- Email: [email protected]
Is The Lateral Cervical Spine Plain Film Obsolete?
Journal of Surgical Research 147, 267–269 (2008) doi:10.1016/j.jss.2008.02.062
Is The Lateral Cervical Spine Plain Film Obsolete? Therèse M. Duane, M.D.,1 Tracey Dechert, M.D., Holly Brown, B.S., Luke G. Wolfe, M.S., Ajai K. Malhotra, M.D., Michel B. Aboutanos, M.D., M.P.H., and Rao R. Ivatury, M.D. Division of Trauma, Critical Care, and Emergency General Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia Submitted for publication January 26, 2008
Background. The objective of this study was to determine the utility of a lateral cervical spine plain film in the evaluation of blunt trauma patients. Methods. We prospectively evaluated blunt trauma patients from February 2004 to September 2006 who had both a lateral cervical spine (LCS) film and a computed tomography of the cervical spine (CTC), comparing the diagnostic accuracy of the LCS to the CTC. Results. There were 1004 patients who met inclusion criteria. Eighty-four patients had a cervical spine fracture while 920 patients had no fracture on CTC. Of the 84 patients with fractures by CTC, 68 had a negative or incomplete LCS. Of the 920 negative CTC, there were 7 false positive LCSs. LCS compared with CTC showed a sensitivity of 19% (16/84) and positive predictive value of 69.6% (16/23). Of the 981 negative or incomplete LCS films, 96.9% were incomplete (951/981). Of the seven patients with a false positive LCS (negative CTC), none was subsequently found to have a cervical spine fracture on further evaluation. Elimination of the LCS would result in charge savings of $265,056.00 (LCS charges with interpretation, $264 each) and increase patient safety by eliminating error. Conclusions. LCS has no value as a screening tool in the blunt trauma patient since most are either inaccurate or incomplete. It should be eliminated from the Advanced Trauma Life Support algorithm, and CTC should receive emphasis as the diagnostic gold standard. © 2008 Elsevier Inc. All rights reserved. Key Words: cervical spine fracture; lateral cervical spine radiograph; trauma; outcomes. INTRODUCTION
As technology improves, so does our ability to evaluate the acutely injured trauma patient. Unfortu1
To whom correspondence and reprint requests should be addressed at Department of Surgery, Virginia Commonwealth University Medial Center, 1200 E. Broad Street, West Hospital, 15th Floor, PO Box 980454, Richmond, VA 23298. E-mail: [email protected].
nately, general guidelines often lag behind with continued recommendations that include tools that may be outdated. The lateral cervical spine is one such tool. Advanced Trauma Life Support (ATLS) [1] and the current Eastern Association for the Surgery of Trauma (EAST) guidelines [2] for the evaluation of cervical spine fractures include the lateral cervical spine (LCS) plain radiograph as an initial screening film in the blunt trauma patient. In order for this film to be adequate, the guidelines clearly state that there has to be good visualization from the occiput to the upper part of the first thoracic vertebra. The guidelines suggest that this film, along with the odontoid view and the anteroposterior view when technically adequate and interpreted correctly, have a 0.1% false negative rate. It has been our experience that it is often difficult to obtain an adequate view using LCS secondary to poor technique and the increasing body habitus of the patient population. Hence, we were concerned that this study wasted time and money while adding nothing to the initial evaluation of the trauma patient. This point was emphasized in a previously published paper by the authors [3], which demonstrated the value of the cervical spine CT (CTC) compared with clinical examination. Therefore, we hypothesized that the LCS had no value as an initial screening tool after blunt trauma and determined to test our hypothesis by comparing the LCS with the CTC as the gold standard. MATERIALS AND METHODS We performed a prospective evaluation from February 2004 until September of 2006 of all blunt trauma team alert patients over the age of 16 y admitted to our Level 1 Trauma Center. All adult patients who underwent both a lateral cervical spine film and a cervical spine computed tomography were included in the analysis. The CTC was used as the gold standard for diagnosis of cervical spine fracture. At the time of the study, the standard approach for all trauma activation patients was a thorough clinical examination followed by a lateral cervical spine film. All patients, regardless of level of con-
267
0022-4804/08 $34.00 © 2008 Elsevier Inc. All rights reserved.
268
JOURNAL OF SURGICAL RESEARCH: VOL. 147, NO. 2, JUNE 15, 2008
sciousness or intoxication, then underwent a computed tomography of the cervical spine to evaluate for injury. Further radiographic studies were then performed based on the initial CT scan. Patients with cervical spine fractures were compared with those without fracture. Demographics, mechanism, initial hemodynamics, and laboratory values were included in the comparison. LCS was then compared with CTC to determine its sensitivity, specificity, negative, and positive predictive value. Charges for the radiographic studies were then analyzed to determine potential charge savings. Continuous variables were evaluated using the Wilcoxon rank test and the nominal variables were evaluated using the Fischer’s exact test. This study was approved by the Virginia Commonwealth University Institutional Review Board.
RESULTS
There were 5065 blunt trauma alert patients evaluated at our institution during the time frame of the study. Of those patients, 4608 were over 16 y of age. There were a total of 1004 patients who had both LCS and CTC performed during the initial evaluation of the cervical spine with the results documented prospectively. Eighty-four patients had a cervical spine fracture while 920 had no fracture, based on the final attending radiologist interpretation of the CTC. The two groups had a similar distribution of men (61.9% (52/84) fracture versus 64.3% (592/920) no fracture, P ⫽ 0.72). The majority of both groups were white (62% (52/84) fracture versus 59% (540/920) no fracture, P ⫽ 0.75) and of similar age (41.3 y ⫾ 19.0 fracture versus 41.3 y ⫾ 21.0 no fracture, P ⫽ 0.3). Most trauma patients suffered injuries from a motor vehicle collision (72.6% (61/84) fracture versus 77.4% (712/920) no fracture, P ⫽ 0.44). Table 1 demonstrates the initial hemodynamics of the two groups. The fracture group had significantly higher ISS scores (20.8 ⫾ 14.2 fracture versus 11.6 ⫾ 10.6 no fracture, P ⬍ 0.0001), lactates (3.6 mmol/L ⫾ 2.7 fracture versus 2.8 mmol/L ⫾ 4.7 no fracture, P ⫽ 0.0005), initial blood sugars (143.8 ⫾ 60.1 mg/dL fracture versus 124.0 mg/dL ⫾ 46.6 no fracture, P ⫽ 0.0019) and base deficits (⫺0.2 ⫾ 5.5 fracture versus 2.3 ⫾ 17.4 no fracture, P ⫽ 0.0017). Table 2 illustrates how the LCS compares with the CTC in diagnosis of cervical spine fracture. As shown in the table, the sensitivity was 19% (16/84) with a positive predictive value of 69.6% (16/23). The specificity was 99.2% (913/ 920) and negative predictive value of 93.1% (913/981). TABLE 1 Initial Hemodynamics
Systolic blood pressure (mmHg) Heart rate (beats/min) Respiratory rate (per min) Glasgow Coma Scale
Fracture
No fracture
P-value
138.0 ⫾ 33.4 98.5 ⫾ 18.8 19.2 ⫾ 4.9 12.4 ⫾ 4.6
140.8 ⫾ 24.3 91.5 ⫾ 18.1 19.8 ⫾ 6.8 14.0 ⫾ 3.0
0.70 0.0043 0.57 0.0003
TABLE 2 LCS Compared with CTC
Fracture by CTC No fracture by CTC Total
Incomplete/negative LCS
Positive LCS
Total
68 913 981
16 7 23
84 920 1004
Of the seven patients with a false positive LCS (negative CTC), none was found to have a cervical spine fracture on further evaluation. The LCS has a charge of $264.00, which includes the film and the attending radiologist interpretation. Elimination of the 1004 LCS films performed during the study would result in charge savings of $265,056.00. DISCUSSION
The lateral cervical spine plain film continues to be used at institutions as part of the initial evaluation of the blunt trauma patient. Indeed, it still is included as an adjunctive study in ATLS [1]. However, we believe that its use should be discontinued given the inaccuracy and often inadequacy of the examination. Barba et al. [4], in a study to evaluate CTC, compared it with the standard three-view radiography of anteroposterior, lateral, and odontoid view plain films. In this study, of 324 patients, there were 15 injuries of which 6 were missed by the LCS. Their sensitivity, although higher than the 19% in this trial, was still poor for an injury that has such dire consequences when it goes unrecognized. Other studies confirm that additional plain films do not add to the accuracy of diagnosis. Gale et al. [5] used both AP films and LCS and still only had a sensitivity of 31.6% with evaluation of 848 patients. Griffen et al. [6] reviewed 1199 patients at risk for cervical spine injuries and found a 9.5% fracture rate. Plain films only identified 75 of these injuries, missing 41 fractures. All of the missed injuries required some form of treatment. Moreover, the average GCS in this group was 12, suggesting that these patients would not have been clearable by clinical examination if one is to follow the current EAST guidelines for evaluation in the awake and alert patient. This group of patients is at most risk. They are not good candidates for clinical examination clearance and would have missed injuries if plain films were used alone. Like the Griffen study, many others have combined the LCS and other plain films to increase the diagnostic accuracy with little success. In the NEXUS study, Mower et al. [7], using three view plain films when radiographic evaluation was indicated per their proto-
DUANE ET AL.: LATERAL CERVICAL SPINE PLAIN FILM
col, missed 35 injuries, three of which were potentially unstable. Furthermore, the majority of missed injuries occurred in cases in which the plain radiograph was either abnormal and not diagnostic of injury or inadequate. The extent of inadequacy cannot be overemphasized. In our study, almost 96% of the lateral cervical spine plain films were unable to be evaluated, mostly because they were incomplete. The main reason for incomplete films is an inability to visualize down to the first thoracic vertebra. Since obesity is on the rise in this country, the ability to evaluate the lower cervical spine will be more compromised secondary to greater adiposity in the shoulder and neck region. Many other trials have noted that the majority of these films are inadequate [8 –10]. In a small study by DiGiacomo et al. [11], there were six patients with nine missed injuries thought secondary to error in film interpretation. In hindsight, only two of those were felt to have technically adequate films. When there is high volume turnover and demand for films to be read quickly, such mistakes of accuracy and acceptance of adequacy may rise with increases in missed injury. Although this is a theoretical concern, other options such as CT have been proven more cost effective by being more accurate. Grogan et al. [12] demonstrated the value of using CT instead of plain films. This cost minimization study noted that screening CTs cost less than plain films since fewer injuries were missed, resulting in a lower settlement cost. They found that settlement costs would average over $58,000.00 for an institution while screening plain films would be $2142.00 and CT’s would cost $554.00, even if the fracture rate were only 0.9% with a paralysis rate of 1.7%. Given that up to 29% of patients with a delay in diagnosis of cervical spine injuries go on to develop some form of paralysis [13, 14], immediate diagnosis is paramount. Minimizing missed injury will simultaneously decrease overall cost and should be the goal of all health care professionals caring for the critically injured trauma patient. We believe that removing plain films such as the LCS will accomplish both of these goals. Our study confirms that just the LCS alone carries a significant charge burden when done on a routine basis. Almost a quarter of a million dollars would have been saved during the time frame of this study if the test had been eliminated. Moreover, it never assisted with the diagnosis since all injuries were identified by CT. Because of the mounting literature against plain films, the EAST guidelines [2] are currently being redone. Previously, the standard three-view plain radiographs were recommended with addition of CT when they were inadequate for patients who qualified for radiographic evaluation. This group includes any patient who is not completely awake and alert, without a
269
distracting injury, intoxication, or any evidence of neurological deficits or pain or tenderness over the cervical spine. There is a strong possibility that the new guidelines will include CT as the diagnostic modality of choice in those patients who require radiographic work-up, eliminating plain films altogether during the initial evaluation of these patients, [personal correspondence with Dr. John Como, January 15, 2008, chairperson EAST cervical spine practice management guidelines 2008]. Advances in technology allow for better screening tools with greater diagnostic accuracy. The LCS is no longer a reasonable modality to evaluate these patients. Our data support the elimination of LCS in the initial evaluation of the polytrauma patient with significant mechanism of injury. For those patients who require radiographic evaluation of the cervical spine after significant injury, the CTC should be the diagnostic modality of choice. REFERENCES 1. 2.
3.
4.
5.
6.
7.
8.
9.
10. 11. 12.
13. 14.
American College of Surgeons Committee on Trauma: Advanced Trauma Life Support. ATLS Instructor Manual, 1997. Eastern Association for the Surgery of Trauma (EAST) Guidelines. Determination of Cervical Spine Stability in Trauma. Available at: http.www.east.org. Accessed: December 2007. Duane TM, Dechert TA, Wolfe LG, et al. Clinical examination and its reliability in identifying cervical spine fractures. J Trauma 2007;62:1404. Barba CA, Taggert J, Morgan AS, et al. A new cervical spine clearance protocol using computed tomography. J Trauma 2001;51:652. Gale SC, Gracias VH, Reilly PM, et al. The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J Trauma 2005;59:1121. Griffen MM, Frykberg ER, Kerwin AJ, et al. Radiographic clearance of blunt cervical spine injury: Plain radiograph or computed tomography scan? J Trauma 2003;55:222. Mower WR, Hoffman JR, Pollack CV, et al. Use of plain radiography to screen for cervical spine injuries. Ann Em Med 2001;38:1. McCulloch PT, France J, Jones DL, et al. Helical computed tomography alone compared with plain radiographs with adjunct computed tomography to evaluate the cervical spine after high-energy trauma. J Bone Joint Surg Am 2005;87:2388. Borock EC, Gabram SG, Jacobs LM, et al. A prospective analysis of a two-year experience using computed tomography as an adjunct for cervical spine clearance. J Trauma 1991;31:1001. Besman A, Kaban J, Jacobs L, et al. False-negative plain cervical spine x-rays in blunt trauma. Am Surg 2003;69:1010. DiGiacomo JC, Frankel HL, Rotondo MF. Clearing the cervical spine in victims of blunt trauma. Mil Med 2002;167:398. Grogan EL, Morris JA, Dittus RS, et al. Cervical spine evaluation in urban trauma centers: Lowering institutional costs and complications through helical CT scan. J Am Coll Surg 2005; 200:160. Davis JW, Phreaner DL, Hoyt DB, et al. The etiology of missed cervical spine injuries. J Trauma 1993;34:342. Reid DC, Henderson R, Saboe L, et al. Etiology and clinical course of missed spine fractures. J Trauma 1987;27:980.
Is The Lateral Cervical Spine Plain Film Obsolete? Therèse M. Duane, M.D.,1 Tracey Dechert, M.D., Holly Brown, B.S., Luke G. Wolfe, M.S., Ajai K. Malhotra, M.D., Michel B. Aboutanos, M.D., M.P.H., and Rao R. Ivatury, M.D. Division of Trauma, Critical Care, and Emergency General Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia Submitted for publication January 26, 2008
Background. The objective of this study was to determine the utility of a lateral cervical spine plain film in the evaluation of blunt trauma patients. Methods. We prospectively evaluated blunt trauma patients from February 2004 to September 2006 who had both a lateral cervical spine (LCS) film and a computed tomography of the cervical spine (CTC), comparing the diagnostic accuracy of the LCS to the CTC. Results. There were 1004 patients who met inclusion criteria. Eighty-four patients had a cervical spine fracture while 920 patients had no fracture on CTC. Of the 84 patients with fractures by CTC, 68 had a negative or incomplete LCS. Of the 920 negative CTC, there were 7 false positive LCSs. LCS compared with CTC showed a sensitivity of 19% (16/84) and positive predictive value of 69.6% (16/23). Of the 981 negative or incomplete LCS films, 96.9% were incomplete (951/981). Of the seven patients with a false positive LCS (negative CTC), none was subsequently found to have a cervical spine fracture on further evaluation. Elimination of the LCS would result in charge savings of $265,056.00 (LCS charges with interpretation, $264 each) and increase patient safety by eliminating error. Conclusions. LCS has no value as a screening tool in the blunt trauma patient since most are either inaccurate or incomplete. It should be eliminated from the Advanced Trauma Life Support algorithm, and CTC should receive emphasis as the diagnostic gold standard. © 2008 Elsevier Inc. All rights reserved. Key Words: cervical spine fracture; lateral cervical spine radiograph; trauma; outcomes. INTRODUCTION
As technology improves, so does our ability to evaluate the acutely injured trauma patient. Unfortu1
To whom correspondence and reprint requests should be addressed at Department of Surgery, Virginia Commonwealth University Medial Center, 1200 E. Broad Street, West Hospital, 15th Floor, PO Box 980454, Richmond, VA 23298. E-mail: [email protected].
nately, general guidelines often lag behind with continued recommendations that include tools that may be outdated. The lateral cervical spine is one such tool. Advanced Trauma Life Support (ATLS) [1] and the current Eastern Association for the Surgery of Trauma (EAST) guidelines [2] for the evaluation of cervical spine fractures include the lateral cervical spine (LCS) plain radiograph as an initial screening film in the blunt trauma patient. In order for this film to be adequate, the guidelines clearly state that there has to be good visualization from the occiput to the upper part of the first thoracic vertebra. The guidelines suggest that this film, along with the odontoid view and the anteroposterior view when technically adequate and interpreted correctly, have a 0.1% false negative rate. It has been our experience that it is often difficult to obtain an adequate view using LCS secondary to poor technique and the increasing body habitus of the patient population. Hence, we were concerned that this study wasted time and money while adding nothing to the initial evaluation of the trauma patient. This point was emphasized in a previously published paper by the authors [3], which demonstrated the value of the cervical spine CT (CTC) compared with clinical examination. Therefore, we hypothesized that the LCS had no value as an initial screening tool after blunt trauma and determined to test our hypothesis by comparing the LCS with the CTC as the gold standard. MATERIALS AND METHODS We performed a prospective evaluation from February 2004 until September of 2006 of all blunt trauma team alert patients over the age of 16 y admitted to our Level 1 Trauma Center. All adult patients who underwent both a lateral cervical spine film and a cervical spine computed tomography were included in the analysis. The CTC was used as the gold standard for diagnosis of cervical spine fracture. At the time of the study, the standard approach for all trauma activation patients was a thorough clinical examination followed by a lateral cervical spine film. All patients, regardless of level of con-
267
0022-4804/08 $34.00 © 2008 Elsevier Inc. All rights reserved.
268
JOURNAL OF SURGICAL RESEARCH: VOL. 147, NO. 2, JUNE 15, 2008
sciousness or intoxication, then underwent a computed tomography of the cervical spine to evaluate for injury. Further radiographic studies were then performed based on the initial CT scan. Patients with cervical spine fractures were compared with those without fracture. Demographics, mechanism, initial hemodynamics, and laboratory values were included in the comparison. LCS was then compared with CTC to determine its sensitivity, specificity, negative, and positive predictive value. Charges for the radiographic studies were then analyzed to determine potential charge savings. Continuous variables were evaluated using the Wilcoxon rank test and the nominal variables were evaluated using the Fischer’s exact test. This study was approved by the Virginia Commonwealth University Institutional Review Board.
RESULTS
There were 5065 blunt trauma alert patients evaluated at our institution during the time frame of the study. Of those patients, 4608 were over 16 y of age. There were a total of 1004 patients who had both LCS and CTC performed during the initial evaluation of the cervical spine with the results documented prospectively. Eighty-four patients had a cervical spine fracture while 920 had no fracture, based on the final attending radiologist interpretation of the CTC. The two groups had a similar distribution of men (61.9% (52/84) fracture versus 64.3% (592/920) no fracture, P ⫽ 0.72). The majority of both groups were white (62% (52/84) fracture versus 59% (540/920) no fracture, P ⫽ 0.75) and of similar age (41.3 y ⫾ 19.0 fracture versus 41.3 y ⫾ 21.0 no fracture, P ⫽ 0.3). Most trauma patients suffered injuries from a motor vehicle collision (72.6% (61/84) fracture versus 77.4% (712/920) no fracture, P ⫽ 0.44). Table 1 demonstrates the initial hemodynamics of the two groups. The fracture group had significantly higher ISS scores (20.8 ⫾ 14.2 fracture versus 11.6 ⫾ 10.6 no fracture, P ⬍ 0.0001), lactates (3.6 mmol/L ⫾ 2.7 fracture versus 2.8 mmol/L ⫾ 4.7 no fracture, P ⫽ 0.0005), initial blood sugars (143.8 ⫾ 60.1 mg/dL fracture versus 124.0 mg/dL ⫾ 46.6 no fracture, P ⫽ 0.0019) and base deficits (⫺0.2 ⫾ 5.5 fracture versus 2.3 ⫾ 17.4 no fracture, P ⫽ 0.0017). Table 2 illustrates how the LCS compares with the CTC in diagnosis of cervical spine fracture. As shown in the table, the sensitivity was 19% (16/84) with a positive predictive value of 69.6% (16/23). The specificity was 99.2% (913/ 920) and negative predictive value of 93.1% (913/981). TABLE 1 Initial Hemodynamics
Systolic blood pressure (mmHg) Heart rate (beats/min) Respiratory rate (per min) Glasgow Coma Scale
Fracture
No fracture
P-value
138.0 ⫾ 33.4 98.5 ⫾ 18.8 19.2 ⫾ 4.9 12.4 ⫾ 4.6
140.8 ⫾ 24.3 91.5 ⫾ 18.1 19.8 ⫾ 6.8 14.0 ⫾ 3.0
0.70 0.0043 0.57 0.0003
TABLE 2 LCS Compared with CTC
Fracture by CTC No fracture by CTC Total
Incomplete/negative LCS
Positive LCS
Total
68 913 981
16 7 23
84 920 1004
Of the seven patients with a false positive LCS (negative CTC), none was found to have a cervical spine fracture on further evaluation. The LCS has a charge of $264.00, which includes the film and the attending radiologist interpretation. Elimination of the 1004 LCS films performed during the study would result in charge savings of $265,056.00. DISCUSSION
The lateral cervical spine plain film continues to be used at institutions as part of the initial evaluation of the blunt trauma patient. Indeed, it still is included as an adjunctive study in ATLS [1]. However, we believe that its use should be discontinued given the inaccuracy and often inadequacy of the examination. Barba et al. [4], in a study to evaluate CTC, compared it with the standard three-view radiography of anteroposterior, lateral, and odontoid view plain films. In this study, of 324 patients, there were 15 injuries of which 6 were missed by the LCS. Their sensitivity, although higher than the 19% in this trial, was still poor for an injury that has such dire consequences when it goes unrecognized. Other studies confirm that additional plain films do not add to the accuracy of diagnosis. Gale et al. [5] used both AP films and LCS and still only had a sensitivity of 31.6% with evaluation of 848 patients. Griffen et al. [6] reviewed 1199 patients at risk for cervical spine injuries and found a 9.5% fracture rate. Plain films only identified 75 of these injuries, missing 41 fractures. All of the missed injuries required some form of treatment. Moreover, the average GCS in this group was 12, suggesting that these patients would not have been clearable by clinical examination if one is to follow the current EAST guidelines for evaluation in the awake and alert patient. This group of patients is at most risk. They are not good candidates for clinical examination clearance and would have missed injuries if plain films were used alone. Like the Griffen study, many others have combined the LCS and other plain films to increase the diagnostic accuracy with little success. In the NEXUS study, Mower et al. [7], using three view plain films when radiographic evaluation was indicated per their proto-
DUANE ET AL.: LATERAL CERVICAL SPINE PLAIN FILM
col, missed 35 injuries, three of which were potentially unstable. Furthermore, the majority of missed injuries occurred in cases in which the plain radiograph was either abnormal and not diagnostic of injury or inadequate. The extent of inadequacy cannot be overemphasized. In our study, almost 96% of the lateral cervical spine plain films were unable to be evaluated, mostly because they were incomplete. The main reason for incomplete films is an inability to visualize down to the first thoracic vertebra. Since obesity is on the rise in this country, the ability to evaluate the lower cervical spine will be more compromised secondary to greater adiposity in the shoulder and neck region. Many other trials have noted that the majority of these films are inadequate [8 –10]. In a small study by DiGiacomo et al. [11], there were six patients with nine missed injuries thought secondary to error in film interpretation. In hindsight, only two of those were felt to have technically adequate films. When there is high volume turnover and demand for films to be read quickly, such mistakes of accuracy and acceptance of adequacy may rise with increases in missed injury. Although this is a theoretical concern, other options such as CT have been proven more cost effective by being more accurate. Grogan et al. [12] demonstrated the value of using CT instead of plain films. This cost minimization study noted that screening CTs cost less than plain films since fewer injuries were missed, resulting in a lower settlement cost. They found that settlement costs would average over $58,000.00 for an institution while screening plain films would be $2142.00 and CT’s would cost $554.00, even if the fracture rate were only 0.9% with a paralysis rate of 1.7%. Given that up to 29% of patients with a delay in diagnosis of cervical spine injuries go on to develop some form of paralysis [13, 14], immediate diagnosis is paramount. Minimizing missed injury will simultaneously decrease overall cost and should be the goal of all health care professionals caring for the critically injured trauma patient. We believe that removing plain films such as the LCS will accomplish both of these goals. Our study confirms that just the LCS alone carries a significant charge burden when done on a routine basis. Almost a quarter of a million dollars would have been saved during the time frame of this study if the test had been eliminated. Moreover, it never assisted with the diagnosis since all injuries were identified by CT. Because of the mounting literature against plain films, the EAST guidelines [2] are currently being redone. Previously, the standard three-view plain radiographs were recommended with addition of CT when they were inadequate for patients who qualified for radiographic evaluation. This group includes any patient who is not completely awake and alert, without a
269
distracting injury, intoxication, or any evidence of neurological deficits or pain or tenderness over the cervical spine. There is a strong possibility that the new guidelines will include CT as the diagnostic modality of choice in those patients who require radiographic work-up, eliminating plain films altogether during the initial evaluation of these patients, [personal correspondence with Dr. John Como, January 15, 2008, chairperson EAST cervical spine practice management guidelines 2008]. Advances in technology allow for better screening tools with greater diagnostic accuracy. The LCS is no longer a reasonable modality to evaluate these patients. Our data support the elimination of LCS in the initial evaluation of the polytrauma patient with significant mechanism of injury. For those patients who require radiographic evaluation of the cervical spine after significant injury, the CTC should be the diagnostic modality of choice. REFERENCES 1. 2.
3.
4.
5.
6.
7.
8.
9.
10. 11. 12.
13. 14.
American College of Surgeons Committee on Trauma: Advanced Trauma Life Support. ATLS Instructor Manual, 1997. Eastern Association for the Surgery of Trauma (EAST) Guidelines. Determination of Cervical Spine Stability in Trauma. Available at: http.www.east.org. Accessed: December 2007. Duane TM, Dechert TA, Wolfe LG, et al. Clinical examination and its reliability in identifying cervical spine fractures. J Trauma 2007;62:1404. Barba CA, Taggert J, Morgan AS, et al. A new cervical spine clearance protocol using computed tomography. J Trauma 2001;51:652. Gale SC, Gracias VH, Reilly PM, et al. The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J Trauma 2005;59:1121. Griffen MM, Frykberg ER, Kerwin AJ, et al. Radiographic clearance of blunt cervical spine injury: Plain radiograph or computed tomography scan? J Trauma 2003;55:222. Mower WR, Hoffman JR, Pollack CV, et al. Use of plain radiography to screen for cervical spine injuries. Ann Em Med 2001;38:1. McCulloch PT, France J, Jones DL, et al. Helical computed tomography alone compared with plain radiographs with adjunct computed tomography to evaluate the cervical spine after high-energy trauma. J Bone Joint Surg Am 2005;87:2388. Borock EC, Gabram SG, Jacobs LM, et al. A prospective analysis of a two-year experience using computed tomography as an adjunct for cervical spine clearance. J Trauma 1991;31:1001. Besman A, Kaban J, Jacobs L, et al. False-negative plain cervical spine x-rays in blunt trauma. Am Surg 2003;69:1010. DiGiacomo JC, Frankel HL, Rotondo MF. Clearing the cervical spine in victims of blunt trauma. Mil Med 2002;167:398. Grogan EL, Morris JA, Dittus RS, et al. Cervical spine evaluation in urban trauma centers: Lowering institutional costs and complications through helical CT scan. J Am Coll Surg 2005; 200:160. Davis JW, Phreaner DL, Hoyt DB, et al. The etiology of missed cervical spine injuries. J Trauma 1993;34:342. Reid DC, Henderson R, Saboe L, et al. Etiology and clinical course of missed spine fractures. J Trauma 1987;27:980.