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Dear editor
*he kwrnai
oi Emergency
Meciicine.
Vol. 3, pp
69-74.
1991
resented. I would have my radiobgy Volume 8, pages 183-198, 1990, Kirshcenresent an interesting and disturbing series of routine cervical spine x-rays fail to demonstrate significant fractures. One cannot fault their conclusions and indeed would be advised to consider use of their algorithm recommending CT evaluation of the upper cervical spine in cases of significant head injured patients and certainly those with positive CT brain ans. Bowever. before we abandon or severely criticize ain film ra~iogra~by~ we must find those x-rays to have been optimally performed, developed, and interpreted. Despite the fact that the authors had several radiologists’ (blinded and retrospective) interpretations, and considering the suboptimal ways x-rays are photo-reproduced in journals even with fine quality paper, I still would criticize the following:
2.
technlcjan
Figure 4a, page 1X7, no ~r~~~~r~or ruhuxatlon IS evident, but there appears to be borderline ly dem5ns~ra~ed~
vX7 tissue swell-
3. Figure 12a, page 193: This is an abn spine x-ray. Bony alignment is good, no fracture is seen, but there is sig~i~cant bulging and swelling of the soft tissues anterior to (32. oint is not to criticize the au:.hors. the study conclusions, or this jou al, but IO aclvosate for no less than high quality, compiete p&n fi
1. Figure %b, page 185, Figure lob, page 192, and Figure k5b, page 195, may all be interpreted as “llOlTXd” but are suboptimal and inconclusive as
(Figures Tb, 12b.b) shove ~~~~e~~a% lateral masses of C%. Of the seven lateral views, two (Figures two
The article by Kirshenbaum et al on the role of CT of the upper cervical spine in patients with head trauma requires comment, Seven upper cervical fractures are described in patients with “significant intracranial hemorrhage’ ’ after blunt trauma. These were considered occult as the lateral and open mouth views (OMV) were “normal.” Of what clinical significance were these discoveries? Did any of these patients recover to a functional neurologic status? Detecting an occult cervical spine in$u-y in a brain dead patient is no great victory. In reviewing the plain radiographs included with the article the term “normal” is applied to each. Of the seven Open Mouth Views included. three are uninterpretable (Figures Ib. 1Ob. 15b) due to poor quality, and
=
others
indicating injury to the Cl-C%
q&x
(2). Taken
graphs were suspicious, then one ~~~~~~~~ say the were truly “‘occult.” Finally, the authors state additional views of the upper cervical 5 integral to the CT brain e~a~i~~~~~ in ~a~i~~ts with
Guidelines for Letters - Letters will appear at the discrenon of the editor as spacepermits and nsay be ~u~iectedtc some editing. Three typewritten. double-spaced copies should be submitted.
69
oi Emergency
Meciicine.
Vol. 3, pp
69-74.
1991
resented. I would have my radiobgy Volume 8, pages 183-198, 1990, Kirshcenresent an interesting and disturbing series of routine cervical spine x-rays fail to demonstrate significant fractures. One cannot fault their conclusions and indeed would be advised to consider use of their algorithm recommending CT evaluation of the upper cervical spine in cases of significant head injured patients and certainly those with positive CT brain ans. Bowever. before we abandon or severely criticize ain film ra~iogra~by~ we must find those x-rays to have been optimally performed, developed, and interpreted. Despite the fact that the authors had several radiologists’ (blinded and retrospective) interpretations, and considering the suboptimal ways x-rays are photo-reproduced in journals even with fine quality paper, I still would criticize the following:
2.
technlcjan
Figure 4a, page 1X7, no ~r~~~~r~or ruhuxatlon IS evident, but there appears to be borderline ly dem5ns~ra~ed~
vX7 tissue swell-
3. Figure 12a, page 193: This is an abn spine x-ray. Bony alignment is good, no fracture is seen, but there is sig~i~cant bulging and swelling of the soft tissues anterior to (32. oint is not to criticize the au:.hors. the study conclusions, or this jou al, but IO aclvosate for no less than high quality, compiete p&n fi
1. Figure %b, page 185, Figure lob, page 192, and Figure k5b, page 195, may all be interpreted as “llOlTXd” but are suboptimal and inconclusive as
(Figures Tb, 12b.b) shove ~~~~e~~a% lateral masses of C%. Of the seven lateral views, two (Figures two
The article by Kirshenbaum et al on the role of CT of the upper cervical spine in patients with head trauma requires comment, Seven upper cervical fractures are described in patients with “significant intracranial hemorrhage’ ’ after blunt trauma. These were considered occult as the lateral and open mouth views (OMV) were “normal.” Of what clinical significance were these discoveries? Did any of these patients recover to a functional neurologic status? Detecting an occult cervical spine in$u-y in a brain dead patient is no great victory. In reviewing the plain radiographs included with the article the term “normal” is applied to each. Of the seven Open Mouth Views included. three are uninterpretable (Figures Ib. 1Ob. 15b) due to poor quality, and
=
others
indicating injury to the Cl-C%
q&x
(2). Taken
graphs were suspicious, then one ~~~~~~~~ say the were truly “‘occult.” Finally, the authors state additional views of the upper cervical 5 integral to the CT brain e~a~i~~~~~ in ~a~i~~ts with
Guidelines for Letters - Letters will appear at the discrenon of the editor as spacepermits and nsay be ~u~iectedtc some editing. Three typewritten. double-spaced copies should be submitted.
69