Thursday, June 18, 2009
Traumatic Cervical Spine Injury: Is CT now the preferred imaging modality?
Leafing through this month's Journal of Trauma, I noticed an article written by the good people at my old stomping ground, Cook County Hospital in Chicago (I refuse to call it Stroger Hospital), that prospectively compares the diagnostic efficacy of CT scan of the cervical spine with the standard of three plain radiographic views of the c-spine. I remember they had just started accumulating the data when I was a chief resident. Over 1500 patients were accrued. Radiographic evidence of cervical spine injury was detected in 78 of the patients, with 50 having clinically significant injuries.
Here's where it gets good. CT scan of the cervical spine detected all 50 injuries (100% sensitivity) while the plain films only identified 18/50. Even in patients with clinically significant injuries, the plain films only had a sensitivity of 46%. The paper concludes by advocating that CT of the cervical spine replace plain c-spine radiographs as the preferred initial test to exclude blunt cervical injury.
This is a classic case of where the data has finally caught up to what actually happens in real life. (Got that, you CER disciples? Science isn't as accomodating or as quick as we would like. The proof of what is already apparent in clinical practice can lag years behind.) I cover trauma at a level II center and I'll be honest; I don't spend a lot of time looking at plain films of the neck. They're always sort of suboptimal and don't consistently show all the vertebrae you need and if there's a question, you're just going to get a CT cervical spine anyway. So I go straight to the CT films. Thanks to the County trauma team, we can now all feel better about doing what has, for years, seemed obvious and intuitive.