A Proposed Standard to Identify Patients at Risk of Cervical Spine Injury
Abstract & Commentary
Synopsis: A prediction rule for cervical spine injury is used to identify patients at risk of cervical spine injury for screening helical CT. Clinical parameters are used to stratify patients on the basis of the probability of cervical spine injury.
Source: Hanson JA, et al. Cervical spine injury: A clinical decision rule to identify high-risk patients for helical CT screening. AJR Am J Roentgenol 2000;174:713-717.
Most of the cases of spinal cord injury are caused by blunt force cervical spine trauma. The current standard of a lateral radiograph and an open-mouth odontoid view for screening is supplemented with helical computed tomography (CT), which improves accuracy and results in faster diagnosis. The choice of a patient for helical CT of the cervical spine depends on the probability of injury.
A study to test clinical predictors was undertaken in which high-risk blunt trauma requiring head CT was combined with helical CT of the cervical spine. Over six months, 4285 screening imaging studies of the cervical spine were performed in adult patients ranging from 16-100 years (median age, 38 yr). Six hundred one patients underwent helical CT. The remainder underwent 3684 conventional examinations with radiography. Of 84 patients in whom a cervical spine injury was confirmed, 57 (68%) had the diagnosis made on helical CT and seven (8%) on conventional radiographs. True-positive detection rates for cervical spine injury in helical CT and radiography-screened patients were 77 (13%) of 601 and seven (0.2%) of 3684, respectively. The abnormalities most frequently identified on helical CT were fractures or subluxations involving the C3-C7 pedicles, facets, or laminae.
A cervical spine trauma screening policy used a modified CT protocol with narrower collimation and more extensive spinal coverage.
Helical CT may be a cost-effective strategy in populations with fracture risk exceeding approximately 5%.
Comment by beverly p. wood, md
The cost of helical CT is prohibitive as a general screening mechanism for patients with suspected cervical spine trauma and the radiation exceeds that from a radiographic cervical spine study. However, it is known that the lateral and odontoid radiographs are not sensitive to subtle injuries. Hanson and colleagues have provided an excellent reference guide for selection of those patients in whom a helical CT examination of the cervical spine is warranted.
What are the most frequently visualized cervical spine injuries on helical CT?
a. Fractures or subluxations of pedicles, facets, laminae
b. Vertebral body compression fractures
c. Posterior subluxations of vertebrae
d. Spinous process fractures
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