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Published on: July 24, 2012
Traumatic cervical spine injuries: characteristics of missed injuries
Ankur R Rana1, Robert Drongowski, Gretchen Breckner
1Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, Ann Arbor, 48109, USA.
Insights
Computed tomography (CT) scans are superior to X-rays for diagnosing cervical spine injuries (CSIs) in pediatric trauma patients, offering higher accuracy and fewer missed injuries. Flexion/extension views are not necessary after CT evaluation.
Area of Science:
- Trauma imaging
- Pediatric orthopedics
- Radiology
Background:
- Computed tomography (CT) scans are increasingly used for imaging, but concerns about radiation, missed injuries, and effectiveness in intubated patients persist.
- Traditional X-rays may miss critical cervical spine injuries (CSIs).
Purpose of the Study:
- To characterize missed cervical spine injuries (CSIs) in pediatric trauma patients.
- To compare the diagnostic accuracy of CT scans versus X-rays for CSIs.
Main Methods:
- Retrospective analysis of 1307 pediatric trauma patients (2004-2006) with 318 imaged for potential CSIs.
- Comparison of imaging modalities: CT scan alone, X-ray alone, or both.
- Review of patient demographics, Injury Severity Score (ISS), mechanism, time to clearance, and missed injuries.
- Analysis of flexion/extension views in intubated patients.
Main Results:
- CT scans demonstrated a sensitivity of 1.0 and specificity of 0.976 for CSIs, with no false negatives.
- X-rays had a sensitivity of 61.5% and specificity of 1.6%, with 5 false negatives (missed injuries).
- All injuries missed by X-ray were identified by CT scan; flexion/extension views did not reveal additional injuries.
Conclusions:
- CT scans should be the primary imaging modality for diagnosing CSIs in pediatric trauma.
- Flexion/extension views do not enhance C-spine clearance decisions when CT has already been performed.
Purpose:
Computed tomographic (CT) scanning has mostly replaced x-rays as an imaging modality, but concerns exist because of excess radiation, missed injuries, and whether it is the definitive procedure for intubated patients. The purpose of this study was to characterize missed cervical spine injuries (CSIs).
Methods:
All pediatric (<18) trauma patients from 2004 to 2006 were analyzed. Age, sex, Injury Severity Score (ISS), mechanism, time, and missed injuries were reviewed. Flexion/extension views were used in patients with prolonged intubation. Descriptive statistics, chi(2), Student's t test, and bivariate correlation were used.
Results:
There were 1307 pediatric trauma patients admitted with 318 imaged for potential CSI. Computed tomography was the sole imaging study in 200, x-rays in 64, and both in 54. Time to C-spine clearance was similar for all modalities (P > .05). For CT, 34 (10.7%) were initially positive for CSI with 7 false-positives (FPs) and no false-negative (FN). There were 18 patients with CSI identified by x-ray, with 5 FPs and 5 FNs (missed injuries). The 5 FNs missed by x-ray were all positive by CT scan and required no intervention. None of the flexion/extension views revealed an additional injury. Sex, intubated patients, ISS, age, type, and injury location were not predictive of a missed injury (P > .05).The sensitivity of CT scan was 1.0, specificity was 0.976, and the positive predictive value was 79.4%. The sensitivity of plain x-ray was 61.5%, the specificity was 1.6%, and the positive predictive value was 61.5%.
Conclusions:
Our data suggest that CT scans should be the primary modality to image a CSI. Flexion/extension views did not add to the decision making for C-spine clearance after CT evaluation.
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