Limitation of the cross table lateral view in detecting cervical spine injuries: a retrospective analysis.
ABSTRACT A city-wide survey of 17 emergency departments revealed that 94.7% of physicians relied exclusively on the cross table lateral view in their initial radiologic disposition of patients suspected of having cervical spine injury, and most of these physicians think it is more than 90% effective in detecting potentially unstable injuries of the cervical spine. A three-year retrospective study was conducted in a midwestern suburban community hospital with 27,000 annual emergency visits to determine the incidence of false negative cross table lateral views of the cervical spine. Of 35 patients with cervical spine fracture/dislocation, we found three cases difficult to diagnose, and six in which this initial view was interpreted as normal. In all nine cases, a standard anteroposterior view (APV) or standard open mouth view (OMV) would have increased the diagnostic yield to 100%. A revised radiologic approach to the patient suspected of having cervical spine injuries is suggested.
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ABSTRACT: Cervical spine injuries are difficult to diagnose in children. They tend to occur in different locations than in adults, and they are more difficult to identify based on history or physical examination. As a result, children are often subjected to radiographic examinations to rule out cervical spine injury. This two-part series will review the classic cervical spine injuries encountered in children based on age and presentation. Part I will discuss the mechanisms of injury, clinical presentations, and the use of different imaging modalities, including X-ray studies and computed tomography (CT). Part II discusses management of these injuries and special considerations, including the role of magnetic resonance imaging, as well as injuries unique to children. Although X-ray studies have relatively low risks associated with their use, they do not identify all injuries. In contrast, CT has higher sensitivity but has greater radiation, and its use is more appropriate in children over 8 years of age. With knowledge of cervical spine anatomy and the characteristic injuries seen at different stages of development, emergency physicians can make informed decisions about the appropriate modalities for diagnosis of pediatric cervical spine injuries.Journal of Emergency Medicine 08/2011; 41(2):142-50. · 1.33 Impact Factor
Article: Treatment of Odontoid Fractures[Show abstract] [Hide abstract]
ABSTRACT: Odontoid fractures are common cervical spine injuries, particularly in the elderly. Odontoid fractures are generally classified as type I, type II, or type III. Type I and III fractures are generally treated nonoperatively, while debate continues regarding the optimal treatment of displaced and nondisplaced type II fractures. A trend favoring operative intervention has been found in older patients, in fractures with posterior displacement, and in fractures with displacement >4 to 6 mm. Various surgical approaches exist, each having its own distinct advantages and disadvantages. Higher-quality studies would be needed to better-guide surgeons and their patients in the decision process in managing odontoid fractures.Neurosurgery Quarterly 08/2010; 20(3):183-188. · 0.09 Impact Factor
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ABSTRACT: BACKGROUND: The concept of distracting pain (DP) is a controversial subjective confounder that often impedes the efficient and timely clearance of the cervical spine (C-spine). This study attempted to define DP more objectively and assess its true potential to mask the presence of C-spine injury. It also evaluated reliability and safety of clinical judgment in discounting the significance of pain peripheral to the neck (PP). METHODS: This prospective study included patients with a Glasgow Coma Score ≥14 at a level I trauma center presenting in a C-spine collar. Demographics, mechanism of injury, severity and location of all pain, and C-spine imaging data were obtained. Patient and examiner perception of DP were ascertained using the Verbal Numerical Rating Scale (VNRS) along with the examiner's clinical opinion as to the presence of a fracture. RESULTS: A total of 160 patients were studied: 65 % male, mean age 39 years, and 44 % presenting after a motor vehicle crash. In all, 16 % complained of neck pain (NP) and 82 % of PP. There were 134 patients without NP, 110 of whom (82 %) had PP. The mean VNRS in patients with no NP was 4.2; in patients with NP it was 4.8. When examined, 14 patients without NP exhibited posterior cervical tenderness, one of whom had a fracture (7 %). Of the patients with PP, 10 % stated it was DP. The mean VNRS described as DP by all patients was 7.5 but by clinician 6.5. VNRS described as not DP was 4.8 for both patients and clinicians. Overall, 8 of the 160 patients (5 %) had confirmed C-spine injuries. Regardless of NP or PP and its potentially distracting nature, clinicians believed no fracture was present in 95 % of all cases. Clinical impression was 98 % accurate. For patients with NP, clinical impression had a 91 % negative predictive value (NPV) and a 100 % a positive predictive value (PPV). In those without NP, the NPV was 99 % and the PPV 25 %. CONCLUSIONS: The concept of DP is subjective and unreliable as a method to mitigate missed C-spine injuries. If it is to be considered for use, DP should be defined as VNRS ≥5. Reliance on clinical impressions regardless of the presence or absence of NP or PP, distracting or otherwise, is accurate and safe.World Journal of Surgery 09/2012; · 2.23 Impact Factor