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Is prevertebral soft tissue swelling a useful sign in injury of the cervical spine?
Injury (1988) 19, 177-179
Printedin
177
Great Britain
Is prevertebral soft tissue swelling a useful sign in injury of the cervical spine? K. A. Miles and D. Finlay Department
of Radiology,
Leicester
Royal Infirmary
Summary A group of 58 patients with suspected injuries of the cervical spine were reviewed retrospectively. Prevertebral soft tissue swelling occurred in 20 (49 per cent) of 41 patients with definite bone injury. Soft tissue swelling occurred significantly more frequently with injuries to the anterior portion of the cervical spine than to the posterior vertebral elements. No significant correlation was found between soft tissue swelling and level of injury and age of the patient. Out of 17 patients with cervical injuries, 4 (24 per cent) who were subsequently considered not to have sustained bony injury demonstrated apparent soft tissue swelling. The absence of soft tissue swelling should not be considered as evidence for no bony injury. Its presence does not necessarily indicate bony injury.
INTRODUCTION AN increase in the width of the prevertebral
soft tissues is a well recognized sign in injury of the cervical spine. The incidence of this sign and whether it is more commonly related to particular injuries is not well documented. Furthermore, several different methods for assessing the normal soft tissue width have been suggested (Wholey et al., 19.58; Oon, 1964; Weir, 1975; Babcock, 1976; Fielding and Hawkins, 1976). The aim of this study was to assess the value of this sign in radiological practice by determining its incidence and whether its presence is related to specific injuries. METHODS
A retrospective review of radiographs and clinical notes of patients sustaining injuries of the cervical spine over a 30 month period was made. Only patients radiographed within 24 h of injury were included. The width of the soft tissue in front of each cervical vertebra and the width of the vertebra itself were measured. The soft tissues were assessed by two methods. First, values for the maximum normal widths of the soft tissue at various levels as stated by Meschan (1975) based on
Tab/e 1. Normal values for widths of prevertebral soft tissue Vertebral level
Maximum
width of soft tissue (mm)
c2 c3 c5 C6 0 IYXX Butterworth c(cCo (Puhlishcrs) Ltd 0(~2~~1.3X3/XX/030177-03 $034)0
7 5 22 17
work by Oon (1964) and Wholey et al. (1958) were used. These are set out in Table I. The second method compared the width of the soft tissue to the anteroposterior diameter of the vertebral body at the same level. At the second and third cervical vertebrae, up to half the width of the vertebral body and at the fifth to seventh cervical vertebrae, up to equal the width of the vertebral body were considered normal. RESULTS
A total of 58 patients were reviewed; their ages ranged between 17 and 84 years. In 41 patients there was radiographic evidence of bony injury to the cervical spine. Another 17 patients were initially suspected of having bony injury but subsequent physical examination and radiological investigation showed this not to be so. This group was considered separately. Of the 41 patients with bony injury, 20 (49 per cent) had soft tissue widths exceeding the values in Table I. These results were analysed in three ways: 1. Anterior versus posterior injury. 2. High versus low injury. 3. By age. Anterior versus posterior injury
Anterior injuries were considered as fractures or dislocations of the vertebral bodies including fractures of the odontoid peg. Posterior injuries were taken as injuries involving the posterior vertebral elements. Twenty-four patients had anterior injuries of which 15 (63 per cent) had associated swelling of the soft tissue. Seventeen patients had posterior injuries of which 5 (29 per cent) had swelling of the soft tissue (Tub/e II). This difference was found to be significant at the 5 per cent probability
level (x1=4.38).
Table II. Number of patients with and without soft tissue swellings related to type of injury
Group Anterior injury Posterior injury No bony injury
Soft tissue swelling present
Normal soft
tissues
Total
15
9
24
5
12
17
4
13
17
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 3
178
Fig. I. Hangman’s soft tissue swellinp.
fracture
demonstrating
no prevertehral
High versus low injury Injuries of the upper three cervical vertehrac wcrc found in 14 patients. of which 8 (57 per cent) had swelling of the soft tissue; 27 patients had injuries to vertebrae below the third cervical vertebra, of which I2 (44 per cent) had soft tissue swelling. This difference was not significant (x’= -0.5Y).
Using non-parametric statistical tests, the age distribution for those with and without swelling of the soft tissue was compared. Initially. those patients with soft tissue swelling were found to be significantly older. but this group had a higher incidence of anterior fractures. When correction was made no significant difference in age was found.
No bony injury Of the 17 patients with no bony in,[ury. 4 (24 per cent) had apparent swelling of the soft tissue. There was no significant difference in the incidence of swelling of the with the posterior soft tissue in this group compared injury
group
(x2=0.16).
to The method of assessing soft tissue by comparison the width of the vertebral body afforded no benefit over direct measurement and appears to be less sensitive; the overall incidence using this method being only 17 (45 per cent).
Ei
peg demonstrating
swelling
DISCUSSION 4Y per cent incidence of swelling of the soft tissue in bony injury to the cervical spine casts doubt on the value of this sign in radiological practice. Its absence cannot be considered as evidence of no bony injury (Fig. I). Its presence should make one look more carefully for bony injury. particularly to the anterior portion of the cervical spine (Fis. 2). It may also help confirm that a bony abnormality represents a recent injury. The fact that soft tissue swelling occurred in some of those patients sustaining injury to the cervical spine without actual bony injury is worthy of note. This may possibly reflect the limitations of radiography in the accident and emergency department with techniques that are variable and different from those used in the standard normal groups. Alternatively. this soft tissue may not be artefactual but indicate a ‘soft tissue injury’ to the neck. Indeed. soft tissue injury and swelling in injury without bony injury is an accepted occurrence A
to sites elsewhere
in the body.
REFERENCES Babcock J. L. (1076) Cervical Spine Injuries: Diagnosis and Classification. Arch. Strrg. I Il. 646. Fielding J. W. and Hawkins R. J. (IY7h) Rorrzt~rrzogrccplzic rliccgtmsis of‘ the injured mck. A. A.O.S. instructional course lectures. St Louis. C. V. Mosby, Vol XXV; chapter 7. 130.
Miles and Finlay: Prevettebral swelling in injury of the cervical spine Meschan I. (1975) Anatomy Basic to Radiology. Philadelphia, W. B. Saunders, 536, 588. Oon C. L. (1964) Some sagittal measurements of the neck in normal adults. Br. J. Radiol. 37, 674. Weir D. C. (1975) Roentgenographic signs of cervical injury. Clin. Orthop. 109, 9.
Requests for reprinrs should Leicester LEI 5WW.
he uddressed 10: Dr
K. A.
Miles,
179
Wholey M. H. et al. (1958) The lateral roentgenogram neck. Radiology 71. 350.
Paper accepted 15 December
Department
of Radiology.
Leicester
1987.
Royal
Notice THE RADIOLOGY OF TRAUMA 13th and 14th October 1988 Leicester Royal Infirmary A two-day course on the Radiology of Fractures basic principles of fracture diagnosis.
including
The course includes lectures and tutorial groups. The course is intended to be of interest to all those involved in the diagnosis and management of trauma. The lectures are drawn from the specialties of Radiology, Orthopaedic and Casualty Surgery. Further details and applications to: Dr D. Finlay, Consultant Radiologist, X-Ray Department, The Leicester Royal Infirmary, Infirmary Square, Leicester LEl 5WW. Closing date for applications:
16th September
1988
of the
Infirmary,
Infirmary
Square.
Printedin
177
Great Britain
Is prevertebral soft tissue swelling a useful sign in injury of the cervical spine? K. A. Miles and D. Finlay Department
of Radiology,
Leicester
Royal Infirmary
Summary A group of 58 patients with suspected injuries of the cervical spine were reviewed retrospectively. Prevertebral soft tissue swelling occurred in 20 (49 per cent) of 41 patients with definite bone injury. Soft tissue swelling occurred significantly more frequently with injuries to the anterior portion of the cervical spine than to the posterior vertebral elements. No significant correlation was found between soft tissue swelling and level of injury and age of the patient. Out of 17 patients with cervical injuries, 4 (24 per cent) who were subsequently considered not to have sustained bony injury demonstrated apparent soft tissue swelling. The absence of soft tissue swelling should not be considered as evidence for no bony injury. Its presence does not necessarily indicate bony injury.
INTRODUCTION AN increase in the width of the prevertebral
soft tissues is a well recognized sign in injury of the cervical spine. The incidence of this sign and whether it is more commonly related to particular injuries is not well documented. Furthermore, several different methods for assessing the normal soft tissue width have been suggested (Wholey et al., 19.58; Oon, 1964; Weir, 1975; Babcock, 1976; Fielding and Hawkins, 1976). The aim of this study was to assess the value of this sign in radiological practice by determining its incidence and whether its presence is related to specific injuries. METHODS
A retrospective review of radiographs and clinical notes of patients sustaining injuries of the cervical spine over a 30 month period was made. Only patients radiographed within 24 h of injury were included. The width of the soft tissue in front of each cervical vertebra and the width of the vertebra itself were measured. The soft tissues were assessed by two methods. First, values for the maximum normal widths of the soft tissue at various levels as stated by Meschan (1975) based on
Tab/e 1. Normal values for widths of prevertebral soft tissue Vertebral level
Maximum
width of soft tissue (mm)
c2 c3 c5 C6 0 IYXX Butterworth c(cCo (Puhlishcrs) Ltd 0(~2~~1.3X3/XX/030177-03 $034)0
7 5 22 17
work by Oon (1964) and Wholey et al. (1958) were used. These are set out in Table I. The second method compared the width of the soft tissue to the anteroposterior diameter of the vertebral body at the same level. At the second and third cervical vertebrae, up to half the width of the vertebral body and at the fifth to seventh cervical vertebrae, up to equal the width of the vertebral body were considered normal. RESULTS
A total of 58 patients were reviewed; their ages ranged between 17 and 84 years. In 41 patients there was radiographic evidence of bony injury to the cervical spine. Another 17 patients were initially suspected of having bony injury but subsequent physical examination and radiological investigation showed this not to be so. This group was considered separately. Of the 41 patients with bony injury, 20 (49 per cent) had soft tissue widths exceeding the values in Table I. These results were analysed in three ways: 1. Anterior versus posterior injury. 2. High versus low injury. 3. By age. Anterior versus posterior injury
Anterior injuries were considered as fractures or dislocations of the vertebral bodies including fractures of the odontoid peg. Posterior injuries were taken as injuries involving the posterior vertebral elements. Twenty-four patients had anterior injuries of which 15 (63 per cent) had associated swelling of the soft tissue. Seventeen patients had posterior injuries of which 5 (29 per cent) had swelling of the soft tissue (Tub/e II). This difference was found to be significant at the 5 per cent probability
level (x1=4.38).
Table II. Number of patients with and without soft tissue swellings related to type of injury
Group Anterior injury Posterior injury No bony injury
Soft tissue swelling present
Normal soft
tissues
Total
15
9
24
5
12
17
4
13
17
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 3
178
Fig. I. Hangman’s soft tissue swellinp.
fracture
demonstrating
no prevertehral
High versus low injury Injuries of the upper three cervical vertehrac wcrc found in 14 patients. of which 8 (57 per cent) had swelling of the soft tissue; 27 patients had injuries to vertebrae below the third cervical vertebra, of which I2 (44 per cent) had soft tissue swelling. This difference was not significant (x’= -0.5Y).
Using non-parametric statistical tests, the age distribution for those with and without swelling of the soft tissue was compared. Initially. those patients with soft tissue swelling were found to be significantly older. but this group had a higher incidence of anterior fractures. When correction was made no significant difference in age was found.
No bony injury Of the 17 patients with no bony in,[ury. 4 (24 per cent) had apparent swelling of the soft tissue. There was no significant difference in the incidence of swelling of the with the posterior soft tissue in this group compared injury
group
(x2=0.16).
to The method of assessing soft tissue by comparison the width of the vertebral body afforded no benefit over direct measurement and appears to be less sensitive; the overall incidence using this method being only 17 (45 per cent).
Ei
peg demonstrating
swelling
DISCUSSION 4Y per cent incidence of swelling of the soft tissue in bony injury to the cervical spine casts doubt on the value of this sign in radiological practice. Its absence cannot be considered as evidence of no bony injury (Fig. I). Its presence should make one look more carefully for bony injury. particularly to the anterior portion of the cervical spine (Fis. 2). It may also help confirm that a bony abnormality represents a recent injury. The fact that soft tissue swelling occurred in some of those patients sustaining injury to the cervical spine without actual bony injury is worthy of note. This may possibly reflect the limitations of radiography in the accident and emergency department with techniques that are variable and different from those used in the standard normal groups. Alternatively. this soft tissue may not be artefactual but indicate a ‘soft tissue injury’ to the neck. Indeed. soft tissue injury and swelling in injury without bony injury is an accepted occurrence A
to sites elsewhere
in the body.
REFERENCES Babcock J. L. (1076) Cervical Spine Injuries: Diagnosis and Classification. Arch. Strrg. I Il. 646. Fielding J. W. and Hawkins R. J. (IY7h) Rorrzt~rrzogrccplzic rliccgtmsis of‘ the injured mck. A. A.O.S. instructional course lectures. St Louis. C. V. Mosby, Vol XXV; chapter 7. 130.
Miles and Finlay: Prevettebral swelling in injury of the cervical spine Meschan I. (1975) Anatomy Basic to Radiology. Philadelphia, W. B. Saunders, 536, 588. Oon C. L. (1964) Some sagittal measurements of the neck in normal adults. Br. J. Radiol. 37, 674. Weir D. C. (1975) Roentgenographic signs of cervical injury. Clin. Orthop. 109, 9.
Requests for reprinrs should Leicester LEI 5WW.
he uddressed 10: Dr
K. A.
Miles,
179
Wholey M. H. et al. (1958) The lateral roentgenogram neck. Radiology 71. 350.
Paper accepted 15 December
Department
of Radiology.
Leicester
1987.
Royal
Notice THE RADIOLOGY OF TRAUMA 13th and 14th October 1988 Leicester Royal Infirmary A two-day course on the Radiology of Fractures basic principles of fracture diagnosis.
including
The course includes lectures and tutorial groups. The course is intended to be of interest to all those involved in the diagnosis and management of trauma. The lectures are drawn from the specialties of Radiology, Orthopaedic and Casualty Surgery. Further details and applications to: Dr D. Finlay, Consultant Radiologist, X-Ray Department, The Leicester Royal Infirmary, Infirmary Square, Leicester LEl 5WW. Closing date for applications:
16th September
1988
of the
Infirmary,
Infirmary
Square.