CT versus X-ray for Cervical Spine Blunt Trauma
Search Strategy: You search PUBMED using Clinical Queries [(cervical spine AND computed tomography) AND (specificity[Title/Abstract])] and obtain three of the articles selected below among 51 “hits”. The final article is identified by reviewing the meta-analysis.
An 86 year old male presents to your ED via EMS after a fall from standing. Apparently, he tripped while walking down his basement steps and has a large boggy contusion to his left parietal area. He was found by his daughter shortly after the fall who reported that her father was awake but disoriented without any reported loss of consciousness or emesis. His Glascow Coma Scale has been 15 since the time of his injury. As per your local EMS protocol, he arrived on a backboard wearing a cervical collar. The patient complains of a left parietal headache with midline cervical neck pain. His daughter reports that her father has hypertension and arthritis for which he sporadically takes Aleve as needed.
Your primary and secondary surveys only reveal the cranial injury described above and some paraspinal tenderness from cervical vertebrate 2-4. The patient has a normal neurological exam. The charge nurse, aware of the recent departmental push to limit costs, asks if the patient can be cleared based on c-spine and head injury clinical decision rules. When you apply the clinical rules, you quickly discover that the patient is not low risk on either count and will require imaging of both his head and c-spine. Plain radiology is experiencing some back up issues so the charge nurse asks you to CT his head and neck together “just to get it done”. Radiology questions the evidence supporting CT as first-line imaging for non-low risk cervical neck trauma imaging.
You are faced with a decision as to how to best treat and diagnose the patient. In patients that fail low risk clinical c-spine rules are c-spine plain x-rays the best diagnostic option? Is CT superior to plain x-rays in all patients including this elderly trauma patient? And finally, is it cost-effective to start with a lower sensitivity study knowing full well that you may still need to get a more sensitive study thus adding extra cost (financial and length of stay) to this patient’s ED visit?
Population: Blunt trauma patients who fail low risk clinical criteria for cervical spine injury
Intervention: CT Cervical-spine as primary C-spine evaluation
Comparison: Plain radiographs for initial C-spine evaluation
Outcome: Diagnostic test characteristics, cost-effectiveness
First years: Computed Tomography Versus Plain Radiography to Screen for Cervical Spine Injury: A Meta-analysis? J Trauma 2005; 58: 902-905.
Second years: Radiographic Clearance of Blunt Cervical Spine Injury: Plain Radiographs or Computed Tomography Scan? J Trauma 2003; 55: 222-227.
Third years: Helical Computed Tomography Alone Compared With Adjunct Computed Tomography to Evaluate the Cervical Spine After High-Energy Trauma. J Bone Joint Surgery 2005; 87-A: 2388-2394.
Fourth years: Cervical Spine Evaluation in Urban Trauma Centers: Lowering Institutional Costs and Complications Through Helical CT Scan. J Am Coll Surg 2005; 200: 160-165.
Article 1: CT versus Plain Radiograph to Screen for Cervical Spine Injury: A Meta-analysis, J Trauma 2005; 58: 902-905
Article 2: Radiographic Clearance of Blunt Cervical Spine Injury: Plain Radiograph or Computed Tomography Scan? J Trauma 2003; 55: 222-227
Article 3: Helical Computed Tomography Alone Compared with Plain Radiographs with Adjunct Computed Tomography to Evaluate the Cervical Spine After High-Energy Trauma, J Bone Joint Surgery 2005; 87A: 2388-2394
Article 4: Cervical Spine Evaluation in Urban Trauma Centers: Lowering Institutional Costs and Complications Through Helical CT Scan, J Am Coll Surg 2005; 200: 160-165
All current studies suffer from selection bias (non-low risk cervical spine trauma patient predominate) and ascertainment bias (most studies only recruit subjects which have had both CT and x-rays). Nonetheless, CT offers superior sensitivity (95-100% compared with 45-65 % for x-rays) and can obtain images more rapidly and cost-effectively for high-risk blunt trauma patients. Unfortunately, the low risk blunt trauma patient who represent the bulk of any Level 1 trauma center’s practice have not been adequately studied and await further research.