Cervical spine radiography in alert asymptomatic blunt trauma patients
Date First Published:
October 10, 2001
Last Updated:
October 12, 2004
Report by:
Damian Bates, Specialist Registrar in Emergency Medicine (Stepping Hill Hospital, Stockport)
Search checked by:
John Butler, Stepping Hill Hospital, Stockport
Three-Part Question:
In [alert asymptomatic blunt trauma patients] is [cervical spine radiography] necessary to [exclude bony injury to the cervical spine]?
Clinical Scenario:
A 46 year old man is brought to hospital after a road traffic accident, involving a rear end shunt, to "get checked out". He is fully alert and co-operative. You are aware that many people advise x-rays in all patients to exclude cervical spine injury. You wonder whether it is really necessary.
Search Strategy:
Medline 1996-10/04 using OVID interface.
Search Details:
[exp cervical vertebrae OR exp spinal cord injuries OR exp spinal fractures OR exp spinal injuries OR cervical spine injury.mp] AND [exp x-rays OR x-rays.mp OR exp radiography OR radiograph$.mp OR cervical radiograph$.mp] AND [exp prospective studies OR prospective studies.mp] LIMIT to human AND English.
Outcome:
240 papers were identified of which 8 were relevant.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Selective application of cervical spine radiography in alert victims of blunt trauma: a prospective study. Roberge RJ, Wears RC, Kelly M et al. 1988, USA | 467 blunt trauma patients undergoing c-spine x-ray |
Prospective | Cervical spine injury | In alert patients cervical spine pain. Sensitivity 100% (54-100). Cervical spine tenderness, sensitivity 100% (54-100) | |
| Evaluation of neck discomfort, neck tenderness and neurological deficits as indicators for radiography in blunt trauma victims. Roberge RJ and Wears RC. 1992, USA | 480 blunt trauma patients undergoing c-spine x-ray |
Prospective | Cervical spine injury | Clinical examination in alert patients, sensitivity 93% (75-100). Negative predictive value 98.7% (94.9-100) | Not all patients included Total number of blunt trauma victims not known No search for misses |
| Low risk criteria for cervical spine radiography in blunt trauma. Hoffman JR, Schriger DL, Mower W et al. 1992, USA | 974 blunt trauma patients who had x-ray performed and data sheet filled in |
Prospective | Cervical spine fracture | Alert patient with no intoxication, midline neck tenderness or distracting injury, sensitivity = 100% | Not all patients included in the study No search for misses |
| Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: much ado about nothing. Velhamos GC, Theodorou D, Tatevossian R et al. 1996, USA | 549 blunt trauma patients Alert, not intoxicated and no neck pain Brought to hospital in hard collar |
Prospective | Cervical spine injury or fracture | All patients had normal c-spine examination. No c-spine fractures or cord injuries found | |
| Role of clinical examination in screening for blunt cervical spine injury. Gonzalez RP, Fried PO, Bukhalo M et al. 1999, USA | 2176 consecutive blunt trauma patients GCs 14 or 15 |
Prospective | Cervical spine injury | Clinical examination 91% sensitivity for CSI; Lateral c-spine screen (xr, swimmers CT) 61% sensitivity for CSI | Includes intoxicated patients No power calculation No search for misses |
| Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilisation Study Group. Hoffman JR, Mower WR, Wolfson AB et al. 2000, USA | 34,069 patients having cervical spine x-ray after blunt trauma 21 Centres |
Prospective | Clinically significant cervical spine injury | Decision instrument (alert with no evidence of intoxication, no midline cervical tenderness and no neurological deficit or distracting injury). Sensitivity of 99.6% (98.6-100) for significant injury, negative predictive value 99.9% (98.8-100) | |
| The Canadian c-spine rule versus the NEXUS low-risk criteria in patients with trauma. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH et al. Dec-03 Canada | Alert trauma patients attending 9 Canadian emergency departments. | Prospective Diagnostic Cohort Study | Incidence of clinically important cervical spine injuries | 160 out of 8283 patients (2.0%) had clinically important injury | 845 patients (10.2%) did not have range of motion evaluation. |
| Radiography rates | Sensitivity results: Canadian rules 99.4% versus NEXUS rules 90.7% (p<0.001) | ||||
| Important injuries missed | Specificity: Canadian rules 90.7% versus NEXUS 36.8% (p<0.001) | ||||
| Canadian rules - 55.9% versus NEXUS 66.6% (p<0.001). | |||||
| Canadian rules- 1 patient, NEXUS rules - 16 patients. | |||||
| The Canadian c-spine rule performs better than unstructured physician judgement. Bandiera G, Stiell IG, Wells GA, De Maio V, Vandemheen KL et al. 2003 Canada | Alert, stable, adult patients with a GCS of 15 and trauma to the head and neck. | Prospective multi-centre cohort study. | Clinically important spinal injuries | 64 out of 6265 patients (1%) | Not all patients had cervical spine radiography. |
| Area under ROC curve for predicting cervical spine injury | Physician judgement - 0.85 (95% CI 0.80 to .089), Canadian rules 0.91 (95% CI 0.89 to 0.92) (p<0.05). | ||||
| Sensitivity | Physician judgement 92.2% versus Canadian rules 100% (p<0.001) | ||||
| Specificity | Physician judgement 53.9% versus Canadian rules 44.0% (p<0.001) |
Author Commentary:
Several prospective studies have been done on this topic, and all reached roughly the same conclusion. However, in this potentially disastrous situation all authors are keen to suggest that any clinical decision strategy can never be 100% sensitive and should be used on an individual patient basis rather than as an unbendable rule.
Bottom Line:
The studies show that Canadian c-spine rules appear to be more sensitive and specific than the NEXUS criteria for clinical clearnance of the cervical spine. Patients who satisfy the Canadian c-spine rules for clinical clearance of the neck do not need to have cervical spine radiography.
Level of Evidence:
Level 2: Studies considered were neither 1 or 3
References:
- Roberge RJ, Wears RC, Kelly M et al.. Selective application of cervical spine radiography in alert victims of blunt trauma: a prospective study.
- Roberge RJ and Wears RC.. Evaluation of neck discomfort, neck tenderness and neurological deficits as indicators for radiography in blunt trauma victims.
- Hoffman JR, Schriger DL, Mower W et al.. Low risk criteria for cervical spine radiography in blunt trauma.
- Velhamos GC, Theodorou D, Tatevossian R et al.. Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: much ado about nothing.
- Gonzalez RP, Fried PO, Bukhalo M et al.. Role of clinical examination in screening for blunt cervical spine injury.
- Hoffman JR, Mower WR, Wolfson AB et al.. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilisation Study Group.
- Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH et al.. The Canadian c-spine rule versus the NEXUS low-risk criteria in patients with trauma.
- Bandiera G, Stiell IG, Wells GA, De Maio V, Vandemheen KL et al.. The Canadian c-spine rule performs better than unstructured physician judgement.