Diagnosing Cervical Spine Injury in Severe Head Injury: A Case for Replacing Plain Radiography With Computed Tomographic Scan of the Cervical Spine

Abstract

Introduction The diagnosis and management of cervical spine injuries in head-injured patients is problematic due to an altered level of consciousness and the overall critical nature of their injuries. It is a routine practice in most of the hospitals to get plain radiography for detection of bony spinal injuries which can miss some cases of fractures and fracture dislocations. It is imperative not to miss a cervical spine injury in patients with severe head injury. The aim of our study was to find which modality offers the greatest accuracy as the initial diagnostic test among patients suspected of having sustained a cervical spine surgery following severe head injury: plain radiography or computed tomography (CT) of cervical spine.

Patients and Methods This is a prospective study conducted on patients with severe head injury. In this study, 50 patients with severe head injuries were investigated by both plain X-rays and CT scan of the cervical spine. In these patients, the level and type of cervical spine injury were compared between plain X-ray and CT scan.

Results Plain X-rays detected cervical spine injury in 20%, while CT scan demonstrated spinal injury in 26% of the patients. Four patients of cervical spine fracture missed by plain radiography were diagnosed by CT cervical spine. In one patient in whom plain radiography showed fracture-dislocation at C5—C6 level was found to have degenerative changes at that level. C6—C7 was the most common site of fracture-dislocation (40.0%) followed by C5—C6 (20.0%), C4—C5 (20.0%), and C3—C4 (10.0%). C2 is the most common site of fracture diagnosed by CT scan which was missed by plain radiograph.

Conclusion It was concluded that it would be prudent to replace the practice of routine plain radiography with routine use of CT scans for detection of spinal bony injuries.

Keywords

severe head injury - cervical spine injury - CT scan

• References

• 1 Grossman MD, Reilly PM, Gillett T , et al. National survey of the incidence of cervical spine injury and approaches to cervical spine clearance in U.S. trauma centres. J Trauma 1999; 47: 684-690
• 2 Mower WR, Hoffman JR, Pollack CV , et al. Use of plain radiography to screen for cervical spine injuries. Ann Emerg Med 2001; 38: 1-7
• 3 Berne JD, Velmahos GC, Tawil QE , et al. Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study. J Trauma 1999; 47: 896-902
• 4 Daffner RH, Sciulli RL, Rodriguez A , et al. Evaluation of suspected cervical spine trauma: a 2-year analysis. Injury 2006; 37: 652-658
• 5 Diaz JJ, Gillman C, Morris JA , et al. Are five-view plain films of the cervical spine unreliable? A prospective evaluation in blunt trauma patients with altered mental status. J Trauma 2003; 55: 658-664
• 6 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: 222-226
• 7 Mathen R, Inaba K, Munera F , et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J Trauma 2007; 62: 1427-1431
• 8 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: 2388-2394
• 9 Nguyen GK, Clark R. Adequacy of plain radiography in the diagnosis of cervical spine injuries. Emerg Radiol 2005; 11: 158-161
• 10 Nuñez DB, Zuluaga A, Fuentes-Bernardo DA , et al. How much do we learn by routinely using helical CT?. Radiographics 1996; 16: 1307-1318
• 11 Sharma OP, Oswanski MF, Yazdi JS , et al. Assessment for additional spinal trauma in patients with cervical spine injury. Am Surg 2007; 73: 70-74
• 12 Widder S, Doig C, Burrowes P , et al. Prospective evaluation of computed tomographic scanning for the spinal clearance of obtunded trauma patients: preliminary results. J Trauma 2004; 56: 1179-1184
• 13 Hills MM, Deanne SA. Head injury and facial injury: is there an increased risk of cervical spine injury?. J Trauma 1993; 34: 549-554
• 14 Williams J, Jehle D, Cottington E , et al. Head, facial and clavicular trauma as a predictor of cervical spine injury. Ann Emerg Med 1992; 21: 719-722
• 15 Holly LT, Kelly DF, Counelis GJ , et al. Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics. J Neurosurg 2002; 96: 285-291
• 16 Morris CG, McCoy E. Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening. Anaesthesia 2004; 59: 464-482
• 17 Woodring JH, Lee C. Limitations of cervical radiography in the evaluation of acute cervical trauma. J Trauma 1993; 34: 32-39
• 18 Davis JW, Phreaner DL, Hoyt DB , et al. The etiology of missed cervical spine injuries. J Trauma 1993; 34: 342-346
• 19 Gerrelts BD, Petersen EU, Mabry J , et al. Delayed diagnosis of cervical spine injuries. J Trauma 1991; 31: 1622-1626
• 20 Reid DC, Henderson R, Saboe L , et al. Etiology and clinical course of missed spine fractures. J Trauma 1987; 27: 980-986
• 21 West OC, Anbari MM, Pilgram TK , et al. Acute cervical spine trauma: diagnostic performance of single view versus three-view radiographic screening. Radiology 1997; 204: 819-823
• 22 Ross SE, Schwab CW, David El , et al. Clearing the cervical spine: initial radiologic evaluation. J Trauma 1987; 27: 1055-1060
• 23 Blacksin MF, Lee HJ. Frequency and significance of fractures of the upper cervical spine detected by CT in patients with severe neck trauma. Am J Roentgenol 1995; l65: 1201-1204
• 24 Link TM, Schuierer G, Horch C , et al. Substantial head trauma: value of routine CT examination of the cervicocranium. Radiology 1995; 196: 741-745
• 25 Ball C, Watson DA. 12 month clinical audit of cervical spine imaging in multiply injured and intubated patients. Br J Radiol 2010; 83: 257-260
• 26 Acheson MB, Livingston RR, Richardson ML , et al. High-resolution CT scanning in the evaluation of cervical spine fractures: comparison with plain film examinations. Am J Roentgenol 1987; 148: 1179-1185
• 27 Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma 2005; 58: 902-905