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Cervical radiography in the emergency department: Who, when, how extensive?
The Journal ofEmergency Medicine, Vol 11, pp 619-620. 1993
Printed in the USA Copyright 0 1993 Pergamon Press Ltd.
Cl CERVICAL RADIOGRAPHY IN THE EMERGENCY DEPARTMENT: WHO, WHEN, HOW EXTENSIVE?
were deemed to be mentally alert and without symptoms referable to the cervical region. It is estimated (in 1989 dollars) that the cost of unnecessary cervical radiography and CT scan is nearly $60,000 at the Maryland Institute for Emergency Medical Services System alone (1). Vandemark, in 1990 (2), suggests a “risk-tailored” approach to cervical radiography in trauma patients. To determine those patients who need radiographs and those who do not, he proposes four clinical risk categories. The first category, “no-risk,” includes those patients who are mentally alert, not under the influence of alcohol or other drugs, and who have no history or physical findings suggesting a neck injury. The majority of these patients arrive in the emergency department with a cervical collar placed by paramedical personnel at the accident site because of protocol. These patients need not undergo cervical radiography. The next category, “low-risk,” includes those patients with a history of a mechanism of injury likely to have exceeded the physiologic range of cervical motion. For these patients, Vandemark recommends a limited cervical series consisting of lateral, anteroposterior (AP), and atlantoaxial (odontoid) views. The third category, “medium-risk,” includes those patients with a history or mechanism of injury sufficient to have exceeded the physiologic range of motion. The fourth category, “high-risk,” includes those patients with a history or mechanism of injury very likely to have exceeded the physiologic range of motion. Included in both of these groups are all patients with impaired sensorium. For both of these categories, he recommends five-view series to be performed in the supine position. This series includes the supine (“trauma”) oblique radiographs (2). How does one determine those patients with a “high risk” for cervical injury? A number of historical and clinical factors should be taken into account to make this determination. As a rule, patients may be considered “high-risk” if any one of the following parameters are present: high-velocity blunt trauma; multiple fractures (closed or open); evidence of direct cervical region injury (cervical pain, spasm, or obvious deformity); drowning or diving accident; falls of greater than 10 feet; significant head or facial injury;
One of the controversies in trauma care in medicine today pertains to the assessment of the cervical vertebrae in emergency patients who have suffered trauma. This group of patients provides an area of great concern not only to the physicians who must manage the patients but also to the hospital administrators who seek ways to augment hospital income, and to third-party providers (including the Federal Government) who just as vigorously are seeking ways of cost containment. Thus, the emergency physician is caught between the “rock” of “protocol-driven” requirements to obtain cervical radiographs and fear of malpractice litigation if an injury is missed, and the “hard place,” resulting from the efforts of medical cost-containment to evaluate indications for “routine” cervical radiography and trauma. Is there a middle ground? Is there a way to selectively identify patients needing cervical radiography? The answers to these questions are a qualified “yes,” and may be found within two excellent papers that have addressed this subject in recent years (1,2). Many large centers dealing with trauma victims employ a “protocol-driven” approach for patients who fit into certain diagnostic categories. These generally include all patients involved in a motor vehicle accident or serious fall. In many instances, these protocols conform to the guidelines of the American College of Surgeons who recommend routine lateral cervical radiography for all patients suffering major trauma (3). However, as was demonstrated by Mirvis and colleagues (I), many of these studies are not indicated. The Mirvis study surveyed 125 North American hospitals caring for acutely injured patients. It finds that 96% of those hospitals responding routinely obtained cervical radiographs on all patients suffering major blunt trauma. In an attempt to determine the cost-benefit effect of this practice, this group conducted a prospective in-house study comparing the results of clinical assessment with radiographic and computed tomography (CT scan) on a group of 408 patients with a history of blunt trauma. One hundred thirty-eight (34%) of this patient group
0736-4679/93 $6.00 + .OO 619
620
thoracic or lumbar vertebral fracture; and a history of preexisting vertebral disease such as ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis (DISH) (2). It is the author’s feeling that any patient within this category should undergo a full series of cervical radiographs (4,5). Allegheny General Hospital is a level-one trauma center that admits approximately 1800 major trauma cases a year. The majority of these patients are victims of high-speed motor vehicle trauma. Significant vertebral injury occurs in 250 patients a year. Eightytwo percent of these injuries are due to motor vehicle accidents and 17% are due to falls. The majority of our patients involved in motor vehicle accidents have their sensorium compromised by head injury, alcohol, or drug ingestion. Thus, we have a large, selected group of trauma patients on whom cervical radiographs are obtained in a majority of admissions. A few patients with “minor” cervical injuries are encountered. This is in contrast with many of the smaller suburban hospitals in the Pittsburgh area who also receive a preselected patient population from accidents, but that generally are considered minor “fender benders.” The reason for this is that the local paramedical personnel automatically refer victims of severe trauma to the 3 large level-one trauma centers in Pittsburgh. In these community hospitals where the degrees of injury are less severe, emergency department physicians may have the luxury of being able to adequately assess their patients prior to radiography to determine if there is a need. A study by Roberge and colleagues (6), at our institution, supported this approach by demonstrating that alert trauma patients without complaints or findings refer-
The Journal of Emergency Medicine
able to the neck need not undergo cervical vertebral radiography. The 2 key principles are 1) an alert patient and 2) absence of any other severe injury that could mask pain from an occult cervical abnormality. In summary, the author endorses Vandemark (2) who recommends that patients be assessed as individuals. Furthermore, the decision to obtain cervical radiographs should be determined by a combination of clinical findings and historical risk factors. The radiographic menu for each patient should be custom-tailored. Richard H. Daffner, MD, FACR Department of Diagnostic Radiology Alleghany General Hospital Pittsburgh, Pennsylvania
REFERENCES 1. Mirvis SE, Diaconis JN, Chirico PA, et al. Protocol-driven radiologic evaluation of suspected cervical injury: efficacy study. Radiology 1989;170:831-4. 2. Vandemark RM. Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficacy and communication. AJR. 1990x155:465-72. 3. American College of Surgeons Committee on Trauma. Advanced trauma life support course for physicians. Chicago, Illinois: American College of Surgeons; 1984:256. 4. Daffner RH. Imaging of vertebral trauma. Rockville, Maryland: Aspen Publishers; 1988. 5. Daffner RH. Evaluation of cervical vertebral injuries. Semin Roentgenol. 1992;27:239-53. 6. 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. 1988;28:784-8.
Printed in the USA Copyright 0 1993 Pergamon Press Ltd.
Cl CERVICAL RADIOGRAPHY IN THE EMERGENCY DEPARTMENT: WHO, WHEN, HOW EXTENSIVE?
were deemed to be mentally alert and without symptoms referable to the cervical region. It is estimated (in 1989 dollars) that the cost of unnecessary cervical radiography and CT scan is nearly $60,000 at the Maryland Institute for Emergency Medical Services System alone (1). Vandemark, in 1990 (2), suggests a “risk-tailored” approach to cervical radiography in trauma patients. To determine those patients who need radiographs and those who do not, he proposes four clinical risk categories. The first category, “no-risk,” includes those patients who are mentally alert, not under the influence of alcohol or other drugs, and who have no history or physical findings suggesting a neck injury. The majority of these patients arrive in the emergency department with a cervical collar placed by paramedical personnel at the accident site because of protocol. These patients need not undergo cervical radiography. The next category, “low-risk,” includes those patients with a history of a mechanism of injury likely to have exceeded the physiologic range of cervical motion. For these patients, Vandemark recommends a limited cervical series consisting of lateral, anteroposterior (AP), and atlantoaxial (odontoid) views. The third category, “medium-risk,” includes those patients with a history or mechanism of injury sufficient to have exceeded the physiologic range of motion. The fourth category, “high-risk,” includes those patients with a history or mechanism of injury very likely to have exceeded the physiologic range of motion. Included in both of these groups are all patients with impaired sensorium. For both of these categories, he recommends five-view series to be performed in the supine position. This series includes the supine (“trauma”) oblique radiographs (2). How does one determine those patients with a “high risk” for cervical injury? A number of historical and clinical factors should be taken into account to make this determination. As a rule, patients may be considered “high-risk” if any one of the following parameters are present: high-velocity blunt trauma; multiple fractures (closed or open); evidence of direct cervical region injury (cervical pain, spasm, or obvious deformity); drowning or diving accident; falls of greater than 10 feet; significant head or facial injury;
One of the controversies in trauma care in medicine today pertains to the assessment of the cervical vertebrae in emergency patients who have suffered trauma. This group of patients provides an area of great concern not only to the physicians who must manage the patients but also to the hospital administrators who seek ways to augment hospital income, and to third-party providers (including the Federal Government) who just as vigorously are seeking ways of cost containment. Thus, the emergency physician is caught between the “rock” of “protocol-driven” requirements to obtain cervical radiographs and fear of malpractice litigation if an injury is missed, and the “hard place,” resulting from the efforts of medical cost-containment to evaluate indications for “routine” cervical radiography and trauma. Is there a middle ground? Is there a way to selectively identify patients needing cervical radiography? The answers to these questions are a qualified “yes,” and may be found within two excellent papers that have addressed this subject in recent years (1,2). Many large centers dealing with trauma victims employ a “protocol-driven” approach for patients who fit into certain diagnostic categories. These generally include all patients involved in a motor vehicle accident or serious fall. In many instances, these protocols conform to the guidelines of the American College of Surgeons who recommend routine lateral cervical radiography for all patients suffering major trauma (3). However, as was demonstrated by Mirvis and colleagues (I), many of these studies are not indicated. The Mirvis study surveyed 125 North American hospitals caring for acutely injured patients. It finds that 96% of those hospitals responding routinely obtained cervical radiographs on all patients suffering major blunt trauma. In an attempt to determine the cost-benefit effect of this practice, this group conducted a prospective in-house study comparing the results of clinical assessment with radiographic and computed tomography (CT scan) on a group of 408 patients with a history of blunt trauma. One hundred thirty-eight (34%) of this patient group
0736-4679/93 $6.00 + .OO 619
620
thoracic or lumbar vertebral fracture; and a history of preexisting vertebral disease such as ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis (DISH) (2). It is the author’s feeling that any patient within this category should undergo a full series of cervical radiographs (4,5). Allegheny General Hospital is a level-one trauma center that admits approximately 1800 major trauma cases a year. The majority of these patients are victims of high-speed motor vehicle trauma. Significant vertebral injury occurs in 250 patients a year. Eightytwo percent of these injuries are due to motor vehicle accidents and 17% are due to falls. The majority of our patients involved in motor vehicle accidents have their sensorium compromised by head injury, alcohol, or drug ingestion. Thus, we have a large, selected group of trauma patients on whom cervical radiographs are obtained in a majority of admissions. A few patients with “minor” cervical injuries are encountered. This is in contrast with many of the smaller suburban hospitals in the Pittsburgh area who also receive a preselected patient population from accidents, but that generally are considered minor “fender benders.” The reason for this is that the local paramedical personnel automatically refer victims of severe trauma to the 3 large level-one trauma centers in Pittsburgh. In these community hospitals where the degrees of injury are less severe, emergency department physicians may have the luxury of being able to adequately assess their patients prior to radiography to determine if there is a need. A study by Roberge and colleagues (6), at our institution, supported this approach by demonstrating that alert trauma patients without complaints or findings refer-
The Journal of Emergency Medicine
able to the neck need not undergo cervical vertebral radiography. The 2 key principles are 1) an alert patient and 2) absence of any other severe injury that could mask pain from an occult cervical abnormality. In summary, the author endorses Vandemark (2) who recommends that patients be assessed as individuals. Furthermore, the decision to obtain cervical radiographs should be determined by a combination of clinical findings and historical risk factors. The radiographic menu for each patient should be custom-tailored. Richard H. Daffner, MD, FACR Department of Diagnostic Radiology Alleghany General Hospital Pittsburgh, Pennsylvania
REFERENCES 1. Mirvis SE, Diaconis JN, Chirico PA, et al. Protocol-driven radiologic evaluation of suspected cervical injury: efficacy study. Radiology 1989;170:831-4. 2. Vandemark RM. Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficacy and communication. AJR. 1990x155:465-72. 3. American College of Surgeons Committee on Trauma. Advanced trauma life support course for physicians. Chicago, Illinois: American College of Surgeons; 1984:256. 4. Daffner RH. Imaging of vertebral trauma. Rockville, Maryland: Aspen Publishers; 1988. 5. Daffner RH. Evaluation of cervical vertebral injuries. Semin Roentgenol. 1992;27:239-53. 6. 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. 1988;28:784-8.