Accuracy of standard radiographic views in detecting cervical spine fractures

doi:10.1016/S0196-0644(83)80293-5

Annals of Emergency Medicine

Volume 12, Issue 9, September 1983, Pages 538-542

https://doi.org/10.1016/S0196-0644(83)80293-5 Get rights and content

Recent studies have challenged the accuracy of standard radiographs for detecting cervical spine injuries. We used thin-section tomography to determine the accuracy of the cross-table lateral view (CTLV) alone, and the three standard emergency department views (CTLV, anteroposterior, and open-mouth) together, for detecting acute cervical spine fractures. Seventy-one patients with blunt cervical spine injuries had thin-section tomography performed for the following indications: fracture, dislocation, or suspicious findings on standard radiographs; or persistent severe pain or neurologic deficit. Tomography detected acute fractures in 44 of the 71 patients. The CTLV had a sensitivity of 82%, specificity of 70%, and accuracy of 77% for detecting patients with fractures. The three standard views had a corresponding sensitivity, specificity, and accuracy of 93%, 71%, and 84%, respectively. Eight patients with fractures had the CTLV interpreted as normal, and three patients with fractures had all three standard views interpreted as normal. The use of thin-section tomography is recommended when there are suspicious radiographic or clinical findings suggesting a severe cervical spine injury.

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Cervical spine evaluation in pediatric trauma: A cost-effectiveness analysis
2020, American Journal of Emergency Medicine
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However, sensitivity analyses showed wide variation across reasonable clinical ranges. It is difficult to discern the true cost-effectiveness of x-ray screening alone, given that estimates for sensitivity range widely [13,28,48,50,65,66]. In light of this uncertainty, clinicians may find screening with x-ray alone to be inadequate and may continue to consider the CT evaluation, regardless of x-ray findings.
The emergent evaluation of children with suspected traumatic cervical spine injuries (CSI) remains a challenge. Pediatric clinical pathways have been developed to stratify the risk of CSI and guide computed tomography (CT) utilization. The cost-effectiveness of their application has not been evaluated. Our objective was to examine the cost-effectiveness of three common strategies for the evaluation of children with suspected CSI after blunt injury.
We developed a decision analytic model comparing these strategies to estimate clinical outcomes and costs for a hypothetical population of 0–17 year old patients with blunt neck trauma. Strategies included: 1) clinical pathway to stratify risk using NEXUS criteria and determine need for diagnostic testing; 2) screening radiographs as a first diagnostic; and 3) immediate CT scanning for all patients. We measured effectiveness with quality-adjusted life years (QALYs), and costs with 2018 U.S. dollars. Costs and effectiveness were discounted at 3% per year.
The use of the clinical pathway results in a gain of 0.04 QALYs and a cost saving of $2800 compared with immediate CT scanning of all patients. Use of the clinical pathway was less costly and more effective than immediate CT scan as long as the sensitivity of the clinical prediction rule was greater than 87% and when the sensitivity of x-ray was greater than 84%.
A strategy using a clinical pathway to first stratify risk before further diagnostic testing was less costly and more effective than either performing CT scanning or screening cervical radiographs on all patients.
Pediatric cervical spine injury evaluation after blunt trauma: A clinical decision analysis
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Additional smaller studies had somewhat lower sensitivities reported, and these data were used in sensitivity analyses.19,20 Specificity obtained from various trauma literature supported a wide range, from 70% to 95%.21-24 We estimated probability of malignancy related to CT radiation exposure from the most recently published data on projected lifetime cancer risk for pediatric patients.25,26
Although many adult algorithms for evaluating cervical spine injury use computed tomography (CT) as the initial screening modality, this may not be appropriate in low-risk children, considering radiation risks. We determine the optimal initial evaluation strategy for cervical spine injury in pediatric blunt trauma.
We constructed a decision analysis tree for a hypothetical population of patients younger than 19 years with blunt trauma, using 3 strategies: clinical stratification, screening radiographs followed by focused CT if the radiograph result was positive, and CT. For the model inputs, we used the current literature to determine the probabilities of cervical spine injury and estimate the long-term risks of malignancy after CT, as well as test characteristics of radiographic imaging. We used published utilities and conducted 1- and 2-way sensitivity analyses to determine the optimal strategy for evaluation of pediatric cervical spine injury.
In our model of a population with blunt trauma, the expected value of a clinical stratification strategy was the highest of the 3 strategies, making it the overall preferred management. One-way sensitivity analysis of several contributing factors revealed that the only independent factor that altered the dominant strategy was the sensitivity of clinical clearance criteria, lowering the threshold at which screening-radiograph strategy is optimal. Within the patient population considered as having non-negligible risk by clinical stratification and thus requiring imaging, the preferred imaging modality was screening radiograph/focused CT. The probability of cervical spine injury above which CT became the preferred strategy was 24.9%.
The model highlights that clinical clearance and screening radiographs in a hypothetical trauma pediatric population are preferred strategies, whereas CT scanning is rarely the initial optimal evaluation.
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: Presented at the University Association for Emergency Medicine Annual Meeting in Salt Lake City, Utah, April 1982.

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Original contributionAccuracy of standard radiographic views in detecting cervical spine fractures

Ann Emerg Med

Cervical spine tomography in trauma

Spine

The influence of thin-section tomography on the treatment of cervical spine injuries

Radiology

Atlas of Roentgenographic Positions

Original contribution
Accuracy of standard radiographic views in detecting cervical spine fractures