Development of an evidence-based guideline for imaging in cervical spine trauma
Stacy K Goergen
1 Department of Diagnostic Imaging, 2 Emergency Department, 3 Centre for Clinical Effectiveness and 4 Monash Institute for Health Services Research, Monash Medical Centre, Melbourne, Victoria, Australia
Search for more papers by this authorChristina Fong
1 Department of Diagnostic Imaging, 2 Emergency Department, 3 Centre for Clinical Effectiveness and 4 Monash Institute for Health Services Research, Monash Medical Centre, Melbourne, Victoria, Australia
Search for more papers by this authorKim Dalziel
1 Department of Diagnostic Imaging, 2 Emergency Department, 3 Centre for Clinical Effectiveness and 4 Monash Institute for Health Services Research, Monash Medical Centre, Melbourne, Victoria, Australia
Search for more papers by this authorGabby Fennessy
1 Department of Diagnostic Imaging, 2 Emergency Department, 3 Centre for Clinical Effectiveness and 4 Monash Institute for Health Services Research, Monash Medical Centre, Melbourne, Victoria, Australia
Search for more papers by this authorStacy K Goergen
1 Department of Diagnostic Imaging, 2 Emergency Department, 3 Centre for Clinical Effectiveness and 4 Monash Institute for Health Services Research, Monash Medical Centre, Melbourne, Victoria, Australia
Search for more papers by this authorChristina Fong
1 Department of Diagnostic Imaging, 2 Emergency Department, 3 Centre for Clinical Effectiveness and 4 Monash Institute for Health Services Research, Monash Medical Centre, Melbourne, Victoria, Australia
Search for more papers by this authorKim Dalziel
1 Department of Diagnostic Imaging, 2 Emergency Department, 3 Centre for Clinical Effectiveness and 4 Monash Institute for Health Services Research, Monash Medical Centre, Melbourne, Victoria, Australia
Search for more papers by this authorGabby Fennessy
1 Department of Diagnostic Imaging, 2 Emergency Department, 3 Centre for Clinical Effectiveness and 4 Monash Institute for Health Services Research, Monash Medical Centre, Melbourne, Victoria, Australia
Search for more papers by this authorSK Goergen MB BS, FRACR; C Fong MB BS, FRACEM; K Dalziel MS, BHealthSc(Hon); G Fennessy PhD, MSc, BA.
Summary
Cervical spine trauma is a common reason for presentation to an emergency department. However, less than 5% of patients who have suffered possible neck injury actually have an injury requiring medical treatment. Nevertheless, the consequences, both for the patient and the doctor, of a missed injury are well recognized by emergency department medical staff. This results in the vast majority of these patients receiving some form of diagnostic imaging. We describe the development of an evidence-based imaging guideline for use in the patient who has suffered cervical spine trauma. The guideline aims to help clinicians determine, at the bedside, when it is appropriate to use imaging and which imaging modality should be used first. Correct utilization of the guideline should lead to a reduction in the number of imaging tests required to reach a diagnosis without adverse patient outcomes.
References
- 1 Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000; 343: 94−9.
- 2 Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J Trauma 1993; 34: 342−6.
- 3 Gerrelts BD, Petersen EU, Mabry J, Petersen SR. Delayed diagnosis of cervical spine injuries. J Trauma 1991; 31: 1622−6.
- 4 Hendey GW, Wolfson AB, Mower WR, Hoffman JR. Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma. J Trauma 2002; 53: 1−4.
- 5 Bachulis BL, Long WB, Hynes GD, Johnson MC. Clinical indications for cervical spine radiographs in the traumatized patients. Am J Surg 1987; 153: 473−8.
- 6 Kreipke DL, Gillespie KR, McCarthy MC, Mail JT, Lappas JC, Broadie TA. Reliability of indications for cervical spine films in trauma patients. J Trauma 1989; 29: 1438−9.
- 7 Field M, Lohr K. Guidelines for Clinical Practice: from Development to Use. National Academy Press, Washington D.C., 1992.
- 8 Sackett D, Strauss S, Richardson WS, Rosenberg W, Haynes R. Evidence Based Medicine: How to Practice and Teach EBM, 2nd edn. Churchill Livingstone, Edinburgh, 2000.
- 9 Centre for Evidence Based Medicine Oxford. Levels of Evidence and Grades of Recommendations. Centre for Evidence Based Medicine, Oxford, 1999. Available from URL: http:www.cebm.jr2.ox.ac.ukdocslevels.html
- 10 Anonymous. In patients with minor head injury, can a clinical decision rule using 7 clinical criteria identify those patients who do not need computed tomography (CT) scanning? ACP J Club 2001; 2: 74.
- 11 Bachulis BL, Long WB, Hynes GD, Johnson MC. Clinical indications for cervical spine radiographs in the traumatized patient. Am J Surg 1987; 153: 473−8.
- 12 Banit DM, Grau G, Fisher JR et al. Evaluation of the acute cervical spine: a management algorithm. J Trauma Injury Infect Crit Care 2000; 49: 450−6.
- 13 Berne JD, Velmahos GC, El-Tawil Q et al. 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. J Trauma Injury infect Crit Care 1999; 47: 896−902.
- 14 Blackmore CC, Emerson SS. Cervical spine imaging in patients with trauma: Determination of fracture risk to optimize use. Radiology 1999; 211: 759−65.
- 15 Bloch R. Absence of 5 clinical criteria ruled out cervical-spine injury in blunt trauma in the emergency department … com-mentary on Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI, for the National Emergency X-Radiography Utilization Study Group. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2001; 343: 94−9.
- 16 Blue M, Tintinalli J. Cervical spine radiography in blunt trauma. Ann Emerg Med 1999; 33: 727−8.
- 17 Bresler MJ, Rich GH. Occult cervical spine fracture in an ambulatory patients. Ann Emerg Med 1982; 11: 440−2.
- 18 Brown J. Commentary on the role and limitations of computed tomographic scanning in the evaluation of cervical trauma. Trauma 1992; 33: 698−708.
- 19 Brynin R, Yomtob C. Missed cervical spine fracture: Chiropractic implications. J Manipulative Physiol Ther 1999; 22: 610−14.
- 20 Cornelius RS. Imaging of acute cervical spine trauma. Neuroimag Clin North Am 2001; 11: 403−20.
- 21 Cornelius RS, Leach JL. Imaging evaluation of cervical spine trauma. Neuroimag Clin North Am 1995; 5: 451−63.
- 22 Crim JRMKBD. Clearance of the cervical spine in multitrauma patients: the role of advanced imaging. Semin Ultrasound CT MR 2001; 22: 283−305.
- 23 Cusmano F, Ferrozzi F, Uccelli M, Bassi S. Upper cervical spine fracture: sources of misdiagnosis. Radiolog Med 1999; 98: 230−5.
- 24 Daffner RH. Cervical radiography for trauma patients: a time-effective technique? Am J Roentgenol 2000; 175: 1309−11.
- 25 Daffner RH. Helical CT of the cervical spine for trauma patients: a time study. Am J Roentgenol 2001; 177: 677−9.
- 26 Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J Trauma Injury Infect Crit Care 1993; 34: 342−6.
- 27 Eckhardt WF, Doyle M, Woodward A, Freundlich I, Rockett FX. Cervical spine fracture following a motor vehicle accident. J Emerg Med 1988; 6: 179−83.
- 28 Edwards MJR, Frankema SPG, Kruit MC, Bode PJ, Breslau PJ, Van Vugt AB. Routine cervical spine radiography for trauma victims: Does everybody need it? J Trauma Injury Infect Crit Care 2001; 50: 529−34.
- 29 Elkhoury GY, Kathol MH, Daniel WW et al. Imaging of acute injuries of the cervical spine − value of plain radiography, CT and MR imaging. Am J Roentgenol 1995; 164: 43−50.
- 30 Gbaanador GB, Fruin AH, Taylon C et al. Role of routine emergency cervical radiography in head trauma. Am J Surg 1986; 152: 643−8.
- 31 Geehr RB, Rothman SL, Kier EL et al. The role of computed tomography in the evaluation of upper cervical spine pathology. Comput Tomogr 1978; 2: 79−97.
- 32 Gonsalves CG, Hudson AR, Horsey WJ, Tucker WS. Computed tomography of the cervical spine and spinal cord. Comput Tomogr 1978; 2: 279−93.
- 33 Graber MA, Kathol M. Cervical spine radiographs in the trauma patient. Am Fam Phys 1999; 59: 331−42.
- 34 Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CT screening. Am J Roentgenol 2000; 174: 713−17.
- 35 Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000; 343: 94−9.
- 36 Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med 1992; 21: 1454−60.
- 37 Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma − methodology of the national emergency x-radiography utilization study (nexus). Ann Emerg Med 1998; 32: 461−9.
- 38 Holliman CJ, Mayer JS, Cook RT, Jr, Smith JS Jr. Is the anteroposterior cervical spine radiograph necessary in initial trauma screening? Am J Emerg Med 1991; 9: 421−5.
- 39 Hsieh M, Gutman M, Haliscak D. Clinical clearance of cervical spinal injuries by emergency nurses. Acad Emerg Med 2000; 7: 342−7.
- 40 Kaiser JA, Holland BA. Imaging of the cervical spine. Spine 1998; 23: 2701−12.
- 41 Kathol MH. Cervical spine trauma − what is new. Radiolog Clin North Am 1997; 35: 507.
- 42 Katz MA, Beredjiklian PK, Vresilovic EJ et al. Computed tomographic scanning of cervical spine fractures: Does it influence treatment? J Orthopaed Trauma 1999; 13: 338−43.
- 43 Keats TE, Dalinka MK, Alazraki N et al. Cervical spine trauma. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000; 215 (Suppl.): 243−6.
- 44 Kirshenbaum KJ, Nadimpalli SR, Fantus R, Cavallino RP. Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT. J Emerg Med 1990; 8: 183−98.
- 45 Kreipke DL, Gillespie KR, McCarthy MC, Mail JT, Lappas JC, Broadie TA. Reliability of indications for cervical spine films in trauma patients. J Trauma Injury Infect Crit Care 1989; 29: 1438−9.
- 46 Lindsey RW, Diliberti TC, Doherty BJ, Watson AB. Efficacy of radiographic evaluation of the cervical spine in emergency situations. South Med J 1993; 86: 1253−5.
- 47 MacDonald RL, Schwartz ML, Lewis AJ. Diagnosis of cervical spine injury in motor vehicle crash victims: how many X-rays are enough?. J Trauma Injury Infect Crit Care 1990; 30: 392−7.
- 48 Mace SE. Unstable occult cervical-spine fracture. Ann Emerg Med 1991; 20: 1373−5.
- 49 Mace SE. The unstable occult cervical spine fracture: a review. Am J Emerg Med 1992; 10: 136−42.
- 50 Macnamara AF, Brazil E, Evans PA. Computed tomography of the head by the accident and emergency department − why 24 hour access is vital. J Accid Emerg Med 1998; 15 (5): 294−7.
- 51 Malomo AO, Shokunbi MT, Adeloye A. Evaluation of the use of plain cervical spine radiography in patients with head injury. East African Med J 1995; 72: 186−8.
- 52 Miller JS, Craw MM. Diagnostic imaging of the cervical spine following whiplash-induced injury. Topics Clin Chiropr 1997; 4: 26−33.
- 53 Mower WR, Hoffman JR, Pollack CV Jr et al. Use of plain radiography to screen for cervical spine injuries. Ann Emerg Med 2001; 38: 1−7.
- 54 Newman J. Medical imaging of trauma to the upper cervical spine (published erratum appears in RADIOL TECHNOL 1997 May − Jun; 68 (5): 378). Radiolog Technol 1997; 68: 201−23.
- 55 Nunez DB, Zuluaga A, Fuentes-Bernardo DA, Rivas LA, Becerra JL. Cervical spine trauma: how much more do we learn by routinely using helical CT? Radiographics 1996; 16: 1307−18.
- 56 Panacek EA, Mower WR, Holmes JF, Hoffman JR and the NEXUS Group. Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury. Ann Emerg Med 2001; 38: 22−5.
- 57 Patton JH, Kralovich KA, Cushieri J, Gasparri M. Clearing the cervical spine in victims of blunt assault to the head and neck: What is necessary? Am Surg 2000; 66: 326−30.
- 58 Quekel LG, Van Der Kruijk RA, Hekster RE. The value of skull and cervical spine radiography in patients following blunt head injury. Nederlands Tijdschrift Voor Geneeskunde 1992; 136: 2366−70.
- 59 Ringenberg BJ, Fisher AK, Urdaneta LF, Midthun MA. Rational ordering of cervical spine radiographs following trauma. Ann Emerg Med 1988; 17: 792−6.
- 60 Roberge RJ. Cervical spine radiography after blunt trauma. Is it always needed?. Postgrad Med 1993; 93: 212.
- 61 Roberge RJ, Wears RC. Evaluation of neck discomfort, neck tenderness, and neurologic deficits as indicators for radiography in blunt trauma victims. J Emerg Med 1992; 10: 539−44.
- 62 Roberge RJ, Wears RC, Kelly M et al. Selective application of cervical spine radiography in alert victims of blunt trauma: a prospective study. J Trauma Injury Infect Crit Care 1988; 28: 784−8.
- 63 Ross SE, O'Malley KF, DeLong WG, Born CT, Schwab CW. Clinical predictors of unstable cervical spinal injury in multiply injured patients. Injury 1992; 23: 317−19.
- 64 Saddison D, Vanek VW, Racanelli JL. Clinical indications for cervical spine radiographs in alert trauma patients. Am Surg 1991; 57: 366−9.
- 65 Scher AT. A plea for routine radiographic examination of the cervical spine after head injury. South African Med J 1977; 51: 885−7.
- 66 Schleehauf K, Ross SE, Civil ID, Schwab CW. Computed tomography in the initial evaluation of the cervical spine. Ann Emerg Med 1989; 18: 815−17.
- 67 Touger M, Gennis P, Nathanson N et al. Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma. Ann Emerg Med 2002; 40: 287−93.
- 68 Tress BM, Hare WS. CT of the spine: are plain spine radiographs necessary?. Clin Radiol 1990; 41: 317−20.
- 69 Vandemark RM. Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficiency and communication. Am J Roentgenol 1990; 155: 465−72.
- 70 Velmahos GC, Theodorou D, Tatevossian R et al. Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim − much ado about nothing. J Trauma Injury Infect Crit Care 1996; 40: 768−74.
- 71 Woodring JH, Lee C. The role and limitations of computed tomographic scanning in the evaluation of cervical trauma. J Trauma Injury Infect Crit Care 1992; 33: 698−708.
- 72 Woodring JH, Lee C. Limitations of cervical radiography in the evaluation of acute cervical trauma. J Trauma Injury Infect Crit Care 1993; 34: 32−9.
- 73 Zabel DD, Tinkoff G, Wittenborn W, Ballard K, Fulda G. Adequacy and efficacy of lateral cervical spine radiography in alert, high-risk blunt trauma patient. J Trauma Injury Infect Crit Care 1997; 43: 952−8.
