Computed tomographic scanning of cervical spine fractures: does it influence treatment?

What should an ideal spinal injury classification system consist of? A methodological review and conceptual proposal for future classifications

Since Böhler published the first categorization of spinal injuries based on plain radiographic examinations in 1929, numerous classifications have been proposed. Despite all these efforts, however, only a few have been tested for reliability and validity. This methodological, conceptual review summarizes that a spinal injury classification system should be clinically relevant, reliable and accurate. The clinical relevance of a classification is directly related to its content validity. The ideal content of a spinal injury classification should only include injury characteristics of the vertebral column, is primarily based on the increasingly routinely performed CT imaging, and is clearly distinctive from severity scales and treatment algorithms. Clearly defined observation and conversion criteria are crucial determinants of classification systems' reliability and accuracy. Ideally, two principle spinal injury characteristics should be easy to discern on diagnostic images: the specific location and morphology of the injured spinal structure. Given the current evidence and diagnostic imaging technology, descriptions of the mechanisms of injury and ligamentous injury should not be included in a spinal injury classification. The presence of concomitant neurologic deficits can be integrated in a spinal injury severity scale, which in turn can be considered in a spinal injury treatment algorithm. Ideally, a validation pathway of a spinal injury classification system should be completed prior to its clinical and scientific implementation. This review provides a methodological concept which might be considered prior to the synthesis of new or modified spinal injury classifications.

Routine versus selective multidetector-row computed tomography (MDCT) in blunt trauma patients: level of agreement on the influence of additional findings on management

INTRODUCTION

This study was performed to determine the agreement between and within surgeons concerning the influence on treatment plan of routine versus selective multidetector-row computed tomography (MDCT) findings in blunt trauma patients.

PATIENTS

For this study, 50 patients were randomly selected from a customized database that was originally used to compare a diagnostic algorithm with a selective use of MDCT with an algorithm with routine MDCT of the spine, chest, and abdomen within the same population. In all 50 patients, routine MDCT found additional diagnoses as compared with the selective MDCT algorithm. Of all patients, paper cases were created with detailed information on clinical parameters, findings by physical examination, and radiologic findings. The cases were independently presented to three different trauma surgeons. First, the surgeons were asked for their treatment plan based upon diagnoses found by physical examination, conventional radiography, and selective MDCT alone. Subsequently they were asked for their treatment plan with knowledge of the injuries additionally found by routine MDCT. This procedure was repeated after 3 months. The agreement between and within surgeons was determined for the change of patient management because of additional findings by routine MDCT.

RESULTS

The agreement on the influence of routine MDCT findings on patient management between surgeons was moderate ([kappa] = 0.46) in the first procedure and substantial in the second ([kappa] = 0.67). The agreement within surgeons ranged from moderate ([kappa] = 0.60) to excellent ([kappa] = 0.87).

CONCLUSION

All surgeons agreed that the traumatic injuries additionally found by routine MDCT, frequently resulted in a change of treatment plan. There was a moderate-to-excellent agreement between and within surgeons that these additional findings resulted in a change of treatment plan.

The value of indicated computed tomography scan of the chest and abdomen in addition to the conventional radiologic work-up for blunt trauma patients

BACKGROUND

Multidetector computed tomography (CT) is more sensitive and specific in detecting traumatic injuries than conventional radiology is. However, still little is known about the diagnostic value and the therapeutic impact of indicated thoraco-abdominal CT scan when it is performed in addition to the complete conventional radiologic work-up for blunt trauma patients.

METHODS

Clinical and radiologic data from 106 consecutive blunt trauma patients were reviewed. Diagnoses revealed by conventional work-up of the chest, abdomen, pelvis, and thoracolumbar spine were compared with that detected by CT scan of the chest and abdomen. Unexpected findings by CT scan and rejected diagnoses by CT scan were collected. Therapeutic consequences of these diagnoses were determined both theoretically and collected from the medical records.

RESULTS

In 74% (95% confidence interval [CI] 65-82) of the 106 patients, 1 or more diagnoses were demonstrated by chest or abdominal CT scan, whereas they had not been revealed by preceding conventional work-up. This resulted in an actual change of treatment in 34% (95% CI 25-43) of the patients. CT scan of the chest resulted in a change of treatment in 33% (95% CI 23-44) and abdominal CT scan in 16% (95% CI 9-24).

CONCLUSIONS

CT scan of the chest and abdomen has a high diagnostic value in the evaluation of blunt trauma patients, when it is selectively performed in addition to the early conventional radiologic work-up. Unexpected pathologic findings are detected by CT scan in the majority of the patients. These findings result in an adaptation of treatment in a substantial number of the patients.

The early work-up for isolated ligamentous injury of the cervical spine: does computed tomography scan have a role?

BACKGROUND

Helical computed tomography (HCT) scan is the preferred modality for diagnosing fractures of the cervical spine in blunt trauma. We hypothesize that HCT can be used as a screening tool for isolated ligamentous injury (LI) in blunt trauma.

METHODS

A prospective, consecutive series study design was used to include patients that could not have their cervical spine cleared clinically. All patients underwent HCT (occiput-T1) and plain radiographs (PR) with five views of the cervical spine. Patients with clinical or radiographic abnormalities without fracture underwent cervical magnetic resonance imaging (MRI). Demographic and outcome data were collected. The attending radiologist's interpretation was used for clinical management. Three neuroradiologists in a blinded fashion re-reviewed the studies (HCT, PR, and MRI) of the MRI subgroup.

RESULTS

One thousand five hundred seventy-seven patients met the study criteria. Two hundred seventy-eight had 416 cervical spine fractures. PR failed to identify 299 of 416 (72%) cervical spine fractures in 208 of 278 (74.8%) patients. Of the 1,299 (82%) patients who had no fracture, 85 (6.5%) required an MRI. The mean time from admission to MRI was 3 days for the LI subgroup. Of these, 21 of 85 (25%) had LI by MRI. Seven of 21 (33.3%) patients had an abnormal HCT versus 3 of 21 (14.3%) patients who had an abnormal PR. Four of 85 (4.7%) patients had spinal cord injury without radiographic abnormality. One (1.2%) patient required surgical stabilization of LI, as seen on all studies performed (PR, HCT, and MRI). Sensitivities for PR and HCT for LI were 16% and 32%, respectively. Negative predictive values for PR and HCT for LI were 74% and 78%, respectively. Measurements of interrater reliability for MRI, HCT, and PR had kappa values of 0.60, 0.14, and 0.41, respectively.

CONCLUSION

HCT is the most sensitive, specific, and cost-effective modality for screening the cervical spine bony injuries, but it is not an effective modality for screening for cervical LI. MRI is clearly superior to HCT for LI. The indications for MRI include abnormalities on HCT, neurologic deficits, cervical pain or tenderness on examination, or the inability to clear the cervical spine in the obtunded patient. With the current state of the art technology, we have redefined the definition of spinal cord injury without radiographic abnormality to include spinal cord injuries without boney injuries or LI.

Development of an evidence-based guideline for imaging in cervical spine trauma

Cervical spine trauma is a common reason for presentation to an emergency department. However, less than 5% of patients who have suffered possible neck injury actually have an injury requiring medical treatment. Nevertheless, the consequences, both for the patient and the doctor, of a missed injury are well recognized by emergency department medical staff. This results in the vast majority of these patients receiving some form of diagnostic imaging. We describe the development of an evidence-based imaging guideline for use in the patient who has suffered cervical spine trauma. The guideline aims to help clinicians determine, at the bedside, when it is appropriate to use imaging and which imaging modality should be used first. Correct utilization of the guideline should lead to a reduction in the number of imaging tests required to reach a diagnosis without adverse patient outcomes.

Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma

BACKGROUND

The purpose of this study is to investigate the usefulness of flexion and extension radiographs of the cervical spine for the acute evaluation of ligamentous injury in cases of awake blunt trauma.

METHODS

A review of 106 consecutive cases of blunt trauma evaluated with flexion and extension radiographs of the cervical spine obtained in the acute setting at a Level I trauma center was performed. The data compiled included the age, sex, mechanism of injury, type of radiographic evaluations, interpretation of all radiographic studies, and clinical outcome on follow-up.

RESULTS

Sixty-six of the patients (62%) were involved in motor vehicle crashes. Other injuries included 15 falls (14%), 9 blunt assaults (8.5%), and 16 other types of blunt trauma (15%). Thirteen cervical spine injuries were diagnosed in 9 of 106 patients (8.5%). Injuries included two fractures, eight acute disc herniations, two ligamentous injuries, and one cord contusion diagnosed on the basis of all radiologic evaluation and clinical follow-up. Seventy-four patients (70%) had a range of flexion and extension motion interpreted as adequate for diagnostic purposes. Five of the 74 patients (6.75%) with an adequate range of motion had cervical spine injuries. No ligamentous injuries were misdiagnosed in this group. Thirty-two of the flexion and extension examinations (30%) were interpreted as inadequate because of limited motion. Four of the 32 patients (12.5%) with inadequate flexion and extension examinations had injuries subsequently detected on cross-sectional imaging (computed tomographic scanning or magnetic resonance imaging) including severe ligamentous injury.

CONCLUSION

When adequate motion was present on flexion and extension radiographs, the false-negative rate was zero in this study. However, in the acute setting, 30% of the examinations were limited by inadequate motion. A higher percentage of injury (12.5%) was detected by subsequent cross-sectional imaging in these patients. Limited flexion and extension motion on physical examination should preclude the use of flexion and extension radiographs, as they are of limited diagnostic utility. Cross-sectional imaging may be warranted in this high-risk group of patients.

Variability in computed tomography and magnetic resonance imaging in patients with cervical spine injuries

OBJECTIVE

The purpose of this study was to describe the performance of adjunctive radiologic imaging in patients with cervical spine injury.

METHODS

All patients undergoing cervical spine radiography were prospectively enrolled at 16 diverse emergency departments. We recorded the imaging modalities and radiographic interpretations rendered by unblinded faculty radiologists at each center. Only patients with cervical spine injury were included in this analysis. Findings revealed by individual modalities were compared with the final diagnosis (after all evaluations) in each patient.

RESULTS

Six hundred eighty-eight patients with 1,302 separate cervical spine injuries were enrolled. Four hundred seventy-six (69%) patients had magnetic resonance imaging (MRI) and/or computed tomography (CT) of the cervical spine. MRI identified the following injuries among 124 imaged patients: osseous fractures, 85 of 154 (55%); spinal cord injury, 69 of 69 (100%); vertebral subluxation/dislocation, 37 of 43 (86%); ligamentous injury, 38 of 38 (100%); and unilateral/bilateral locked facets, 14 of 18 (78%). Among 418 patients undergoing CT, the following injuries were identified: osseous fractures, 721 of 740 (97%); spinal cord injury, 0 of 30 (0%); vertebral subluxation/dislocation, 76 of 88 (86%); ligamentous injury, 9 of 36 (25%); and unilateral/bilateral locked facets, 34 of 35 (97%). CT identified 29 patients with fractures who had normal plain radiographs. Cervical myelograms were obtained in two patients and cervical tomograms in seven patients.

CONCLUSION

The majority of patients with cervical spine injury undergo MRI and/or CT imaging. In clinical practice, MRI is superior at identifying soft tissue injuries, whereas CT performs better in identifying bony injuries. Cervical myelograms and tomograms are rarely obtained.

The role of plain films and computed tomography in the evaluation of scapular neck fractures

OBJECTIVE

To assess the ability of plain films and computed tomography scans to show the pattern, displacement, and angulation of scapular neck fractures. To assess the ability of computed tomography to identify concomitant occult shoulder injuries.

DESIGN

Masked retrospective radiographic review.

SETTING

Level I trauma center.

PARTICIPANTS

Three orthopaedic surgeons (two attending physicians and one senior resident) and one musculoskeletal radiology attending physician reviewed the imaging studies of scapula neck fractures in twenty patients treated at our institution.

MAIN OUTCOME MEASURES

Kappa analysis of agreement of fracture characteristics and benefits of computed tomography for scapular neck fractures.

RESULTS

The mean weighted kappa coefficient for interobserver reliability of fracture displacement was 0.49 when the fractures were assessed by plain films alone, 0.15 when they were assessed by computed tomography scans alone, and 0.35 when they were assessed by plain films and computed tomography scans. The mean weighted kappa coefficients for fracture angulation were 0.30, 0.23, and 0.16, respectively. The mean simple kappa coefficients for fracture classification were 0.81, 0.20, and 0.33, respectively. Concomitant injury to the superior shoulder suspensory complex was seen in 57 percent of cases, including nine clavicle fractures, one coracoid fracture, and three acromion process fractures. The coracoid fracture and two of the acromion process fractures were minimally displaced and seen on computed tomography scans only.

CONCLUSION

Scapular neck fracture displacement, angulation, and anatomic classification showed moderate interobserver reliability by plain films but were not enhanced by computed tomography. Computed tomography confused, rather than clarified, the assessment of these characteristics. Computed tomography may be useful to identify associated injuries to the superior shoulder suspensory complex, which can be missed by plain films alone. Routine computed tomography in patients with scapular neck fractures cannot be recommended based on this study. Computed tomography of scapular neck fractures may be useful in selected cases in which intraarticular extension is noted on plain films.