Spinal Trauma

The balance between the use of plain film radiography and CT in the evaluation of acutely injured patient continues to evolve. The debate over the appropriate triage algorithm considers such factors as time, cost, and diagnostic accuracy. In reality, other factors such as clinical judgment, regional practice variations, and the possibility of litigation also affect the utilization of resources. The issue boils down to two considerations. First, who should be imaged? Second, how should they be imaged? A complete discussion of all of these issues is beyond the scope of this chapter, but a few background points are worth noting. The National Emergency X-Radiography Utilization Study (NEXUS) was a large, multicenter prospective study that evaluated 34,069 patients with neck trauma in an attempt to determine criteria for classifying patients with an extremely low likelihood of clinically significant injury. The goal was to define a subset of patients for whom imaging would not be necessary. Five criteria had to be satisfied in order to be considered for the low probability category. These consisted of the absence of mid-line cervical tenderness, the lack of a focal neurologic deficit, a normal level of consciousness, the absence of intoxication, and the lack of a distracting painful injury. This clinical tool identified 99% (missing 8 of 818 fractures) of the clinically significant injuries. Further investigation revealed that only two of the eight missed fractures were believed to be clinically significant, and in one of those two the criteria had not been correctly applied. Their conclusion was that clinical indicators accurately predict the likelihood of significant cervical spine injury (15). The result would be improved diagnostic yield and cost-effectiveness for imaging studies.

As to the question of how best to image the patient suspected of cervical injury, there is to date no consensus. There appears to be a trend toward the use of CT earlier in the investigation, usually following a series of plain radiographs including anteroposterior, lateral, and odontoid views. In the severely injured patient, obtaining adequate plain films is difficult and time consuming, often requiring multiple repeat images. This can lead to a costly delay in the management of other potentially life-

Reactive Edema Cervical SpineReactive Edema Cervical Spine

Fig. 5. Lateral radiograph (A) and axial CT (B) reveal obvious interruption of the pars interarticularis at L3 bilaterally. There is associated disc degeneration at L3-4 with grade 1 spondylolisthesis. (C) Sagittal CT reformation again demonstrates the spondylolysis. The actual bony defect may be difficult to detect on MR images, as in this case. (D) Sagittal T2 shows reactive edema, which is indirect evidence of instability at that level.

threatening injuries. The cervicothoracic junction is often poorly imaged in the severe trauma patient. The odontoid process is frequently obscured by overlapping bony structures or by the presence of an endotracheal tube. This has led some to advocate the use of CT to clear the cervical spine routinely in the setting of an inadequate initial plain film evaluation (Fig. 6) (1). Others have further proposed that CT should be the initial study in severely injured patients who have already been triaged to CT for evaluation of other critical injuries, such as to the head or viscera (16). Several studies support this proposal. Blacksin and Lee studied routine use of CT of the craniocervical junc

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