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      Cervical Spine Computed Tomography Imaging Artifact Affecting Clinical Decision-Making in the Traumatized Patient

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          Abstract

          CT scanning is an important tool in the evaluation of trauma patients. We review a case involving a trauma patient in which a cervical spine computed tomography (CT) artifact affected decision-making by physicians. The CT artifact mimicked bilateral dislocated facets (51-B1.1). On the basis of CT findings, the patient was transferred to a different hospital for evaluation. Discrepancy between the primary CT scan and patient physical exam prompted secondary CT scans and X-ray evaluation; neither of these studies showed osseous abnormalities. This case reinforces the necessity for physicians to formulate their diagnosis based upon multiple areas of information including physical examination, plain x-ray and subsequent advanced imaging, rather than relying solely on advanced imaging.

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          Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study.

          X. Luo, M Zucker, W Mower … (1992)
          Cervical-spine radiography does not need to be performed on selected blunt trauma patients who are awake, alert, nonintoxicated, do not complain of midline neck pain, and have no tenderness over the bony cervical spine. One thousand consecutive patients seen in the UCLA Emergency Medicine Center with a chief complaint of blunt trauma, for whom cervical-spine films were ordered and for whom prospective data questionnaires were completed. Clinicians completed data forms for each patient before radiograph results were known. Data items included mechanism of injury, evidence of intoxication, presence of cervical-spine pain and/or tenderness, level of alertness, presence of focal neurologic deficits, and presence of other severely painful injuries unrelated to the cervical spine. Physicians were also asked to estimate likelihood of significant cervical-spine injury. Twenty-seven patients with cervical-spine fracture were among the 974 patients for whom data forms were completed. A number of findings were statistically more common in the group of patients with fracture than without, but no single or paired findings identified all patients with fracture. All 27 patients with fracture had at least one of the following four characteristics: midline neck tenderness, evidence of intoxication, altered level of alertness, or a severely painful injury elsewhere. Three hundred fifty-three of 947 (37.3%) patients without cervical-spine fracture had none of these findings. Cervical-spine radiology may not be necessary in patients without spinous tenderness in the neck, intoxication, altered level of alertness, or other severely painful injury. A policy to limit films in such patients would have decreased film ordering by more than one third in this series, while identifying all patients with fracture.
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            Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study.

            Edward Cornwell, D. Demetriades, Q el-Dwairi … (1999)
            To evaluate the role of routine helical computed tomographic (CT) scan of the entire cervical spine in high-risk patients with multiple injuries. Prospective study of patients with severe blunt multiple injuries, requiring intensive care unit admission and CT scan of another body area besides the cervical spine. All patients were evaluated by means of standard cervical spine radiography. A complete cervical spine CT scan was performed during the same trip to the scanner in which other body areas were evaluated. The plain films and the CT scans were read by a radiologist in a blinded manner. Fifty-eight patients fulfilled the criteria for inclusion in the study. The mean Glasgow Coma Scale score was 8.9 and the mean Injury Severity Score was 24.1. Twenty patients (34.4%) had cervical spine injuries (12 stable and 8 unstable injuries). Plain radiography missed eight injuries (including three unstable) and its sensitivity was 60%, specificity 100%, positive predictive value 100%, and negative predictive value 85.1%. The helical CT scan missed two spinal injuries (both stable) and its sensitivity was 90%, specificity was 100%, positive predictive value = 100%, negative predictive value = 95%. There is a high incidence of cervical spine injuries in the severe, blunt, multiple-injury, unevaluable patients requiring intensive care unit admission. Plain radiography alone is not reliable in diagnosing many cervical spine injuries. Complete cervical spiral computed tomography is superior to plain radiography. It is suggested that in this selected group of patients, both plain radiography and spiral computed tomography should be performed.
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              Helical computed tomography alone compared with plain radiographs with adjunct computed tomography to evaluate the cervical spine after high-energy trauma.

              J France, William B. Krantz, P McCulloch … (2005)
              Current literature supports the use of the three-view plain-radiograph series supplemented, when necessary, with helical computed tomography to evaluate the cervical spine in patients who have sustained trauma injury. The purpose of this study was to determine if helical computed tomography alone can be used to evaluate the cervical spine for acute osseous injury following high-energy trauma, thus eliminating the need to make radiographs. Patients were prospectively evaluated with helical computed tomography scanning of the cervical spine and standard three-view plain radiography. At a later date, the plain radiographs and computed tomography scans were independently reviewed by two radiologists who were blinded to both the initial interpretation and the interpretation of the corresponding study. The radiologists documented whether the plain radiographs were adequate and whether they showed an acute process. The findings in the study were compared with the initial findings and, when necessary, with the discharge summaries to determine if an injury had been identified. The accuracy of the plain radiographs, of the plain radiographs that had been deemed adequate, and of helical computed tomography used alone was ascertained. Plain radiographs and helical computed tomography scans were made for 407 patients, and traumatic injuries were identified in fifty-eight of them. Plain radiographs alone were adequate for 194 (48%) of the 407 patients. Plain radiographs had a sensitivity of 45%, a specificity of 97%, a positive predictive value of 74%, and a negative predictive value of 91%. Adequate plain radiographs had a sensitivity of 52%, a specificity of 98%, a positive predictive value of 81%, and a negative predictive value of 93%. Helical computed tomography had a sensitivity and specificity of 98%, a positive predictive value of 89%, and a negative predictive value of >99%. The sensitivity, positive predictive value, and negative predictive value of adequate plain radiographs differed significantly from those of helical computed tomography alone (p < 0.001). Twelve (48%) of twenty-five adequate plain radiographs of patients in whom an injury had been identified on computed tomography missed that injury. Helical computed tomography alone missed one (2%) of the fifty-eight injuries. Although helical computed tomography has a limited ability to detect pure ligamentous injury, it can be safely used without plain radiographs to evaluate the cervical spine for osseous abnormalities such as fractures and dislocations after high-energy trauma.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Open Orthop J
                Journal ID (iso-abbrev): Open Orthop J
                Journal ID (publisher-id): TOORTHJ
                Title: The Open Orthopaedics Journal
                Publisher: Bentham Open
                ISSN (Electronic): 1874-3250
                Publication date (Electronic): 17 October 2014
                Publication date Collection: 2014
                Volume: 8
                Pages: 372-374
                Affiliations
                [1 ]American Health Network, Indy Bone and Spine, Indianapolis, IN, USA
                [2 ]Michigan State University, College of Human Medicine, Grand Rapids, MI, USA
                [3 ]River Valley Orthopedics, Grand Rapids, MI, USA
                Author notes
                [* ] Address correspondence to this author at the Michigan State University, College of Human Medicine, Grand Rapids, MI, USA; Tel: +616 366 8885; E-mail: matthew.nies@ 123456gmail.com
                Article
                Publisher ID: TOORTHJ-8-372
                DOI: 10.2174/1874325001408010372
                PMC ID: 4209502
                PubMed ID: 25352931
                SO-VID: 7ed5cfcb-e4b3-44fd-a9c6-c91f423082b0
                Copyright © © Coats et al.; Licensee Bentham Open.
                License:

                This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

                History
                Date received : 8 May 2014
                Date revision received : 11 September 2014
                Date accepted : 17 September 2014
                Categories
                Subject: Article

                ScienceOpen disciplines: Orthopedics
                Keywords: artifact,cervical spine,computed tomography,discrepancy,osseous abnormality,physical examination.
                Data availability:
                ScienceOpen disciplines: Orthopedics
                Keywords: artifact, cervical spine, computed tomography, discrepancy, osseous abnormality, physical examination.

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