Criteria for radiography in cervical spine injury codified

הסקירה באדיבות מדיקונטקסט:Last Updated: 2001-07-18 16:41:52 EDT (Reuters Health)

WESTPORT, CT (Reuters Health) – Five articles in the July issue of the Annals of Emergency Medicine discuss criteria for radiography in patients with potential cervical spine injury.

"Of the almost 1 million cervical spine radiographs ordered each year in the US, less than 2% of those radiographs show a cervical spine injury. So there has been great interest in developing guidelines to determine who really needs these x-rays and who does not," Dr. Edward A. Panacek from the University of California at Davis in Sacramento noted in an interview with Reuters Health.

Dr. Panacek said that the largest study to examine radiography for cervical spine injury was reported by the NEXUS group in The New England Journal of Medicine. (See Reuters Health report, July 13, 2000.) The new studies, he explained, were also done by the NEXUS group and were designed to address issues related to the previous study.

In one study the researchers evaluated the criteria for obtaining screening x-rays in low-risk patients. Dr. Panacek and colleagues looked at the performance of each of the five standard criteria: no posterior midline cervical tenderness, no evidence of intoxication, normal level of alertness, no focal neurologic deficit and no painful distracting injuries.

"We found," Dr. Panacek said, "that some of the criteria were more important than others–in particular, complaints of pain in the neck, or actual tenderness on exam. Some did not contribute as much valuable information, such as whether the patient was intoxicated or had altered levels of alertness, or neurologic findings."

However, he added, eliminating any one of the criteria could result in missing at least a few patients with significant cervical spine injury. The group recommends retaining all five criteria.

Another study looked at the distribution of injury patterns of cervical spine injuries. Dr. William L. Goldberg from Bellevue Hospital Center in New York and colleagues found that the most common injuries were to the upper cervical spine, followed by the lower cervical spine. Upper cervical spine injuries were more common in children, whereas injuries of the lower cervical spine were more common in adults.

A study by Dr. William R. Mower, from the University of California at Los Angeles, and colleagues was designed to see how accurate plain films are in picking up cervical spine injury as opposed to CT scans. "Of course," Dr. Panacek said, "these findings represent only the subset of patients who received not only regular three-view x-ray, but also those who received additional views or CT scans."

What Dr. Mower's group found, Dr. Panacek said, is reassuring in that the standard three-view x-ray does work well as a general screening tool. "However, it should not be relied upon as definitive in patients where there are ongoing concerns despite normal x-ray results," he added.

For these patients, Dr. Panacek said, additional views are helpful. "There are certainly patients in whom plain films just don't show anything, and if the patient is still having significant symptoms or substantial pain, these patients should undergo additional studies such as CT scans to find bony injury, or an MRI if there are concerns about a spinal cord injury."

An article by Dr. Charles V. Pollack, Jr. from Bryn Mawr, Pennsylvania and colleagues deals with flexion-extension radiographs.

Historically, Dr. Panacek noted, "if the standard x-rays are negative with no evidence of a fracture but there is some concern that there might be a slight subluxation, or if there is still pain, then there may be concern for a ligamentous injury." Such injuries can often be missed in the standard three-view x-ray; therefore, the standard has been to get x-rays in flexion and extension positions to look for a ligamentous injury.

But the fact is, Dr. Panacek said, that this imaging technique evolved before MRI was available. "What this article concludes is that the use of these flexion-extension views probably should be abandoned because we have better techniques and extension flexion-views should not be relied upon. CT and MRIs should be used instead."

Ann Emerg Med 2001;38:1-25.

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