RIVIERA MAYA, MEXICO — For patients with low-risk injuries, three plain-film x-rays are probably sufficient to diagnose clinically significant cervical spine injuries—but for those who have higher-risk injuries or multiple blunt traumas, a computed axial tomographic scan is often a better option.
CTs are “vastly superior” to plain radiographs in identifying cervical injuries, Dr. John Marx said at a meeting on medical negligence and risk management. “While most missed injuries are stable, it only takes one missed unstable injury” to set the stage for a serious problem, he said.
Several key studies have confirmed the usefulness of CT in this setting. One of the best was a subanalysis of the National Emergency X-Radiography Utilization Study, which included 818 patients with cervical spine injuries. About 36% of these patients, all of whom underwent radiographic studies, had a least one additional finding on the cervical spine CT, and 27% of those were not contiguous with the index injury, Dr. Marx said. Plain film also missed 33% of the cervical spine injuries that CT picked up; 74% of those missed injuries were clinically significant. (Ann. Emerg. Med. 2006;47:129–33)
“This is a real argument to go to CT if you see anything on plain film,” he said.
A 2005 study confirmed CT's usefulness in 437 unconscious, intubated blunt trauma patients, including 61 with cervical spine injuries. CT scanning had a sensitivity of 98%, a specificity of 99%, and a negative predictive value of 99.7%.
There were no missed unstable injuries. In contrast, adequate lateral cervical spine films detected only 24 injuries (14 unstable), with a sensitivity of 53.3% (J. Trauma 2005;58:897–901)
Another 2005 study retrospectively examined the effectiveness of CT scans in identifying fractures in the thoracic, lumbar, and cervical regions of 236 patients. The CT scans missed fractures in only two patients, and neither of those fractures was clinically significant (J. Trauma 2005;58:890–6).
Although CT is not an inexpensive study, it can easily prove its worth not only in cervical spine, but also in thoracolumbar injuries, said Dr. Marx, chair of emergency medicine at the Carolinas Medical Center in Charlotte, N.C.
For patients with multiple injuries, a cervical spine CT is not only better diagnostically, but “faster and probably more cost effective than trying to get the three plain film views,” Dr. Marx said.
“We have also gotten into the habit of pan-scanning the neck, head, chest, and pelvis of our very sick patients who are going to need a lot of studies. This isn't cheap—it costs about $15,000—but it's a wonderful study and seems to make sense for selected patients,” he said at the meeting sponsored by Boston University.