Is CT better than X-ray at diagnosing fractures of the thoracolumbar spine?
Date First Published:
June 18, 2007
Last Updated:
July 5, 2007
Report by:
Mark Gilhooly, Medical Student (MRI)
Three-Part Question:
In [adults presenting to the emergency department following spinal trauma] is [CT better than plain film X-ray] at [diagnosing thoracolumbar fracture]
Clinical Scenario:
A 45 year old male patient falls 12 ft from a ladder onto his back. He presents to the emergency department complaining of lower back pain. You wonder if CT is better than plain X-ray at diagnosing thoracolumbar fracture
Search Strategy:
Cochrane Database of Systematic Reviews 2nd Quarter 2007. Medline 1950 to June week 2 using the Ovid interface. EMBASE 1996 to 2007 week 25.
Search Details:
({exp spinal fractures OR spinal trauma mp. OR exp thoracic vertebrae OR exp lumbar vertebrae} AND {exp tomography OR CT mp.} AND {exp X-rays OR X-ray$ mp. OR exp radiography OR lumbar adj radiograph$ mp. OR thoracolumbar adj radiograph$} AND {exp diagnosis}) LIMIT to english language. LIMIT to humans. LIMIT to all adult (19 years plus). LIMIT to "diagnosis (sensitivity)".
Outcome:
1305 papers were found of which 7 were relevant to the clinical question
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Are plain radiographs of the spine necessary during evaluation after blunt trauma? Accuracy of screening torso computed tomography in thoracic/lumbar spine fracture diagnosis Berry GE, et al 2005 USA | 103 patients admitted to a level 1 trauma centre over a 2-month period who underwent CAP CT (chest-abdomen-pelvis) and plain film evaluation of the thoracolumbar spine | Retrospective case series | CT sensitivity and specificity for thoracolumbar fracture | 100 % sensitive, 97 % specific | Only 26 of original 103 patients had TL fracture |
| Plain radiograph sensitivity and specificity for thoracolumbar fracture | 73 % sensitve, 100 % specific | ||||
| Negative predictive value for CT and Plain radiograph | 100 % and 92 % respectively | ||||
| Area under the ROC curve for CT and Plain radiograph | 0.98 and 0.86 (P < 0.02) respectively | ||||
| Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care? Antevil JL, et al 2006 USA | 573 patients evaluated for spinal trauma during two, three-month intervals. X-ray group (1999) 254 patients CT group (2002) 319 patients |
Retrospective case series | Sensitivity in detecting spinal fracture | 70 % specific (14 out of 20) | Only a small proportion of the intial number of patients had spinal fracture |
| Sensitivity of CT in detecting spinal fracture | 100 % specific (34 out of 34) | ||||
| Lumbar fractures in adult blunt trauma: Axial and single-slice helical abdominal and pelvic computed tomographic scans versus portable plain films Rhee PM 2002 USA | 115 patients identified over a period of 6 years wtih diagnosed lumbar fracture 56 patients had AP-CT scans 110 pateints underwent two-view plain films (52 patients had both screening tests) |
Retrospective study | Overall performance of screening methodology using AP-CT and two-view plain films | 13/56 fractures were missed with AP-CT alone (missed fracture rate of 23.2 %), 14/110 fractures were missed by two-view plain films (missed fracture rate of 12.7 %, P = 0.08), a combination of both imaging modalities did not miss any fractures. The fractures that were missed by AP-CT and two-view plain film were not minor fractures, 46 % and 50 % respictively required surgery or brace | |
| Reformatted visceral protocol helical computed tomographic scanning allows conventional radiographs of the thoracic and lumbar spine to be eliminated in the evaluation of blunt trauma patients Sheridan R 2003 USA | 78 trauma patients admitted over a period of 12 months in a level 1 trauma centre with one or more thoracic or lumbar spine fractures Thoracic fractures n = 35 Lumbar fractures n = 43 |
Retrospective case series | Diagnosis of thoracic spine fracture | Sensitivity of reformatted RHCT scanning was 97 %, sensitivity of conventional radiograph in diagnosis was 62 %. | small sample group |
| Diagnosis of lumbar spine fracture | Sensitivity of RHCT scanning in diagnosis of lumbar spine fractures was 95 %, sensitivity of conventional radiograph in diagnosis of lumbar spine fracture was 86 %. | ||||
| Visceral torso computed tomography for clearence of the thoracolumbar spine in trauma: A review of the literature Inaba K 2006 USA | All published studies comparing reformatted CT to traditional plain radiography for thoracolumbar spine clearance | Review article | Evaluation of sensitivity and specificity of reformatted CT and traditional plain radiography | Review articles highlighted superior sensitivity and interobserver variability for reformatted CT compared with plain radiographic screening. CT was also noted to be more accurate at localising , classifying, and delineating the age, bony intrusion, and soft-tissue damage associated with the fracture. | |
| Thoracolumbar spine fractures in patients who have sustained severe trauma: Depiction with multi-detector row CT Wintermark M, et al 2003 Switzerland | 26 patients with fractured vertebrae prospectively identified from 100 consecutive severe trauma patients | Comparitive study | Overall sensitivity of multi-detector row CT | 78.1 % sensitive (97.2 % for unstable fractures) | Multi-detector row CT images were reviewed by the same three radiologists |
| Overall intra-observer agreement for multi-detector row CT | kappa value = 0.787 (0.951 for unstable fractures) | ||||
| Overall sensitivity for conventional radiography | 32 % sensitive (33.3 % for unstable fractures) | ||||
| Overall intraobserver agreement for conventional radiography | kappa value = 0.661 (0.368 for unstable fractures) | ||||
| Evaluation of the lower spine after blunt trauma using abdominal computed tomographic scanning supplemented with lateral scanograms Gestring ML, et al 2002 USA | 71 patients who sustained blunt injury and required computed lumbar spine radiographs (CLSRs) as well as abdominal and pelvic CT scans were propectively identified. 10 patients were found to have thoracolumbar fracture | Case series | Sensitivity and specificity of CT and scanograms | 100 % sensitive and 100 % specific | Only 10 patients from the original study group of 71 were found to have thoracolumbar fracture |
Author Commentary:
Several papers were found relavant to the clinical question. Results highlight that CT was both more specific and more sensitive than plain film x-ray and also gave a higher intra-observer agreement value, therefore indicating that results from CT are more reproducible. Several papers also highlighted cost, radiation exposure and waiting time as important factors when considering the overall benefit of each imaging modality. Although plain film x-ray offers a reduce radiation level, repeat films make exposure levels comparable with CT. Time and cost also demonstrated results which favoured CT.
Bottom Line:
CT scanning is a more sensitive and specific imaging technique than the gold standard of plain film X-ray in the diagnosis of thoracolumbar fracture.
References:
- Berry GE, et al. Are plain radiographs of the spine necessary during evaluation after blunt trauma? Accuracy of screening torso computed tomography in thoracic/lumbar spine fracture diagnosis
- Antevil JL, et al. Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care?
- Rhee PM. Lumbar fractures in adult blunt trauma: Axial and single-slice helical abdominal and pelvic computed tomographic scans versus portable plain films
- Sheridan R. Reformatted visceral protocol helical computed tomographic scanning allows conventional radiographs of the thoracic and lumbar spine to be eliminated in the evaluation of blunt trauma patients
- Inaba K. Visceral torso computed tomography for clearence of the thoracolumbar spine in trauma: A review of the literature
- Wintermark M, et al. Thoracolumbar spine fractures in patients who have sustained severe trauma: Depiction with multi-detector row CT
- Gestring ML, et al. Evaluation of the lower spine after blunt trauma using abdominal computed tomographic scanning supplemented with lateral scanograms