Trauma Report1
An Evidenced-Based Approach to Radiographic Assessment of Cervical Spine Injuries in the Emergency Department

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Abstract

The modern approach to suspected cervical spine injuries is highly dependent on appropriate utilization of radiographic studies. Clinical decision rules have been developed for determination of those most likely to benefit from plain film studies, but there is confusion regarding those who should undergo computed tomography (CT) scanning. This case-based review highlights current available evidence and provides a framework to guide emergency medicine providers in the treatment of patients with trauma to the cervical spine.

Section snippets

Case Report

A 29-year-old man was brought in by Emergency Medical Services (EMS) after a head-on motor vehicle collision (MVC) that occurred earlier in the day. The patient was an unrestrained front-seat passenger, and the vehicle's airbag deployed. The patient initially refused EMS transport, but called 911 4 h later, after he began experiencing neck pain. He denied head injury or loss of consciousness and had no other complaints.

On arrival in the Emergency Department (ED), cervical spine immobilization

Discussion

One of the most challenging and controversial issues facing emergency physicians (EPs) and traumatologists is the accurate and timely evaluation of the cervical spine in blunt trauma patients. There are an estimated 11,000 new cases of spinal cord injury diagnosed annually, and the incidence of cervical spine injury with general blunt trauma has been reported to range from 2% to 6% (1, 2). This incidence increases to 8% when cranial trauma is present, and may be as high as 34% when the patient

Further ED Management

Completion of a five-view cervical spine X-ray series was performed without evidence of fracture or suspected injury. The patient, however, continued to have significant cervical spine tenderness, so a computed tomography (CT) scan of the cervical spine from the skull base to T1 was obtained. The CT scan was remarkable for a fracture of the C6 vertebra involving the right posterior elements and lower right facet. The fracture extended anteriorly across the lamina and right pedicle of C6, just

Discussion

The optimal approach to cervical spine imaging for those with blunt trauma is currently an area of ongoing debate. Most practitioners agree that, of those patients who are determined to need radiological imaging, the minimum acceptable standard of care is a three-view cervical spine series, consisting of AP, odontoid, and lateral views (with swimmer's view if necessary to visualize the C7/T1 junction). This is based, at least in part, on the findings of Woodring and Lee, who, nearly a decade

Author's Recommendations

Two levels of decision-making exist when determining the approach to management of patients with cervical spine trauma: who needs radiographs and which modality should be selected. Clinical decision rules such as the NEXUS LRC and CCR have been developed and validated for the first level, and their use has achieved increased prominence in this era of evidenced-based medicine. Both are highly sensitive tools that can help to minimize unnecessary resource utilization, but distinction between them

Conclusions

Ultimately, our patient was treated non-operatively with external immobilization using a Miami J-collar. By hospital day 2, he was doing well and did not exhibit any evidence of neurological sequelae. Upon discharge, Neurosurgery recommended that the patient continue to wear the collar for 12 weeks. At a 6-week follow-up appointment, his fracture was healing without any evidence of complications.

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    Trauma Reports of the Emergency Medicine Residency Program, Wayne State University School of Medicine, Detroit Receiving Hospital.

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