Monday, August 25, 2003

In this month's Journal of Trauma there is a paper concerning the use of cervical spine CT scans in blunt trauma patients. Their results seem to add weight to the argument that cervical CT is a superior study in determining cervical injury.
Their study consisted of 1,199 patients who where "at risk" for cervical injury over a year period....

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.

Wow. 3.2 percent missed. While 26 of the 41 were treated with cervial collar only, nine required halos and three required surgical stabilization. This is actually an improvement over some other studies cited in this paper. Four other studies were cited from 1999 to 2002. Of the 221 cervical injuries seen in 2946 patients, 132 (60%) were seen on conventional radiographs while 218 (98%) were detected using CT. Even in the latest ATLS material, the standard cervical spine films (lateral from C1-T1, AP, and odontiod views) exclude 85 percent of cervial injury.
EAST has several good guidelines for evaluation of the cervical spine here and here. They currently recommend three views and CT scans of poorly visualized areas as well as CT from the occiput to C2 in patients with expected mental status changes for grater than two days, but as the authors of this study point out..

...If these EAST guidelines had been followed, only 2 of the 41 patients with false-negative CSR (cervical spine radiographs) in this series would have had their injuries identified. None of these 41 patients had inadequate films or suspicious areas so there was no reason to perform CTC(cervical CT).

Other modalities include flextion-extension views and MRI. Flextion-extension views are useful only if flextion greater than 30 degress without pain can be achieved. 30 percent of patients cannot do this. MRI is expensive and can over-call or under-call injuries. Applying this study to your neighborhood should be predicated on the availability of a helical high-speed scanner. Otherwise your patient will spend all day in scan land. I think that I'll take a close look at expanding the use of CT in this area.
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