Can Plain Radiographs Exclude Cervical Spine Injuries?
The baseline risk of C-spine injury is reported to be between 1% and 3% for all blunt trauma patients and up to 11.5% for high-risk patients evaluated at urban trauma centers. Delays in diagnosis or missed injuries have been reported to result in partial or full paralysis in up to 29% of injured patients (6). This underscores the dire consequence of missed C-spine injuries for not only the patient, but for the physicians involved and the health care system as a whole.
The routine use of clinical decision rules and three-view plain radiography to clear the C-spine has been recently called into question. The updated EAST guidelines recommend CT as the diagnostic modality of choice for the evaluation of blunt trauma patients with suspected cervical spine injury that cannot be cleared by clinical prediction rules. In fact, one investigation suggests that all blunt trauma victims requiring trauma team activation should be evaluated with a C-spine CT scan regardless of their clinical findings. Additionally, a recent decision analysis found that the use of CT was significantly more cost effective than plain radiography in the evaluation of moderate- to high-risk blunt trauma patients, not including litigation costs, which average an additional $2.9 million per case.
Routine use of CT, however, may not be without consequence. Aside from a significant financial charge to the patient, the degree of radiation carries a measurable risk of carcinogenesis. If plain radiographs, while exposing patients to much lower doses of radiation, were sufficiently sensitive to rule out C-spine injury, it would offer a safer alternative to indiscriminate use of CT. To answer our clinical question, we review the most recent pertinent literature on this topic.
Context
The baseline risk of C-spine injury is reported to be between 1% and 3% for all blunt trauma patients and up to 11.5% for high-risk patients evaluated at urban trauma centers. Delays in diagnosis or missed injuries have been reported to result in partial or full paralysis in up to 29% of injured patients (6). This underscores the dire consequence of missed C-spine injuries for not only the patient, but for the physicians involved and the health care system as a whole.
The routine use of clinical decision rules and three-view plain radiography to clear the C-spine has been recently called into question. The updated EAST guidelines recommend CT as the diagnostic modality of choice for the evaluation of blunt trauma patients with suspected cervical spine injury that cannot be cleared by clinical prediction rules. In fact, one investigation suggests that all blunt trauma victims requiring trauma team activation should be evaluated with a C-spine CT scan regardless of their clinical findings. Additionally, a recent decision analysis found that the use of CT was significantly more cost effective than plain radiography in the evaluation of moderate- to high-risk blunt trauma patients, not including litigation costs, which average an additional $2.9 million per case.
Routine use of CT, however, may not be without consequence. Aside from a significant financial charge to the patient, the degree of radiation carries a measurable risk of carcinogenesis. If plain radiographs, while exposing patients to much lower doses of radiation, were sufficiently sensitive to rule out C-spine injury, it would offer a safer alternative to indiscriminate use of CT. To answer our clinical question, we review the most recent pertinent literature on this topic.
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