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Ravikanth R. Diagnostic Accuracy and Prognostic Significance of Point-Of-Care Ultrasound (POCUS) for Traumatic Cervical Spine in Emergency care setting: A Comparison of clinical outcomes between POCUS and Computed Tomography on a Cohort of 284 Cases and Review of Literature. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:257-262. [PMID: 34728992 PMCID: PMC8501824 DOI: 10.4103/jcvjs.jcvjs_3_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/28/2021] [Indexed: 11/04/2022] Open
Abstract
Background: The cervical spine is injured in approximately 3% of major trauma patients, and 10% of patients with serious head injury. Therefore, clearance of the cervical spine in multitrauma patients is a critically important task. This is particularly important, considering that there is a positive correlation between a Glasgow Coma Scale of <14 and cervical spine injury. Radiography is not sensitive enough to rule out cervical spine injury, especially as radiography done in the trauma setting is usually technically unsatisfactory. Objective: The current study aims to assess the diagnostic accuracy and prognostic significance of using bedside point-of-care ultrasound (POCUS) in traumatic cervical spine injuries compared to computed tomography (CT) as the reference standard. Materials and Methods: This comparative study enrolled 284 patients with severe multiple trauma at a tertiary care center between July 2017 and March 2020. The inclusion criteria included an indication of cervical spine CT scan, satisfaction of patients with participation in the study, and the lack of history of injury and severe traumatic events. The exclusion criteria were the history of a previous cervical spinal trauma, spondylosis, scoliosis, spinal tuberculosis, degenerative vertebral changes, and patients who refused to give consent to participate in research or CT scanning. The data were analyzed by SPSS software, and sensitivity, specificity, and positive predictive value (PPV)/negative predictive value (NPV) were determined based on CT findings. Results: The best window for the cervical spine was through the anterior triangle using the linear array probe (6–13 MHz). POCUS had a sensitivity of 78.5%, specificity of 98.4%, PPV of 93.2%, NPV of 92.8%, and accuracy of 93.2% in detecting all types of spinal injuries in comparison with CT scan as the standard modality. POCUS had a sensitivity of 100%, specificity of 92.3%, PPV of 62.3%, NPV of 100%, and accuracy of 91.7% in cases with the movement of injured particles. POCUS had a sensitivity of 32.2%, specificity of 100%, PPV of 100%, NPV of 91.4%, and accuracy of 90.8% in detecting the fracture of transverse process. POCUS had a sensitivity of 36.1%, specificity of 100%, PPV of 100%, NPV of 98.1%, and accuracy of 98.4% in ≤14-year age multitrauma patients. In comparison, the current study achieved a sensitivity of 79.4%, specificity of 95.7%, PPV of 92.1%, NPV of 86.3%, and accuracy of 88.6% in >14-year age multitrauma patients. Conclusion: POCUS for cervical spine is feasible using portable ultrasound machine and by neurosurgeons/radiologists/emergency physicians with basic training. It holds great potential in resource-starved settings and in unstable patients for ruling out unstable cervical spine injuries and injuries associated with the movement of fractured or dislocated particles. POCUS examination of the cervical spine was possible in the emergency setting and even in unstable patients and could be done without moving the neck. Future studies, ideally conducted as randomized control trials, are required to establish training and education standards, and to assess the feasibility and safety of POCUS as an alternative to radiography.
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Affiliation(s)
- Reddy Ravikanth
- Department of Radiology, St. John's Hospital, Idukki, Kerala, India
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Kadom N, Palasis S, Pruthi S, Biffl WL, Booth TN, Desai NK, Falcone RA, Jones JY, Joseph MM, Kulkarni AV, Marin JR, Milla SS, Mirsky DM, Myseros JS, Reitman C, Robertson RL, Ryan ME, Saigal G, Schulz J, Soares BP, Tekes A, Trout AT, Whitehead MT, Karmazyn B. ACR Appropriateness Criteria® Suspected Spine Trauma-Child. J Am Coll Radiol 2019; 16:S286-S299. [DOI: 10.1016/j.jacr.2019.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 12/29/2022]
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Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging. J Emerg Med 2018; 56:153-165. [PMID: 30598296 DOI: 10.1016/j.jemermed.2018.10.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 10/16/2018] [Accepted: 10/25/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Delayed diagnoses of unstable thoracolumbar spine (TL-spine) fractures can result in neurologic deficits and avoidable pain, so it is important for clinicians to reach prompt diagnostic decisions. There are no validated decision aids for determining which trauma patients warrant TL-spine imaging. OBJECTIVE Our aim was to quantify the diagnostic accuracy of the injury mechanism, physical examination, associated injuries, clinical decision aids, and imaging for evaluating blunt TL-spine trauma patients. METHODS A search strategy for studies including adult blunt TL-spine trauma using PubMed, Embase, Scopus, CENTRAL, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov was performed. Excluded studies lacked data to construct 2 × 2 tables, were duplicates, were not primary research, did not focus on blunt trauma, examined associated injuries without any utility in identifying TL-spine injuries, only studied cervical-spine fractures, were non-English, had a pediatric setting, or were cadaver/autopsy reports. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Diagnostic predictors were analyzed with a meta-analysis of sensitivity, specificity, and likelihood ratios. RESULTS In blunt trauma patients in the emergency department, the weighted pretest probability of a TL-spine fracture was 15%. The estimates for detection of TL-spine fractures with plain film were: positive likelihood ratio (+LR) = 25.0 (95% confidence interval [CI] 4.1-152.2; I2 = 94%; p < 0.001) and negative likelihood ratio (-LR) = 0.43 (95% CI 0.32-0.59; I2 = 84%; p < 0.001), and for computed tomography (CT) were: +LR = 81.1 (95% CI 14.1-467.9; I2 = 87%; p < 0.001) and -LR = 0.04 (95% CI 0.02-0.08; I2 = 23%; p = 0.26). CONCLUSIONS CT is more accurate than plain films for detecting TL-spine fractures. Injury mechanism, physical examination, and associated injuries alone are not accurate to rule-in or rule-out TL-spine fractures.
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Ahmed AS, Ramakrishnan R, Ramachandran V, Ramachandran SS, Phan K, Antonsen EL. Ultrasound diagnosis and therapeutic intervention in the spine. JOURNAL OF SPINE SURGERY 2018; 4:423-432. [PMID: 30069538 DOI: 10.21037/jss.2018.04.06] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spine pathology afflicts people across the globe and is responsible for a large portion of physician visits and healthcare costs. Imaging such as plain radiographs, CT, MRI, and ultrasound is vital to assess structure, function, and stability of the spine and also provide guidance in therapeutic interventions. Ultrasound utilization in spine conditions is less ubiquitous, but provides benefits in low costs, portability, and dynamic imaging. This study assesses ultrasound efficacy in diagnosis and therapeutic interventions for spine pathology. A systematic review conducted via PubMed, MEDLINE, and Google Scholar identified 3,630 papers with eventual inclusion of 73 papers with an additional 21 papers supplemental papers subsequently added. Findings highlighted ultrasound utilization for different structural elements of the spine such as muscle, bone, disc, ligament, canal, and joints are presented and compared with radiographs, CT, and MRI imaging where relevant. Spinal curvature and mobility are similarly presented. Ultrasound efficacy for guided therapeutics about the spine is presented and assessed against other modalities. Ultrasound is a widely used and efficacious modality to guide injections about the spine. Diagnostic utility is less well studied, but shows promise in assessing fractures, posterior ligamentous stability, and intra-operative hardware placement. The low cost, portability, and dynamic imaging ability make it an attractive modality particularly for developing health systems and resource limited environments such as combat settings and the International Space Station. Further study is recommended before broad adoption in diagnostics.
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Affiliation(s)
- Adil S Ahmed
- Department of Orthopaedic Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | | | | | - Shyam S Ramachandran
- Department of Kinesiology and Health Education, University of Texas, Austin, Texas, USA
| | - Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Randwick, Sydney, Australia.,Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, Sydney, Australia
| | - Erik L Antonsen
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA.,National Aeronautics and Space Administration, Houston, Texas, USA
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Meinig H, Döffert J, Linz N, Konerding MA, Gercek E, Pitzen T. Sensitivity and specificity of ultrasound in spinal trauma in 29 consecutive patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24:864-70. [DOI: 10.1007/s00586-014-3596-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 09/23/2014] [Accepted: 09/23/2014] [Indexed: 11/24/2022]
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Gabriel AC, Angel JPC, Juan JGP, Luis RMS, Hernando RAM, Rubén SB. Diagnostic accuracy of ultrasound for detecting posterior ligamentous complex injuries of the thoracic and lumbar spine: A systematic review and meta-analysis. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2014; 4:25-31. [PMID: 24381453 PMCID: PMC3872657 DOI: 10.4103/0974-8237.121621] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Posterior ligamentous complex injuries of the thoracolumbar (TL) spine represent a major consideration during surgical decision-making. However, X-ray and computed tomography imaging often does not identify those injuries and sometimes magnetic resonance imaging (MRI) is not available or is contraindicated. Objective: To determine the diagnostic accuracy of the ultrasound for detecting posterior ligamentous complex injuries in the TL spine. Materials and Methods: A systematic review was carried out through four international databases and proceedings of scientific meetings. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and their 95% confidence intervals (CIs) were estimated, by using weighted averages according to the sample size of each study. Summary receiver operating characteristic was also estimated. Results: A total of four articles were included in the meta-analysis, yielding a summary estimate: Sensitivity, 0.89 (95% CI, 0.86-0.92); specificity, 1.00 (95% CI, 0.98-1.00); positive likelihood ratio, 224.49 (95% CI, 30.43-1656.26); negative likelihood ratio, 0.11 (95% CI, 0.05-0.19); and diagnostic odds ratio, 2,268.13 (95% CI, 265.84-19,351.24). There was no statistically significant heterogeneity among results of included studies. Summary: Receiver operating characteristic (±standard error) was 0.928 ± 0.047. Conclusion and Recommendation: The present meta-analysis showed that ultrasound has a high accuracy for diagnosing posterior ligamentous complex injuries in patients with flexion distraction, compression, or burst TL fractures. On the basis of present results, ultrasound may be considered as a useful alternative when magnetic resonance imaging (MRI) is unavailable or contraindicated, or when its results are inconclusive.
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Affiliation(s)
- Alcalá-Cerra Gabriel
- Department of Neurological Research, Health Sciences and Neurosciences (CISNEURO) Research Group, University of Cartagena, Cartagena de Indias, Colombia ; Department of Neurosurgery, University of Cartagena, Cartagena de Indias, Colombia
| | - J Paternina-Caicedo Angel
- Department of Neurological Research, Health Sciences and Neurosciences (CISNEURO) Research Group, University of Cartagena, Cartagena de Indias, Colombia
| | - J Gutiérrez-Paternina Juan
- Department of Neurological Research, Health Sciences and Neurosciences (CISNEURO) Research Group, University of Cartagena, Cartagena de Indias, Colombia
| | - R Moscote-Salazar Luis
- Department of Neurological Research, Health Sciences and Neurosciences (CISNEURO) Research Group, University of Cartagena, Cartagena de Indias, Colombia
| | - R Alvis-Miranda Hernando
- Department of Neurological Research, Health Sciences and Neurosciences (CISNEURO) Research Group, University of Cartagena, Cartagena de Indias, Colombia
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Zhao JW, Liu Y, Yin RF, Wang JC, Yang YH, Liu P. Ultrasound assessment of injury to the posterior ligamentous complex in patients with mild thoracolumbar fractures. J Int Med Res 2013; 41:1252-7. [PMID: 23760913 DOI: 10.1177/0300060513483407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To assess the value of ultrasonographic imaging of the posterior ligamentous complex (PLC) to diagnose ligamentous injuries, in patients with mild thoracolumbar fractures. Methods Patients with thoracolumbar fractures were included in this prospective study. Patients underwent palpation of the midline of the back, and ultrasonography was performed over the entire thoracolumbar region by an experienced sonographer. A team that included a musculoskeletal radiologist, an orthopaedic surgeon and a sonographer assessed the ultrasound results. Ultrasonographic and magnetic resonance imaging (MRI) findings were jointly evaluated in a subgroup of patients who were able to fund MRI analysis. Conflicts regarding the results were resolved by a majority vote. Results A total of 21 patients participated in the study, all of whom exhibited abnormal ultrasonographic echogenicity on the supraspinous or interspinous ligaments. Three patients were diagnosed with a rupture of the supraspinous ligament. In 15/17 (88.2%) patients, interspinous ligament injuries were detected caudally to the injured vertebrae. Conclusions Ultrasound examination is a reliable complementary diagnostic tool to identify PLC injuries in patients with mild thoracolumbar fractures.
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Affiliation(s)
- Jian-Wu Zhao
- Department of Orthopaedic Surgery, China-Japan Union Hospital, Jilin University, Changchun, Jilin Province, China
| | - Yan Liu
- Department of Ultrasonography, China–Japan Union Hospital, Jilin University, Changchun, Jilin Province, China
| | - Ruo-Feng Yin
- Department of Orthopaedic Surgery, China-Japan Union Hospital, Jilin University, Changchun, Jilin Province, China
| | - Jin-Cheng Wang
- Department of Orthopaedic Surgery, China-Japan Union Hospital, Jilin University, Changchun, Jilin Province, China
| | - Yu-Hui Yang
- Department of Orthopaedic Surgery, China-Japan Union Hospital, Jilin University, Changchun, Jilin Province, China
| | - Peng Liu
- Department of Orthopaedic Surgery, China-Japan Union Hospital, Jilin University, Changchun, Jilin Province, China
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van Middendorp JJ, Patel AA, Schuetz M, Joaquim AF. The precision, accuracy and validity of detecting posterior ligamentous complex injuries of the thoracic and lumbar spine: a critical appraisal of the literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:461-74. [PMID: 23208081 PMCID: PMC3585631 DOI: 10.1007/s00586-012-2602-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 10/08/2012] [Accepted: 11/20/2012] [Indexed: 01/12/2023]
Abstract
PURPOSE The diagnostic assessment and prognostic value of the posterior ligamentous complex (PLC) remains a controversial topic in the management of patients with thoracolumbar spinal injury. The purpose of this review was to critically appraise the literature and present an overview of the: (1) precision, (2) accuracy, and (3) validity of detecting PLC injuries in patients with thoracic and lumbar spine trauma. METHODS Studies evaluating the precision, accuracy and/or validity of detecting and managing PLC injuries in patients with thoracic and/or lumbar spine injuries were searched through the Medline database (1966 to September 2011). References were retrieved and evaluated individually and independently by two authors. RESULTS Twenty-one eligible studies were identified. Few studies reported the use of countermeasures for sampling and measurement bias. In nine agreement studies, the PLC was assessed in various ways, ranging from use of booklets to a complete set of diagnostic imaging. Inter-rater and intra-rater kappa values ranged from 0.188 to 0.915 and 0.455 to 0.840, respectively. In nine accuracy studies, magnetic resonance (MR) imaging was most often (n = 6) compared with intra-operative findings. In general, MR imaging tended to demonstrate relatively high negative predictive values and relatively low positive predictive values for PLC injuries. CONCLUSIONS A wide variety of methods have been applied in the evaluation of precision and accuracy of PLC injury detection, leaving spinal surgeons with a multitude of variable results. There is scant clinical evidence demonstrating the true prognostic value of detected PLC injuries in patients with thoracic and lumbar spine injuries. We recommend the conduct of longitudinal clinical follow-up studies on those cases assessed for precision and/or accuracy of PLC injuries.
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Affiliation(s)
- Joost J. van Middendorp
- />Stoke Mandeville Spinal Foundation, National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK
- />Harris Manchester College, University of Oxford, Oxford, UK
- />Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD Australia
| | - Alpesh A. Patel
- />Department of Orthopaedic Surgery and Rehabilitation, Loyola University, Chicago, IL USA
| | - Michael Schuetz
- />Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD Australia
- />Trauma Service, Princess Alexandra Hospital, Brisbane, QLD Australia
| | - Andrei F. Joaquim
- />Department of Orthopaedic Surgery and Rehabilitation, Loyola University, Chicago, IL USA
- />Division of Neurosurgery, Department of Neurology, State University of Campinas, Campinas, SP 13083-970 Brazil
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Evans CS, Harris NS. Ultrasound and Ski Resort Clinics: Mapping Out the Potential Benefits. Wilderness Environ Med 2012; 23:239-47. [PMID: 22704080 DOI: 10.1016/j.wem.2012.03.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 03/21/2012] [Accepted: 03/22/2012] [Indexed: 01/10/2023]
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Ultrasound use in ski clinics. Wilderness Environ Med 2012; 23:212-4. [PMID: 22921195 DOI: 10.1016/j.wem.2012.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Accepted: 07/02/2012] [Indexed: 11/20/2022]
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von Scotti F, Schröder RJ, Streitparth F, Kandziora F, Hoffmann R, Schnake K. Ultraschall zur Beurteilung des posterioren Ligamentkomplexes bei thorakolumbalen Wirbelsäulenfrakturen. Radiologe 2010; 50:1132, 1134-40. [DOI: 10.1007/s00117-010-2047-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Mulholland RC. The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the "surgical and research" articles in the European Spine Journal, 2009. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 19:11-8. [PMID: 20024664 DOI: 10.1007/s00586-009-1245-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Indexed: 01/17/2023]
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