tag:blogger.com,1999:blog-2760353953251845523.post244498132796944456..comments2024-02-10T02:14:39.898-05:00Comments on Buckeye Surgeon: Traumatic Cervical Spine Injury: Is CT now the preferred imaging modality?Jeffrey Parks MD FACShttp://www.blogger.com/profile/15650563299849196122noreply@blogger.comBlogger9125tag:blogger.com,1999:blog-2760353953251845523.post-27041556143157619552009-06-23T11:23:50.896-04:002009-06-23T11:23:50.896-04:00If someone is getting a CT anyway, I scan the c-sp...If someone is getting a CT anyway, I scan the c-spine.<br /><br />A distinct, and large, population exists in which plain radiographs of the c-spine can be used to exclude significant injury. And to, perhaps more importantly, re-assure the patient and provider.DKVhttps://www.blogger.com/profile/15449584867334837982noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-54049538863198908972009-06-21T09:55:04.929-04:002009-06-21T09:55:04.929-04:00I used to do an average of 3 DPLs every night I wa...I used to do an average of 3 DPLs every night I was on call (that was during the days when we did every other night call). We did this for everyone that required a Brain CT (for LOC or AMS) or a Chest CT (for widened mediastinum). One rational (albeit not the only) was that scanning more that one body system was time consuming and the scanner would get too hot (this was before we had the nice helical CT). So every night, I could look forward to the occasional bent cath, or the cath that ended up in the properitoneal space, or the more common problem with not getting the fluid back. Not to mention the rare incidence of creating a bowel injury (I was lucky to not have this happen to me). Additionally there is a significant amount of non-information from this test.<br /><br />So I will quickly and avidly pronounce that I do not miss it for a second. More time than not it was a huge pain in the buttocks. Thank the good Lord for Helical CT and FAST.<br /> <br />Now ... that being said. I actually still use DPL occasionally. It is useful for the rare patient in general surgery with an unknown source of infection, that has free fluid on CT and you need to know if it is bad fluid or just physiologic. Performing a DPL in these cases is a minimally invasive way to get that information.<br /><br />JoeJoseph Sucher, MD FACShttps://www.blogger.com/profile/09187702675709935451noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-51691414608652570682009-06-20T11:49:51.054-04:002009-06-20T11:49:51.054-04:00This is not a CER failure. This is a problem with ...This is not a CER failure. This is a problem with the failure to "get the word out" and change practice. It is also an example of the well known phenomena of real-life catching up with the multitudes of data. Notice the references that start in 1999. It is known that it takes as much as 15 years for practice patterns to change despite the evidence in the literature. Honestly, I think that until there is unfettered access to literature we will continue to see this. Read below for proof.<br /><br />I am fortunate to have trained in one of the busiest blunt trauma centers in the world with the famous John "Jack" Harris, Jr. who's incredible ability to read shades of gray on film still astounds me today. Here is a paraphrasing of his comments in the journal of trauma Volume 53(2), August 2002, pp 392-393.<br />_______________________________<br />CLINICAL<br />* Be mindful that a “negative” conventional radiographic examination in the presence of an abnormal clinical evaluation of the cervical spine requires<br />either computed tomography (CT) or magnetic resonance imaging (MRI).<br /><br />RADIOLOGIC<br />CT provides a more complete<br />and accurate assessment of the posterior vertebral elements.<br /><br />The swimmer’s view, always inherently limited by superimposed ribs and clavicles, should be replaced by CT as the definitive imaging examination of<br />the cervicothoracic junction.<br /><br />Flexion-extension views should never be used to determine stability or instability of a cervical spine injury. <br /><br /><br />Even though the incidence of cervical spine injury is less than 6% in multiply injured patients, 1 in those patients in whom the cervical spinal cord<br />cannot be adequately clinically assessed, an anteroposterior and lateral radiograph of the cervical spine, the latter of which must include from the cervicocranium through the cervicothoracic junction, should be part of the initial patient assessment. These radiographs can be obtained in the patient assessment area with portable equipment. The necessity for cervical spine imaging at this stage of patient evaluation is to preclude causing or aggravating cervical cord injury caused by an unrecognized cervical spine injury during the secondary patient assessment.<br /><br />In unconscious or multiply injured<br />patients, the primary attending physician must not accept a lateral radiograph in which the lower cervical vertebrae and the cervicothoracic junction are<br />obliterated by the density of the shoulders. Such patients require immediate CT of the cervical spine, and it is the responsibility of the primary attending physician to order that CT examination. <br />___________________________________<br /><br />This practice was established at the University of Texas - Houston on or about 1999 when helical CT became available to us in the evaluation of patients with severe blunt Trauma.<br /><br />I thank you for your post.<br /><br />JoeJoseph Sucher, MD FACShttps://www.blogger.com/profile/09187702675709935451noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-74017058088090479262009-06-20T09:05:34.329-04:002009-06-20T09:05:34.329-04:00America's gone downhill ever since DPL's w...America's gone downhill ever since DPL's went out of style...<br /><br /> I know, "Whats a DPL??" last time I did one was 1997, and that was on a dog... but you know how hard it is to keep Fido still in the CT scanner...<br />Anyway... I'm heavily levereged in Imaging stocks so scan to your heart's content...<br /><br />FrankAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-31777940255319388322009-06-19T23:47:54.698-04:002009-06-19T23:47:54.698-04:00in other breaking news, MR is better than standard...in other breaking news, MR is better than standard myleogram at detecting clinically significant disc herniations!<br /><br />later, <br />radincradincnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-88649617890170309362009-06-19T22:06:12.645-04:002009-06-19T22:06:12.645-04:00CT has been the recommended imaging modality for e...CT has been the recommended imaging modality for eval of C-spine in trauma for some time according to the EAST guidelines. It is what I use when imaging is indicated.Victor Lazaronhttps://www.blogger.com/profile/11634100793910465958noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-34265347034172169922009-06-19T21:09:26.935-04:002009-06-19T21:09:26.935-04:00Arrgghhh... I'm not a doctor, nor an economic ...Arrgghhh... I'm not a doctor, nor an economic analyst, but it seems to me that a big point is being missed: CT scans show a 100% reliabilty in distinguishing "clinically signficant" c-spine injuries. C-spine injuries can change one's life drastically -- is it reasonable to take the chance of misdiagnosing and perhaps making the injury worse by treating for something else? <br /><br />OK, I'm a quasi-anonymous idealist, but the thought of using a second-level diagnostic for an injury like this horrifies me.Unknownhttps://www.blogger.com/profile/15106683810545049065noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-92107320884270131272009-06-19T18:04:32.923-04:002009-06-19T18:04:32.923-04:00Good point Buckeye. However, part of the point of ...Good point Buckeye. However, part of the point of the CER is to force us to actually parse out what works. You are describing a case where a study was already taking place comparing the imaging modalities in question. Not to mention the difference in cost between a 200 dollar xray and a 1000 dollar ct is pittance. <br /><br />Now compare that to lumbar discectomy/ fusions/ x-stop and the ten other commonly done back surgeries. There is a paucity of indication data and CER. Only the crusaders e.g. dartmouth (SPORT trial) are even interested.<br /><br />Where is the fun in proving that ortho/neurosurgery bread and butter isnt helping? <br /><br />And who the hell is going to fund a study that hits everyone in the wallet? Nobody, until we put the almighty wrath of CER behind it.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-24222710422721455812009-06-19T09:58:15.032-04:002009-06-19T09:58:15.032-04:00I dont know, sounds expensive to me... What do the...I dont know, sounds expensive to me... What do they do in England???Anonymousnoreply@blogger.com