Shaffer MA, Doris PE. 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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- "The commonest problem was failure to identify the C7/T1 junction, potentially missing 9% of cervical injuries . Although our standard for neck imaging will only identify 85% of cervical spine injuries , it is the standard practice in excluding cervical spine injuries in unconscious patients in the UK. With these criteria, satisfactory immobilisation only occurred in 66% of patients. "
ABSTRACT: High-quality resuscitation and care during transfer of head-injured patients is essential to prevent secondary brain injury. We have prospectively assessed the standard of resuscitation in 50 consecutive head-injured patients transferred to our unit, and compared our findings with previous studies performed before the advanced trauma life support course (ATLS) had become widespread and national guidelines on the transfer of head injuries had been produced by the Association of Anaesthetists of Great Britain and Ireland (AAGBI). Delays in transfer, management of the airway, adequate cervical spine assessment, hypoxia (P(a)O(2) <13 kPa), hypotension (systolic BP <90 mmHg), missed injuries and the experience of the medical escort were compared against the standards laid out in ATLS and AAGBI Guidelines. The mean, unavoidable delay from arrival at the local accident and emergency unit to arrival was 7.4+/-1.9h (mean+/-95%CI) with most of the delay being prior to initial referral. Two patients arrived with an unsecured airway with a GCS=8/15; 26 had inadequate cervical spine imaging; 7 patients arrived hypoxic and 2 patients arrived hypotensive; most of these insults occurred during the transfer. Forty-six percent of medical escorts did not fulfil the minimum standard of experience. ATLS and AAGBI guidelines have provided only modest improvements in patient care at the expense of long delays in transfer. The incidence of hypoxia and hypotension remains unacceptably high.Injury 11/2003; 34(11):834-8. DOI:10.1016/S0020-1383(03)00028-7 · 2.14 Impact Factor
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- "It has been shown in adult studies to have a sensitivity of 85% with a specificity approaching 50%   . The addition of the AP and open mouth odontoid view increases the sensitivity to almost 100%  . While these studies included few pediatric patients, anecdotal data would suggest similar accuracy for osseous injury. "
ABSTRACT: The ultimate goal of resuscitation of an injured child is delivery of oxygen to intracellular organelles in order to maintain aerobic metabolism. This can be obtained by following ATLS protocols with immediate attention to the "ABCDE's" and compulsive reevaluation of the adequacy of resuscitation maneuvers. After stabilization, seriously injured children should be transferred to trauma centers with established pediatric trauma programs utilizing preexisting transfer agreements and protocols. Pediatric trauma is indeed a team endeavor, requiring the coordinated expertise and teamwork of prehospital EMS providers, trauma team members, and the pediatric trauma and rehabilitation centers. With careful and compulsive communication and coordination, injured children can be returned to their families in better mental and physical condition than pre-injury with reasonable expectation of a full and productive life.Surgical Clinics of North America 05/2002; 82(2):273-301. DOI:10.1016/S0039-6109(02)00006-3 · 1.88 Impact Factor
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ABSTRACT: INTRODUCTION The pressing nature of "clearing the cervical spine" in the obtunded (closed head injured; CHI) or polytrauma patient is fueled by the desire to identify all significant injuries in a timely manner. Significant injuries are those that carry the potential for injury or irreversible morbidity to the patient if they are left unidentified, and thus undertreated. The vulnerable nature of the unprotected spinal cord highlights the importance of an early and accurate assessment of the spinal column 1-3 . Historically, given the unknown status of the stability of a cervical spine, prolonged use of a cervical collar was common. However, continued collar use in the polytrauma patient, the CHI patient, or any patient requiring prolonged ventilator assis-tance, is associated with skin and soft-tissue problems, as well as basic nursing concerns 4-6 . As the mechanism of injury increases in energy or the pres-ence of associated injuries becomes prevalent, the dependence on radiographic assessment increases. Both spiral computed tomography (CT) and magnetic resonance imaging (MRI) are readily integrated into the work-up as needed, depending on the primary radiographic findings and the clinical presentation. As the physical examination loses its credence (distracting inju-ries, associated CHI, alcohol or drug presence) the number and complexity of the radiographic studies increases. The concern remains, however, that without a reliable clinical examination, the cervical spine CANNOT be cleared in the acute setting. THE ROLE OF THE PHYSICAL EXAMINATION Historically, the physical examination directed the work-up algorithm in the trauma patient. However, in order to safely and effectively evaluate the cervical spine in the polytrauma or obtunded (CHI) patient, the trauma community has grown far more dependent on the spiral CT with reconstructive views and, most recently, the MRI findings. As we proceed from plain radiographs to the most sophisticated of current radiographic imaging, the clinical examination loses its essential nature. It has, to a large extent, evolved to play a more supportive or confirmatory role. PLAIN RADIOGRAPHS AND CT SCANNING Plain radiographs of the cervical spine, obtained via the "trauma series" protocol popularized by the Advanced Trauma Life Support Program 8 is claimed to have a sensitivity of > 90% in the detection of significant "cervical spine injuries." 9,10 However, these plain radiographs are largely being supplanted by reconstructive views (coronal and sagittal) obtained from spiral CT scans. CT scans have long been accepted as both more sensitive and specific than plain films in the identification of bony injuries to the cervical spine 11-14 . Therefore, if the CT scan of the entire cervical spine, including the junctions, is free of bony injury, the question arises of the necessity of plain films 15 . The CT scan studies are neither 100% accurate for bony injury identification, nor do they carry a 100% negative predictive value 16 ; however, the clinical significance of these missed bony injuries has yet to be fully characterized. There is also the issue of increased radiation exposure to the trauma patient undergo-ing a CT in lieu of plain films. Rybicki et al 17 measured radiation doses to the thyroid and found that CT of the entire cervical spine delivered 14 times greater the radiation dose than that delivered by plain radiographs. The authors suggest judicious use of helical CT in routine screening. The current "consensus opinion" has the CT scan as the radiographic method of choice to assess for bony injury, par-ticularly in the higher risk category of patients, i.e., those that have suffered high energy mechanism, associated head injuries or focal neurological deficits. This shift from the primary use of plain films is due in large part to the additional utility of CT sagittal and coronal reconstructions . Once the cervical spine has been evaluated and found to be free of bony injuries, the principal remaining problem of "clearing the cervical spine" is one of identifying soft tissue injuries.