Reference
Reference
Study Type
Study Type
Patients/Events
Patients/Events
Study Objective(Purpose of Study)
Study Objective(Purpose of Study)
Study Results
Study Results
Study Quality
Study Quality
1. Hasler RM, Exadaktylos AK, Bouamra O, et al. Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study. J Trauma Acute Care Surg. 72(4):975-81, 2012 Apr. Observational-Dx 250,584 patients To determine predictors for cervical fractures/dislocations or cord injury. A total of 250,584 patients were analyzed. Median age was 47.2 years (interquartile range, 29.8-66.0) and Injury Severity Score 9 (interquartile range, 4-11); 60.2% were male. Six thousand eight hundred two patients (2.3%) sustained cervical fractures/dislocations alone. Two thousand sixty-nine (0.8%) sustained cervical cord injury with/without fractures/dislocations; 39.9% of fracture/dislocation and 25.8% of cord injury patients suffered injuries to other body regions. Age >/= 65 years (odds ratio [OR], 1.45-1.92), males (females OR, 0.91; 95% CI, 0.86-0.96), Glasgow Coma Scale (GCS) score <15 (OR, 1.26-1.30), LeFort facial fractures (OR, 1.29; 95% confidence interval [CI], 1.05-1.59), sports injuries (OR, 3.51; 95% CI, 2.87-4.31), road traffic collisions (OR, 3.24; 95% CI, 3.01-3.49), and falls >2 m (OR, 2.74; 95% CI, 2.53-2.97) were predictive for fractures/dislocations. Age <35 years (OR, 1.25-1.72), males (females OR, 0.59; 95% CI, 0.53-0.65), GCS score <15 (OR, 1.35-1.85), systolic blood pressure <110 mm Hg (OR, 1.16; 95% CI, 1.02-1.31), sports injuries (OR, 4.42; 95% CI, 3.28-5.95), road traffic collisions (OR, 2.58; 95% CI, 2.26-2.94), and falls >2 m (OR, 2.24; 95% CI, 1.94-2.58) were predictors for cord injury. 2
2. Milby AH, Halpern CH, Guo W, Stein SC. Prevalence of cervical spinal injury in trauma. [Review] [98 refs]. Neurosurg. focus. 25(5):E10, 2008. Review/Other-Dx N/A To estimate the prevalence of unstable cervical spinal injury (CSI), particularly among patients in whom clinical evaluation is impossible or unreliable. No results stated in abstract. 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. Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. [Review]. CMAJ. 184(16):E867-76, 2012 Nov 06. Review/Other-Dx N/A To investigate the diagnostic accuracy of the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) criteria, 2 rules that are available to assist emergency physicians to assess the need for cervical spine imaging. No results stated in abstract. 4
7. 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
8. Coffey F, Hewitt S, Stiell I, et al. Validation of the Canadian c-spine rule in the UK emergency department setting. Emerg Med J. 28(10):873-6, 2011 Oct. Observational-Dx 1420 patients To determine the potential of the Canadian Cervical Spine Rule (CCR) to safely reduce the number of cervical spine (c-spine) radiographs performed in the UK emergency department setting. A total of 1420 patients were enrolled in the study (50.4% male). 987 (69.5%) had c-spine radiography performed, with 8 (0.6%) having a c-spine injury. If the decision for radiography had been made according to the outcome of the CCR, only 815 (57.4%) would have had c-spine radiography and all 8 abnormal cases would have undergone imaging. Doctors were comfortable using the rule in 91% of cases. Interobserver reliability was good (kappa=0.75 95% CI 0.44 to 1.06). 3
9. 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
10. Paxton M, Heal CF, Drobetz H. Adherence to Canadian C-Spine Rule in a regional hospital: a retrospective study of 406 cases. J Med Imaging Radiat Oncol. 56(5):514-8, 2012 Oct. Observational-Dx 406 patients To retrospectively determine the proportion of cervical spine radiographs requested through the emergency department for trauma patients that were clinically indicated, according to the Canadian C-Spine Rule. Of 406 patients in the study, 155 patients (38%) (95% confidence interval 33.3%, 42.7%) had cervical spine imaging performed that was not indicated according to the Canadian C-Spine Rule. None of these patients had a significant cervical spine injury on radiography. 3
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. Duane TM, Young A, Mayglothling J, et al. CT for all or selective approach? Who really needs a cervical spine CT after blunt trauma. J Trauma Acute Care Surg. 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
13. Cooper C, Dunham CM, Rodriguez A. Falls and major injuries are risk factors for thoracolumbar fractures: cognitive impairment and multiple injuries impede the detection of back pain and tenderness. J Trauma. 38(5):692-6, 1995 May. Observational-Dx 4142 blunt trauma patients To address this issue, back pain/tenderness detection (BPTD in patients with thoracolumbar fracture (TLF) and Glasgow Coma Scale score (GCS) scores of 13 to 15 was evaluated. Risk factors for TLF (p < or = 0.05) were major non-TLF injuries (Abbreviated Injury Scale score > or = 3) and a fall mechanism of injury. Of 110 with TLF, Glasgow Coma Scale score (GCS) of 13 to 15, and no myelopathy, 34 (30.9%) had no BPTD; 7 of 34 (20.6%) required operative spinal stabilization. BPTD was lacking in 63% of patients with GCS scores of 13 to 14 compared to 22% of patients with GCS scores of 15 (p = 0.001). BPTD was decreased when major non-TLF injuries were present (63 vs. 91%) in the GCS score of 15 group (0.003), but similar in GCS score of 13 to 14 patients. In patients with GCS scores of 13 to 15, decreased BPTD is simultaneously related to both cognitive dysfunction and major injuries (p = 0.005). In conclusion, major injuries and falls are risks for TLF and cognitive deficit and major injury impedes BPTD in TLF. 3
14. 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
15. Doud AN, Weaver AA, Talton JW, et al. Has the incidence of thoracolumbar spine injuries increased in the United States from 1998 to 2011?. Clin Orthop. 473(1):297-304, 2015 Jan. Review/Other-Dx N/A To question whether the incidence of thoracolumbar spine injuries increased in the United States population with time (between 1998 and 2011), and if there was an increased incidence of thoracolumbar injuries, whether there were identifiable compensatory "trade-off injury" patterns, such as reductions in sacropelvic injuries. All databases showed increases in MVC-related thoracolumbar spine injuries when adjusting for age with time. These age-adjusted relative annual percent increases ranged from 8.22% (95% CI, 5.77%-10.72%; p<0.001) using AIS of 2 or more (AIS2 +) injury codes in the NTDB(R), 8.59% (95% CI, 5.88%-11.37%; p<0.001) using ICD-9 codes in the NTDB(R), 8.12% (95% CI, 7.20%-9.06%; p<0.001) using ICD-9 codes in the NIS, and 8.10 % (95% CI 5.00%-11.28%; p<0.001) using AIS2+ injury codes in the NASS. As these thoracolumbar injuries have increased, there has been no consistent trend toward a compensatory reduction in terms of sacropelvic injuries. 4
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, 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
18. Venkatesan M, Fong A, Sell PJ. CT scanning reduces the risk of missing a fracture of the thoracolumbar spine. Journal of Bone &#38; 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
19. 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
20. 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
21. 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
22. Roth CJ, Angevine PD, Aulino JM, et al. ACR Appropriateness Criteria Myelopathy. J. Am. Coll. Radiol.. 13(1):38-44, 2016 Jan. Review/Other-Tx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for myelopathy No results stated in abstract. 4
23. Bykowski J, Aulino JM, Berger KL, et al. ACR Appropriateness Criteria(R) Plexopathy. J Am Coll Radiol. 2017;14(5S):S225-S233. 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. No results stated in abstract. 4
24. American College of Radiology. ACR Appropriateness Criteria®: Suspected Spine Trauma-Child. Available at: https://acsearch.acr.org/docs/310274/Narrative/. 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 in a child. No abstract available. 4
25. American College of Radiology. ACR–ASNR–SPR Practice Parameter For The Performance Of Myelography And Cisternography. Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/Myelog-Cisternog.pdf. Review/Other-Dx N/A To provide Practical Parameter For The Performance Of Myelography And Cisternography. No results stated in abstract. 4
26. 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
27. Nelson DW, Martin MJ, Martin ND, Beekley A. Evaluation of the risk of noncontiguous fractures of the spine in blunt trauma. J Trauma Acute Care Surg. 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
28. Denver D, Shetty A, Unwin D. Falls and Implementation of NEXUS in the Elderly (The FINE Study). J Emerg Med. 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
29. 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?. Am Surg. 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
30. 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
31. 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
32. 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
33. 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
34. Nasir S, Hussain M, Mahmud R. Flexion/extension cervical spine views in blunt cervical trauma. Chin J Traumatol. 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
35. 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
36. Coats AC, Nies MS, Rispler D. Cervical spine computed tomography imaging artifact affecting clinical decision-making in the traumatized patient. Open Orthop J. 8:372-4, 2014. Review/Other-Dx N/A To report Cervical spine computed tomography imaging artifact affecting clinical decision-making in the traumatized patient No results stated in abstract. 4
37. 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 Neurosurg. 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
38. 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
39. 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
40. 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
41. 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
42. 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
43. 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 subclinical finding 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
44. 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
45. 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
46. 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
47. 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
48. 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
49. Mavros MN, Kaafarani HM, Mejaddam AY, et al. Additional Imaging in Alert Trauma Patients with Cervical Spine Tenderness and a Negative Computed Tomographic Scan: Is it Needed?. World J Surg. 39(11):2685-90, 2015 Nov. Observational-Dx 2015 CT To evaluate (1) the safety of C-spine clearance without additional radiological imaging, in alert patients with neck pain/tenderness to palpation (TTP) and a negative C-spine computed tomography (CT) on initial trauma evaluation and (2) the predictors of obtaining additional C-spine radiological images. Of 2015 patients with a C-spine CT, 383 (19 %) fulfilled the inclusion criteria. The median age was 43 (IQR: 30-53) and 44.7 % were female. Thirty-six patients (9.4 %) underwent magnetic resonance imaging (MRI) (3.7 %), flexion-extension imaging (5.2 %), or both (0.5 %), with no significant injuries identified and subsequent removal of the collar allowed. The remaining patients were clinically cleared within 24 h of presentation. None of the patients developed neurological signs following removal of the collar. On bivariate analysis, no variable except for evaluation by trauma surgery was associated with performance of additional imaging. 3
50. 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
51. 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
52. 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
53. 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
54. 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
55. 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 Feb. 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
56. 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
57. 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
58. 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
59. Ben Hassen W, Machet A, Edjlali-Goujon M, et al. Imaging of cervical artery dissection. [Review]. Diagn Interv Imaging. 95(12):1151-61, 2014 Dec. Review/Other-Dx N/A To review Imaging of cervical artery dissection. No results stated in abstract 4
60. Joaquim AF, Ghizoni E, Tedeschi H, da Cruz HY, Patel AA. Clinical results of patients with subaxial cervical spine trauma treated according to the SLIC score. J Spinal Cord Med. 37(4):420-4, 2014 Jul. Observational-Dx 48 patients To improve injury classification and guide surgical decision making yet clinical validation remains necessary. Non-surgical group - Twenty-three patients were treated non-surgically, 14 (61%) of them with some follow-up at our institution. Follow-up ranged from 3 to 5 months (mean of 4.42; median 4). The Subaxial Injury Classification (SLIC) score ranged from 0 to 6 points (mean and median of 1). One patient with a SLIC of 6 points refused surgery. Surgical group: Twenty-five patients were operated, but follow-up after hospital discharge was obtained in 23 (92%) patients (range from 1 to 24 months, mean of 5.82 months). The SLIC score in this group ranged from 4 to 9 points (mean and median of 7). No patients had neurological worsening. Eight of 13 patients with incomplete deficits had some improvement in American Spinal Injury Association score. 2
61. Vaccaro AR, Hulbert RJ, Patel AA, et al. The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex. [Review] [20 refs]. Spine. 32(21):2365-74, 2007 Oct 01. Review/Other-Dx N/A To review the subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex. No results stated in abstract. 4
62. 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
63. 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
64. 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
65. 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
66. 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
67. 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
68. 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
69. Beliaev AM, Barber PA, Marshall RJ, Civil I. Denver screening protocol for blunt cerebrovascular injury reduces the use of multi-detector computed tomography angiography. ANZ J Surg. 84(6):429-32, 2014 Jun. Observational-Dx 36 patients To investigate whether the use of computed tomography angiography (CTA) restricted to the Denver protocol screen-positive patients would reduce the unnecessary use of CTA as a pre-emptive screening tool. Thirty (61%) Blunt cerebrovascular injury (BCVI) and 19 (39%) non-BCVI patients met eligibility criteria. The Denver protocol applied to our cohort of patients had a sensitivity of 97% (95% confidence interval (CI): 83-100%) and a specificity of 42% (95% CI: 20-67%). With a prevalence of BCVI in blunt trauma patients of 0.2% and 2.7%, post-test odds of a screen-positive test were 0.03 (95% CI: 0.002-0.005) and 0.046 (95% CI: 0.314-0.068), respectively. 3
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. 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
72. 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
73. 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
74. 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
75. 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
76. 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
77. 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. Eur Spine J. 2017 Oct 09. 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
78. 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
79. 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
80. 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
81. Tran B, Saxe JM, Ekeh AP. Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan?. J Surg Res. 184(1):411-3, 2013 Sep. Observational-Dx 354 patients To evaluate the utility of FEF in the current era of routine computerized tomography (CT) for imaging the CS in trauma. There were 354 patients (58.5% male) with negative cervical CS CT scans who had FEF for residual neck pain. Incidental degenerative changes were seen in 37%--which did not affect their acute management. FEF were positive for possible ligamentous injury in 5 patients (1.4%). Two of these patients had negative magnetic resonance images and the other three had collars removed within 3 wk as the findings were ultimately determined to be degenerative. 2
82. 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
83. Kumar Y, Hayashi D. Role of magnetic resonance imaging in acute spinal trauma: a pictorial review. [Review]. BMC Musculoskelet Disord. 17:310, 2016 Jul 22. Review/Other-Dx N/A To review the Role of magnetic resonance imaging in acute spinal trauma No results stated in abstract. 4
84. Teasell RW, McClure JA, Walton D, et al. A research synthesis of therapeutic interventions for whiplash-associated disorder: part 1 - overview and summary. [Review]. Pain Res Manag. 15(5):287-94, 2010 Sep-Oct. Review/Other-Dx N/A To review the research synthesis of therapeutic interventions for whiplash-associated disorder No results stated in abstract. 4
85. 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
86. 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
87. 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
88. 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
89. Matsumoto M, Okada E, Ichihara D, et al. Prospective ten-year follow-up study comparing patients with whiplash-associated disorders and asymptomatic subjects using magnetic resonance imaging. Spine. 35(18):1684-90, 2010 Aug 15. Observational-Dx 133 WAD patients and 223 control subjects To clarify long-term impact of whiplash injury on patient's symptoms and on MRI findings of the cervical spine. Progression of decrease in signal intensity was observed in 109 WAD patients (82.0%), and 132 control subjects (59.2%), (age, sex adjusted OR: 3.06), posterior disc protrusion in 101 (75.9%) and in 155 (69.5%) (OR = 1.46), disc space narrowing in 33 (24.8%) and in 59 (26.5%) (OR = 0.98), and foraminal stenosis in 6 (4.5%), and in 20 (9.0%) (OR = 0.52), respectively. Neck pain was observed in 34 WAD patients (25.6%) and 22 control subjects (9.9%) (P<0.0001). There was no statistically significant correlation between neck pain and progression in each MR finding in either group. 3
90. Siegmund GP, Winkelstein BA, Ivancic PC, Svensson MY, Vasavada A. The anatomy and biomechanics of acute and chronic whiplash injury. [Review] [138 refs]. Traffic inj prev. 10(2):101-12, 2009 Apr. Review/Other-Dx N/A To review the anatomy and biomechanics of acute and chronic whiplash injury. No results stated in abstract. 4
91. Vetti N, Krakenes J, Eide GE, Rorvik J, Gilhus NE, Espeland A. MRI of the alar and transverse ligaments in whiplash-associated disorders (WAD) grades 1-2: high-signal changes by age, gender, event and time since trauma. Neuroradiology. 2009;51(4):227-235. Observational-Dx 1,226 patients To describe the prevalence of high signal changes on MRI studies of the alar and transverse ligaments in WAD grade 1-2, in relation to age, gender, spinal degeneration, type of trauma, and time since trauma. MRI showed grades 2-3 alar ligament changes in 449 (35.5%; 95% CI, 32.8% to 38.1%) and grades 2-3 transverse ligament changes in 311 (24.6%; 95% CI, 22.2% to 26.9%) of the 1,266 patients. Grades 2-3 changes were more common in men than women, OR 1.9 (95% CI, 1.5 to 2.5) for alar and 1.5 (95% CI, 1.1 to 2.0) for transverse ligament changes. High-signal changes were not related to age, spinal degeneration, type of trauma event or time since trauma (median 5 years). Unilateral changes were more often left- than right-sided. 4
92. 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
93. Ichihara D, Okada E, Chiba K, et al. Longitudinal magnetic resonance imaging study on whiplash injury patients: minimum 10-year follow-up. J Orthop Sci. 14(5):602-10, 2009 Sep. Observational-Dx 133 patients Prospective, long-term follow-up study to assess associations between MRI findings and changes in clinical symptoms in patients with whiplash injury. Progression of some degenerative changes was recognized on MRI in 98.5% of the 133 whiplash injury patients, and clinical symptoms diminished in more than a half of the 133 patients. There were no statistically significant associations between MRI findings and changes in clinical symptoms. The prognosis for neck pain tended to be poor after accidents with double collisions (rear-end collision followed by frontend collision) [adjusted OR 5.83, 95% CI, 1.15-29.71] and accidents with serious car damage (2.87, 1.03-7.99). The prognosis for stiff shoulders tended to be poor in women (2.83, 1.23-6.51); and the prognosis for numbness in the upper extremities tended to be poor after accidents with serious car damage (3.39, 1.14-10.06). 3
94. Kongsted A, Sorensen JS, Andersen H, Keseler B, Jensen TS, Bendix T. Are early MRI findings correlated with long-lasting symptoms following whiplash injury? A prospective trial with 1-year follow-up. Eur Spine J. 2008;17(8):996-1005. Review/Other-Dx 178 participants Prospective, multicenter study to evaluate the predictive value of cervical MRI after whiplash injuries as well as the value of repeating MRI examinations after 3 months. Traumatic findings were observed in 7 participants. Signs of disc degeneration were common and most frequent at the C5-6 and C6-7 levels. Findings were not associated with outcome after 3 or 12 months. The population had no considerable neck trouble prior to the whiplash injury and the nontraumatic findings represent findings to be expected in the background population. Trauma-related MRI findings are rare in a whiplash population screened for serious injuries in the emergency unit and not related to a specific symptomatology. Also, pre-existing degeneration is not associated with prognosis. 4
95. Li Q, Shen H, Li M. Magnetic resonance imaging signal changes of alar and transverse ligaments not correlated with whiplash-associated disorders: a meta-analysis of case-control studies. [Review]. Eur Spine J. 22(1):14-20, 2013 Jan. Meta-analysis 6 studies To review magnetic resonance imaging signal changes of alar and transverse ligaments not correlated with whiplash-associated disorders. Alar ligaments: Six studies (total n = 622) were included. MRI signal changes of alar ligaments did not appear to be related with WADs (P = 0.20, OR = 1.54, 95 % CI = 0.80-2.94). Heterogeneity was present (I (2) = 46 %, P = 0.10), which was eliminated upon sensitivity analysis bringing the OR to 1.27 (95 % CI = 0.87-1.86, I (2) = 0 %). Transverse ligaments: Four studies (total n = 489) were included. MRI signal changes of transverse ligament did not appear to be related with WADs (P = 0.51, OR = 1.44, 95 % CI = 0.49-4.21). Heterogeneity was present (I (2) = 77 %, P = 0.005), which was eliminated upon sensitivity analysis bringing the OR to 0.79 (95 % CI = 0.49-1.28, I (2) = 0 %). Good
96. Matsumoto M, Ichihara D, Okada E, et al. Modic changes of the cervical spine in patients with whiplash injury: a prospective 11-year follow-up study. Injury. 44(6):819-24, 2013 Jun. Observational-Dx 133 patients To study the compared Modic changes seen in whiplash patients 10 years after the injury with those observed in asymptomatic volunteers. Modic changes were observed in 4 patients (3%) and at 7 intervertebral levels in the initial study, and in 17 patients (12.8%) and at 30 intervertebral levels at the follow-up. Modic Type 2 changes were the most prevalent in the whiplash patients in both the initial and follow-up studies. There was no significant difference in the percentage of whiplash patients versus control subjects with positive Modic changes, either at the initial study or at follow-up. Modic changes were not related to clinical symptoms present at follow-up, but were associated with preexisting disc degeneration. There was no association between Modic changes and the details of the car accident that caused the injury. 3
97. Myran R, Kvistad KA, Nygaard OP, Andresen H, Folvik M, Zwart JA. Magnetic resonance imaging assessment of the alar ligaments in whiplash injuries: a case-control study. Spine (Phila Pa 1976). 2008;33(18):2012-2016. Observational-Dx 173 patients; 2 reviewers Blinded, case-control study to assess signal intensity changes in MRI of the alar ligaments. 3 groups of patients: 59 involved in motor vehicle collision with WAD; 57 with chronic neck pain and no history of trauma; 57 controls with no history of trauma and no pain. Alar ligament changes Grade 0 to 3 were seen in all 3 diagnostic groups. Areas of high signal intensity (Grade 2-3) were found in at least one alar ligament in 49% of the patients in the whiplash associated disorder Grade I-II group, in 33% of the chronic neck pain group and in 40% of the control group (chi, P=0.22). 3
98. Teasell RW, McClure JA, Walton D, et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 2 - interventions for acute WAD. [Review]. Pain Res Manag. 15(5):295-304, 2010 Sep-Oct. Review/Other-Dx N/A To review the research synthesis of therapeutic interventions for whiplash-associated disorder (WAD) No results stated in abstract. 4
99. Teasell RW, McClure JA, Walton D, et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 4 - noninvasive interventions for chronic WAD. [Review]. Pain Res Manag. 15(5):313-22, 2010 Sep-Oct. Review/Other-Dx N/A To review research synthesis of therapeutic interventions for whiplash-associated disorder (WAD) No results stated in abstract. 4
100. 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
101. 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
102. Myran R, Zwart JA, Kvistad KA, et al. Clinical characteristics, pain, and disability in relation to alar ligament MRI findings. Spine. 36(13):E862-7, 2011 Jun. Observational-Dx 173 subjects To evaluate the association between degree of signal changes in the alar ligaments on MRI with respect to pain and disability. With respect to Brief Pain Inventory and Hospital Anxiety and Depression Rating Scale, the scores were highest in the WAD group, intermediate in the chronic nontraumatic neck pain group, and lowest among controls. European Quality of Life scores were lowest in the WAD group, intermediate in the chronic nontraumatic neck pain group, and highest among controls (P<0.001). There was, however, no significant correlation between the alar ligament changes and measures for pain and disability. 2
103. Vetti N, Krakenes J, Ask T, et al. Follow-up MR imaging of the alar and transverse ligaments after whiplash injury: a prospective controlled study. AJNR Am J Neuroradiol. 2011;32(10):1836-1841. Review/Other-Dx 3 patients To review patients that had been extensively examined without any findings of structural lesions and was diagnosed by functional MRI to have injuries in the craniocervical joint region. Functional MRI is a radiological technique that can visualize injuries of the ligaments and the joint capsules, and accompanying pathological movement pattern. 4
104. 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. Eur J Radiol. 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
105. 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
106. 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
107. 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
108. 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
109. 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(2):437-446. 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
110. 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?. EMERG. RADIOL.. 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
111. 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
112. 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 guidelines on exposure of patients to ionizing radiation. No abstract available. 4