Prospective comparison of admission computed tomographic scan and plain films of the upper cervical spine in trauma patients with altered mental status

False-Negative Plain Cervical Spine X-Rays in Blunt Trauma

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

Are Five-View Plain Films of the Cervical Spine Unreliable? A Prospective Evaluation in Blunt Trauma Patients with Altered Mental Status

OBJECTIVES

Clearing the cervical spine in a time-sensitive fashion is difficult. We hypothesized that admission computed tomographic scan of the occiput to T1 (CTS) with multiplanar reformatted images will replace five-view (odontoid, anteroposterior, lateral, and oblique) plain films of the cervical spine (CSX) in the initial evaluation of blunt trauma patients with altered mental status.

METHODS

Between January and July 2001, all patients aged 16 years or older with altered mental status undergoing both CTS and CSX were prospectively entered into the study group. Attending physician interpretation defined the presence of cervical spine injury. Unstable fractures were defined as requiring surgical or halo stabilization.

RESULTS

One thousand six patients met study criteria. One hundred sixteen patients had 172 cervical spine injuries (CSIs) (fracture and subluxation). CSX missed 90 of 172 (52.3%) CSIs in 65 of 172 (56.0%) patients. Anatomically, CSX failed to identify 14 of 15 occipital fractures (93.3%), 17 of 36 (47.2%) C1-3 fractures, and 59 of 121 (48.8%) C4-T1 CSIs. CSX failed to identify 5 of 29 (17.2%) patients with unstable CSIs. CTS failed to diagnose 3 of 172 (1.7%) CSIs that were stable (spinous process fractures at C6-7). Two patients exhibited spinal cord injury without radiologic abnormality missed by both modalities. CTS had a sensitivity of 97.4%, a specificity of 100%, a prevalence of 11.5%, a positive predictive value of 100%, and a negative predictive value of 99.7%. CSX had a sensitivity of 44.0%, a specificity of 100%, a prevalence of 11.5%, a positive predictive value of 100%, and a negative predictive value of 93.2%.

CONCLUSION

CTS outperformed five-view CSX in a group of patients with altered mental status or distracting injuries. Five-view CSX failed to diagnose 52.3% of cervical spine fractures identified by CTS. Five-view CSX failed to diagnose five patients with unstable cervical fractures and failed to identify 93.3% of patients with occipital condyle fractures.

Blunt liver injuries in polytrauma: results from a cohort study with the regular use of whole-body helical computed tomography

The estimated prevalence of liver injury in patients with blunt multiple trauma ranges from 1% to 8%. The objective of this study was to investigate the profile of accompanying liver injury in a cohort of polytraumatized patients who had regularly undergone contrast-enhanced, whole-body helical computed tomography (CT). We enrolled consecutive patients admitted between September 1997 and January 2001 to a level I trauma center. Clinical baseline data were compiled as part of a nationwide trauma registry. Morphologic features were evaluated descriptively, whereas prognostic variables were assessed by logistic regression analysis. We identified 218 patients [149 men, mean age 35 +/- 18 years, mean injury severity score (ISS) 35 +/- 10], 55 of whom had sustained blunt liver trauma [25.2%, 95% confidence interval (CI) 19.6-31.5%]. The prevalence of Moore III to V lesions was 10.1%. There were 99 parenchymal contusions, 15 capsular tears, and 2 liver fractures. Surgery was required in 15 patients and was best predicted by the classification of the American Association for the Surgery of Trauma [odds ratio (OR) 3.91, 95% CI 1.59-9.61]. The mortality rate was 0.0035/person/day. Patients requiring surgical repair had fourfold increased relative odds of case fatality (OR 4.50, 95% CI 1.01-19.96). Sevenfold increased relative odds were observed if liver laceration was considered the leading injury (OR 7.17, 95% CI 1.17-43.97). The prevalence of liver lacerations among multiple-trauma patients is likely to be underestimated and must be determined by the independent application of reference standards, such as helical CT. High-grade hepatic injuries and the need for surgical repair are associated with poorer survival prognosis.

Common tasks and problems in paediatric trauma radiology

Scope of this article is to give practical hints for the most common, typical and important topics of trauma radiology in children to those radiologists who are not exclusively occupied with paediatric imaging. Due to the increased radiation sensitivity of children compared with adults balancing radiation protection and necessary image quality is of utmost importance. Outlines for this optimisation process are given. Especially in imaging of the extremities perhaps the greatest difficulties are posed by the dynamically changing face of the immature, growing, only partially ossified skeleton. Lack of experience must be compensated by meticulous comparison with the normal skeletal development as shown in standard textbooks, and by knowledge of the radiological image of the developmental variants. Besides general remarks about paediatric trauma radiology, some important topics are discussed into more detail. Especially the elbow joint poses a challenge for those less experienced with its radiological appearance in children. More than in adults, ultrasound should remain the primary imaging modality of choice especially in the assessment of abdominal trauma, and CT be tailored to radiological and clinical findings. Imaging and diagnosis of non-accidental injury (NAI) may be a less common task for the general radiologist, however, the severe social implications of physical child abuse mandate a basic knowledge about the radiological symptoms and the imaging management of this problem for all physicians occupied with paediatric radiology.

Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan?

BACKGROUND

The purpose of this study was to evaluate the roles of cervical spine radiographs (CSR) and computed tomography of the cervical spine (CTC) in the exclusion of cervical spine injury for adult blunt trauma patients.

METHODS

At the authors' institution, all adult blunt trauma patients with physical findings of posterior midline neck tenderness, altered mental status, or neurologic deficit are considered at risk of cervical spine injury and undergo both CSR and CTC for evaluation of the cervical spine. The TRACS database at level 1 of the trauma center at this institution was queried for all blunt trauma patients from November 2000 to October 2001. Patient injury severity score (ISS), Glascow Coma Score (GCS), age, gender, CSR results, CTC results, and treatment data were analyzed.

RESULTS

The review included 3,018 blunt trauma patients with appropriate data. For 1,199 of these patients (779 men and 420 women) (40%) at risk for cervical spine injury, both CSR and CTC were performed for cervical spine evaluation. The average age of these patients was 39.4 years (range, 18-89 years). The average GCS was 13 and the average ISS was 8.4 in this study population. In 116 (9.5%) of these patients, a cervical spine injury (fracture or subluxation) was detected. The injury was identified on both CSR and CTC in 75 of these patients. In the remaining 41 patients (3.2%), the CSR results were negative, but injury was detected by CTC. All these injuries missed by CSR required treatment. For this group with false-negative CSR, the average GCS was 12 and the average ISS was 14.6. There were no missed cervical spine injuries among the patients with negative CTC results.

CONCLUSION

No identifiable factors predicted false-negative CSR. There does not appear to be any role for CSR screening in this setting. The data from this study add to the growing body of evidence that CTC should replace CSR for the evaluation of the cervical spine in blunt trauma.

Critical care and perioperative management in traumatic spinal cord injury

Traumatic spinal cord injury is frequently associated with brain injury and with alterations in respiratory and cardiovascular function that require critical care management. Complications include respiratory failure, atelectasis, pneumonia, neurogenic shock, autonomic dysreflexia, venous thromboembolism, and sepsis. While complications may be managed with supportive care, the goal of ameliorating neurologic outcome has proved elusive. Methylprednisolone, when instituted <8 hours after traumatic spinal cord injury, was associated in two clinical trials with statistically significant improvements in motor scores at 6 months and 1 year; however, critical reappraisal of these data raises questions about their validity and clinical relevance. Until more evidence of clinically effective therapies is available, acute management must be driven by pathophysiologic principles, with emphasis on interventions that attenuate secondary neurologic injury; these include the rational use of immobilization, cautious airway management, and promotion of cord perfusion and oxygenation with the appropriate level of hemodynamic and respiratory support. Clinical trials of pharmacologic neuroprotection have yielded disappointing results, but the ongoing elucidation of spinal cord repair and regenerative mechanisms suggests new therapeutic prospects.