitivity for detecting occult CSI and should not be used. 4
50. Padayachee L, Cooper DJ, Irons S, et al. Cervical spine clearance in unconscious traumatic brain injury patients: dynamic flexion/extensionfluoroscopy versus computed tomography with three-dimensional reconstruction. J Trauma. 2006; 60(2):341-345. Observational-Dx 276 patients To determine whether cervical CT with 3D reconstructions obviate the need for flexion/extension radiology in the detection of occult ligamentous injury. Dynamic flexion/extension identified no new positive patients beyond those identified with plain radiograph or CT with 3D reconstruction. Dynamic flexion/extension was true-negative in 260/276 (94%), falsely positive in 6 patients (2.2%) and falsely negative in 1 (0.4%) patient. It was inadequate in 9 patients. Dynamic flexion/extension radiographic studies with fluoroscopy did not identify any patients with cervical fracture or instability not already identified by plain radiographs and fine-cut CT (C0 to T2) with 3D reconstructions. 3
51. Spiteri V, Kotnis R, Singh P, et al. Cervical dynamic screening in spinal clearance: now redundant. J Trauma. 2006; 61(5):1171-1177; discussion 1177. Observational-Dx 839 patients 87 patients with unstable spine injuries Retrospective review to determine if CT is sensitive enough to render dynamic (flexion/extension) screening redundant. Protocol had plain radiographs, CT scanning, and dynamic screening. 85/87 patients with unstable spine injuries were detected by CT. 2 cases were missed by CT (sensitivity 97.7%, specificity 100%). In 1of 2 cases, dynamic screening detected an unstable spine and in the other patient dynamic screening missed an atlanto-occipital dislocation (sensitivity 98.8%, specificity 100%). Dynamic screening offers no real advantage over helical CT. 3
52. 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
53. 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
54. Benzel EC, Hart BL, Ball PA, Baldwin NG, Orrison WW, Espinosa MC. Magnetic resonance imaging for the evaluation of patients with occult cervical spine injury. J Neurosurg. 1996; 85(5):824-829. Review/Other-Dx 174 patients To determine the efficacy of MRI for evaluation and clearance of the cervical spine in trauma victims with no threat to spinal integrity in the early post-trauma period. A negative MRI should be considered as confirmation of a negative or “cleared” subaxial cervical spine and MRI is useful for post trauma assessment of very select group of patients. 4
55. Emery SE, Pathria MN, Wilber RG, Masaryk T, Bohlman HH. Magnetic resonance imaging of posttraumatic spinal ligament injury. J Spinal Disord. 1989; 2(4):229-233. Observational-Dx 37 patients; 2 observers 2 blinded readers examined T-1 and T-2 weighted multiplanar images, 35 radiographs, 16 tomographs, and 30 CT images to evaluate role of MRI in detecting ligament injury in acute post-trauma spinal patients. 19 patients were considered to have torn posterior ligaments. MRI detected ligament damage in 17. All patients considered to have intact posterior ligament clinically and radiographically had no evidence of ligament damage on MRI. T-2 weighted images were essential for valid detection of ligament damage. MRI is recommended in the assessment of the integrity of spinal ligaments after acute trauma. 3
56. White P, Seymour R, Powell N. MRI assessment of the pre-vertebral soft tissues in acute cervical spine trauma. Br J Radiol. 72(860):818-23, 1999 Aug. Review/Other-Dx 31 patients Retrospective review to illustrate MRI appearances of pre-vertebral hematoma in acute cervical spine trauma and compare sensitivity of MRI and conventional radiographs. MRI showed pre-vertebral hematoma in 24 cases; soft-tissue thickening was detected on conventional radiographs in 14 cases. MRI is more sensitive than radiography for detection of pre-vertebral hematoma. 4
57. 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
58. Hogan GJ, Mirvis SE, Shanmuganathan K, Scalea TM. Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi-detector row CT findings are normal? Radiology. 2005; 237(1):106-113. Observational-Dx 366 obtunded patients with blunt trauma To retrospectively determine what information MRI of the cervical spine in obtunded and/or “unreliable” patients with blunt trauma adds to MDCT of the entire cervical spine. MRI was negative for acute injury in 354/366 and negative for cervical spine ligamentous injury in 362. MDCT had NPV of 98.9% (362/366) for ligament injury and 100% (366/366) for unstable CSI. A normal MDCT scan of the total cervical spine in obtunded and/or “unreliable” patients with blunt trauma allows to exclude unstable injuries on the basis of findings at follow-up cervical spine MRI. 2
59. 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
60. 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
61. 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
62. 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
63. Stassen NA, Williams VA, Gestring ML, Cheng JD, Bankey PE. Magnetic resonance imaging in combination with helical computed tomography provides a safe and efficient method of cervical spine clearance in the obtunded trauma patient. J Trauma. 60(1):171-7, 2006 Jan. Observational-Dx 52 patients Retrospective review to evaluate the efficacy and safety of combining MRI with helical CT for clearing the spine in obtunded patients. 44 had negative C-spine CT, of whom 13 (30%) had a positive MRI for ligamentous injury (P<0.01). 31 had both a negative CT and a negative MRI. All patients (n=8) with positive CT had positive MRI. The combination of MRI with CT was effective, with 100% correlation of true positives and true negatives. 3
64. Schwartz ED, Hackney DB. Diffusion-weighted MRI and the evaluation of spinal cord axonal integrity following injury and treatment. Exp Neurol. 2003; 184(2):570-589. Review/Other-Dx N/A Review use of diffusion-weighted MRI and evaluation of spinal cord axonal integrity following injury and treatment. There is controversy concerning how to obtain, interpret, and present diffusion-weighted MRI data. Computer simulations and MR microscopy have been helpful in resolving some of these issues, as well as determining exact histologic correlates to diffusion-weighted MRI findings. 4
65. Mayberry JC, Brown CV, Mullins RJ, Velmahos GC. Blunt carotid artery injury: the futility of aggressive screening and diagnosis. Arch Surg. 2004; 139(6):609-612; discussion 612-603. Review/Other-Dx 17 patients with blunt carotid artery injury; 35,212 admissions Multicenter study. Retrospective review to examine whether the lack of aggressive screening protocol has resulted in delayed diagnosis of blunt carotid artery injury. Although an aggressive screening program may increase early diagnosis of blunt carotid artery injury, it is not certain that patients will have better outcomes or that it is cost-effective. 4
66. Cothren CC, Moore EE, Biffl WL, et al. Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma. 55(5):811-3, 2003 Nov. Review/Other-Dx 92 patients Prospective study to determine whether all patients with cervical spine fractures require arteriography to rule out vertebral artery injury. Blunt vertebral artery injury is associated with complex cervical spine fractures involving subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. These findings should be added to routine screening to maximize yield and reduce use of invasive procedures. 4
67. 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
68. Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg. 236(3):386-93; discussion 393-5, 2002 Sep. Observational-Dx 216 patients Prospective study to examine outcomes associated with an aggressive screening protocol for blunt cerebrovascular injury, and to compare the accuracy of CTA and MRA vs conventional angiography with respect to diagnosis of blunt cerebrovascular injury. In 143 patients, comparison of CTA and MRA with cerebral angiography showed sensitivities of 47% and 50%, respectively, for carotid artery injuries; sensitivities were 53% (CTA) and 47% (MRA) for vertebral artery injury. CTA and MRA are inadequate for screening. Technological advances are necessary before abandonment of conventional angiography, which remains the standard for diagnosis. 2
69. Malhotra AK, Camacho M, Ivatury RR, et al. Computed tomographic angiography for the diagnosis of blunt carotid/vertebral artery injury: a note of caution. Ann Surg. 2007; 246(4):632-642; discussion 642-633. 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
70. Biffl WL, Egglin T, Benedetto B, Gibbs F, Cioffi WG. Sixteen-slice computed tomographic angiography is a reliable noninvasive screening test for clinically significant blunt cerebrovascular injuries. J Trauma. 2006; 60(4):745-751; discussion 751-742. Observational-Dx 331 patients Prospective study to determine ability of CTA to detect clinically significant blunt cerebrovascular injuries. CTA detected all clinically significant injuries (in 18 patients) during this study period. Liberal screening with 16-slice CTA is appropriate and is likely to miss very few significant injuries. A multicenter trial will help to clarify risk factors and the accuracy of noninvasive diagnostic modalities. 2
71. Berry GE, Adams S, Harris MB, et al. Are plain radiographs of the spine necessary during evaluation after blunt trauma? Accuracy of screening torso computed tomography in thoracic/lumbar spine fracture diagnosis. J Trauma. 59(6):1410-3; discussion 1413, 2005 Dec. Observational-Dx 103 patients Retrospective review to determine if data from thorax/abdomen/pelvis CT is effective in diagnosing thoracic and lumbar fractures. CT had 100% sensitivity, 97% specificity, 100% NPV for thoracolumbar fracture. Radiographs had 73% sensitivity, 100% specificity and NPV of 92%. Radiographs are time consuming to obtain. CT is more sensitive than radiography for finding fractures and is more expeditions. 3
72. Brandt MM, Wahl WL, Yeom K, Kazerooni E, Wang SC. Computed tomographic scanning reduces cost and time of complete spine evaluation. J Trauma. 2004; 56(5):1022-1026; discussion 1026-1028. Review/Other-Dx 55 patients reviewed radiographs 50 patients timed radiologic workup To show that CT images of the spine on trauma patients studied for chest and/or abdominal trauma are adequate and cost-effective for detecting fractures. 47 patients had fractures. 13 patients had 33 fractures identified by CT but not by radiography. Study concludes that spinal reformatted images are adequate for finding thoracic and lumbar fractures and overall this reduces the cost. 4
73. Herzog C, Ahle H, Mack MG, et al. Traumatic injuries of the pelvis and thoracic and lumbar spine: does thin-slice multidetector-row CT increase diagnostic accuracy?. Eur Radiol. 14(10):1751-60, 2004 Oct. Observational-Dx 70 patients To determine if MDCT studies were adequate for identifying thoracic, lumbar and pelvic fractures. Conventional radiographs, 3-mm (CT5) and 5-mm scans (CT3) and 3-mm and 5-mm scans combined with MPR (CT3R/CT5R) were compared to surgery, autopsy and clinical course. Overlapping thin-slice multiplanar reformation is effective in identifying such injuries. This is the recommended protocol. 2
74. Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging. Injury. 2003; 34(6):426-433. 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
75. Lucey BC, Stuhlfaut JW, Hochberg AR, Varghese JC, Soto JA. Evaluation of blunt abdominal trauma using PACS-based 2D and 3D MDCT reformations of the lumbar spine and pelvis. AJR. 2005; 185(6):1435-1440. Observational-Dx 156 consecutive patients To show the value of 2D and 3D reformations from CT data from abdominal and pelvic CT in finding lumbar and pelvic fractures. CT was compared with radiographic findings and findings of dedicated repeat CT. CT detected 80 lumbar and 178 pelvic fractures; radiography showed 40 and 138 fractures respectively. No additional fractures were detected on repeat CT exam. Radiographs are no longer needed when data from abdominopelvic CT is available in trauma patients. 2
76. 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
77. van Beek EJ, Been HD, Ponsen KK, Maas M. Upper thoracic spinal fractures in trauma patients - a diagnostic pitfall. Injury. 2000; 31(4):219-223. Review/Other-Dx 23 patients; 2 observers To compare the diagnostic accuracy of radiography with CT for finding fractures of the upper thoracic spine. Radiography failed to identify fractures in 5 (22%) of patients studied. CT found all. They recommend CT and/or MRI in patients with neurological symptoms referable to the upper thoracic spine. 4
78. Wintermark M, Mouhsine E, Theumann N, et al. Thoracolumbar spine fractures in patients who have sustained severe trauma: depiction with multi-detector row CT. Radiology. 2003; 227(3):681-689. Observational-Dx 100 patients; radiographs, 5 observers; CT, 3 observers To determine if MDCT can replace radiography and be performed alone in trauma patients to diagnose thoracolumbar spine fractures. 67 fractures were identified in 26 patients. Mean sensitivity and interobserver agreement, respectively, for detection of unstable fractures were 97.2% and 0.951 for MDCT and 33.3% and 0.368 for conventional radiography. Study concludes that MDCT is more effective than radiography for finding fractures and should replace radiography in patients with severe trauma. 1
79. Chang CH, Holmes JF, Mower WR, Panacek EA. Distracting injuries in patients with vertebral injuries. J Emerg Med. 2005; 28(2):147-152. Review/Other-Dx 336 with distracting injuries among Prospective cohort study to describe the prevalence and types of distracting injuries associated with vertebral injuries at all levels of the spine in blunt trauma patients. Among patients with distracting injuries, bony fractures of any type were important for identifying patients with vertebral injuries. Other types of distracting injuries did not contribute to the sensitivity of the clinical screening criteria in the detection of patients with vertebral injuries. 4
80. Dai LY, Yao WF, Cui YM, Zhou Q. Thoracolumbar fractures in patients with multiple injuries: diagnosis and treatment-a review of 147 cases. J Trauma. 2004; 56(2):348-355. Observational-Dx 147 patients Retrospective review to determine the incidence of missed injuries of the thoracolumbar spine in patients with multiple injuries, to examine the reasons for the delay in diagnosis, and to study the selection of treatment options in the management and timing of surgical intervention. Delayed diagnosis was made in 28 patients; increased incidence of pulmonary complications and length of hospital stay in non-operative cases, although no difference in recovery rate for neurologic function. Neither severity of injury nor timing of surgery impacted recovery rate. 4
81. Gestring ML, Gracias VH, Feliciano MA, et al. Evaluation of the lower spine after blunt trauma using abdominal computed tomographic scanning supplemented with lateral scanograms. J Trauma. 53(1):9-14, 2002 Jul. Observational-Dx 71 patients Prospective study to determine whether a lateral CT scanogram and axial CT views would provide adequate imaging to allow for evaluation of the thoracolumbar junction and lumbar spine and therefore eliminate the need for conventional screening computed lumbar spine radiographs. CT scanogram had sensitivity of 100%; specificity, 100%. Among 10 patients with 20 fractures, CT scanogram protocol (axial CT images plus AP and lateral scanograms) outperformed screening computed lumbar spine radiographs in the detection of fractures of the lower spine after blunt trauma. In addition, scanogram imaging is less dependent on body habitus and adds no additional cost or time to abdominal and pelvic CT scanning. Further study is required to determine whether CT scanogram can routinely replace conventional radiographs of the lower spine after blunt trauma. 2
82. Hauser CJ, Visvikis G, Hinrichs C, et al. Prospective validation of computed tomographic screening of the thoracolumbar spine in trauma. J Trauma. 55(2):228-34; discussion 234-5, 2003 Aug. Observational-Dx 222 patients 215 patients fully evaluated Prospective clinical study to validate CT screening of the thoracolumbar spine in trauma. All patients had CT/CAP and lateral radiographs of the thoracolumbar spine. Sensitivity, specificity, PPV and NPV were better for CT/CAP than for lateral radiographs of the thoracolumbar spine. CT/CAP diagnoses thoracolumbar spine fractures more accurately than lateral radiographs of the thoracolumbar spine. Neither misses unstable fractures, but CT scanning finds small fractures that benefit by treatment and identifies chronic disease better. CT screening is far faster and shortens time to removal of spine precautions. CT scan-based diagnosis does not result in greater radiation exposure and improves resource use. Screening the thoracolumbar spine on truncal helical CT scanning performed for the evaluation of visceral injuries is more accurate than thoracolumbar spine imaging by standard radiography. CT/CAP should replace radiographs in high-risk trauma patients who require screening. 3
83. Inaba K, Munera F, McKenney M, et al. Visceral torso computed tomography for clearance of the thoracolumbar spine in trauma: a review of the literature. [Review] [19 refs]. J Trauma. 60(4):915-20, 2006 Apr. Review/Other-Dx N/A To identify and review all published studies comparing reformatted CT to traditional radiography for thoracolumbar spine clearance. Reformatted CT showed better sensitivity and interobserver variability than radiographic screening. CT was also more accurate in localizing, classifying, and delineating the age, bony intrusion, and soft-tissue damage associated with the fracture. For studies with time-motion components, a protocol utilizing CT clearance was not only more accurate but faster and more economical. Screening with reformatted visceral CT data required no additional scan time or radiation exposure. 4
84. Rhee PM, Bridgeman A, Acosta JA, et al. Lumbar fractures in adult blunt trauma: axial and single-slice helical abdominal and pelvic computed tomographic scans versus portable plain films. J Trauma. 53(4):663-7; discussion 667, 2002 Oct. Observational-Dx 7,216 patients reviewed Retrospective review to determine whether abdominal and pelvic CT are equivalent to portable two-view radiographs in detecting lumbar spine fractures in adults. Both abdominal and pelvic CT scans and radiographs failed to diagnose significant lumbar fractures that required therapy. When screening for lumbar fractures, obtaining both abdominal and pelvic CT scans and portable two-view radiographs may decrease missed lumbar fractures in blunt adult trauma. 3
85. 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; 38 patients chest CT plus thoracic spine radiographs; 87 patients abdominal CT plus lumbar spine radiographs Prospective study to compare the accuracy of spine radiographs with chest and abdominal trauma CT in detection of spine fractures. Of the fractures visible at either chest trauma CT or thoracic spine radiographs, all were diagnosed on CT and 62% on radiographs. Of fractures visible at either abdominal trauma CT or lumbar spine radiographs, 94 % were diagnosed on CT and 67% on radiographs. Study concludes that CT is as accurate as radiographs in the evaluation of spinal trauma. 3
86. Salim A, Sangthong B, Martin M, Brown C, Plurad D, Demetriades D. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Arch Surg. 2006; 141(5):468-473; discussion 473-465. Observational-Dx 1,000 underwent pan scan of whom 592 were evaluable Prospective observational study to determine whether liberal whole body imaging (pan scan) in patients based on mechanism is warranted, even in evaluable patients with no obvious signs of chest or abdominal injury. The use of pan scan based on mechanism in awake, evaluable patients is warranted. Clinically significant abnormalities are not uncommon, resulting in a change in treatment in nearly 19% of patients. 3