Trauma/original researchCervical Spine Magnetic Resonance Imaging in Alert, Neurologically Intact Trauma Patients With Persistent Midline Tenderness and Negative Computed Tomography Results
Introduction
In many cases, midline cervical tenderness after trauma is absent or resolves quickly, allowing clearance of the cervical spine in the absence of intoxication, altered conscious state, painful distracting injury, persistent focal neurologic deficit,1, 2, 3, 4 and acutely abnormal cervical computed tomography (CT) findings. However, persistence of midline cervical tenderness on palpation in alert, neurologically intact patients presents a clinical dilemma because it is unclear which patients require further investigation. The presence of fractures alerts clinicians to the possibility of injury to other cervical structures, but the absence of acute, positive CT findings is often erroneously equated with lack of injury. The level of efficiency in identifying occult cervical disc or ligamentous injury in the absence of fracture is uncertain under many cervical spine clearance protocols. Detection of occult cervical spine injuries and the determination of their clinical significance are imperative in the avoidance of missed injuries, the assignment of appropriate management, and the mitigation of long-term morbidity.
In recent years, magnetic resonance imaging (MRI) has emerged as a definitive and highly sensitive tool in the detection of acute cervical discoligamentous injury.5 However, in the setting of cervical CT findings that are negative for acute injury, MRI is generally indicated in patients with trauma-related neurologic symptoms and signs.
Our objective was to determine the presence of MRI-detected injury, if any, and the characteristics associated with injury extent in alert, neurologically intact trauma patients with CT findings negative for acute injury. Our scope was not limited to the detection of instability but focused more broadly on the characterization of injury that may also result either in delayed neurologic deficit or long-term pain or disability.
Section snippets
Study Design and Setting
We report here the cross-sectional analysis of baseline information collected as part of a prospective cohort study conducted at a Level I adult trauma center. The institution is a referral center for metropolitan and regional major trauma patients and has 15,000 trauma presentations per year, of whom 1,500 patients are categorized as having major trauma. Institutional ethics committee approval was obtained and participating patients' informed consent was obtained in writing.
Selection of Participants
Consecutive, adult,
Characteristics of Study Subjects
There were 9,152 trauma patients who underwent admission cervical spine CT during the 2-year study period to January 2009. Of those patients, 741 had CT findings negative for acute injury and persistent midline cervical tenderness. From this group, 178 eligible patients were recruited to the study. The inclusion/exclusion information is presented in Figure 1 and patient characteristics are presented in Table 1.
For the study cohort, cervical spine MRI was conducted at a median of 37.5 hours
Limitations
The main limitation of our study was the potential for measurement (observer) bias, given that the study personnel were not blinded to the hypothesis of the study. A single, experienced researcher recruited the study participants and was responsible for data collection. However, a standard data collection tool was used, the demographic data were collected before MRI, and the data were consistently complete. In addition, the reporting radiologists were cognizant that participants had all
Discussion
In 1963, Holdsworth14 defined spinal instability as rupture of the posterior ligamentous complex, after the development of his two-column thoracolumbar theory, in which the anterior column comprised the anterior longitudinal ligament, intervertebral disc, and posterior longitudinal ligament and the posterior column involved all components that were posterior to the posterior longitudinal ligament. Subsequent biomechanical studies, however, found that instability in flexion, for example, also
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Cited by (34)
Unilateral Alar Ligament Injury: Diagnostic, Clinical, and Biomechanical Features
2019, World NeurosurgeryCitation Excerpt :It can thus be suggested that investigation should continue with an MRI in the presence of significant clinical findings. MRI is the examination of choice for demonstrating ligamentous injuries in occult cervical injuries.20 Some studies showed that alar ligament hyperintensity can be seen on MRIs of normal patients.21,22
Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma
2018, Annals of Emergency MedicineCitation Excerpt :The NEXUS low-risk criteria and the Canadian C-Spine Rule study have previously demonstrated that imaging is unnecessary in awake and alert patients who are neurologically intact and without distracting injury.34-36 However, the use of these criteria is inconsistent, especially in patients with persistent cervical tenderness.37,38 Although CT has been accepted as the standard first-line diagnostic modality in patients with blunt trauma, the adequacy of a normal CT result alone has been questioned.
Unstable cervical spine fracture with normal computed tomography imaging
2015, American Journal of Emergency MedicineComputed tomography for clearance of cervical spine injury in the unevaluable patient
2013, World NeurosurgeryCitation Excerpt :First, although CT scanning has high sensitivity to detect osseous injury, it is a poor diagnostic study to detect soft-tissue injuries such as ligamentous injury. Of note, even when MRI is used in a separate population of neurologically intact patients with midline cervical tenderness but CT negative studies, up to 44% display evidence of acute cervical injury in a recent prospective trial of 178 patients (1). Second, CT scan is a nonweight-bearing study.
Magnetic resonance imaging cervical spine in trauma: A retrospective single-centre audit of patient outcomes
2022, EMA - Emergency Medicine Australasia
Supervising editor: Allan B. Wolfson, MD
Author contributions: HMA and PAC conceived the study and were responsible for recruitment and managed the data. HMA, PAC, DKV, GJF, DJC, RW, GMM, JVR, and ODW provided input into the study design. HMA secured research funding. HMA, PAC, DKV, GJF, DJC, RW, GMM, and JVR supervised the conduct of the trial. HMA was responsible for primary data collection. DKV and GJF were responsible for review of images. GMM, SML, and JVR were responsible for patient review and management decisions. RW provided advice on statistical design. HMA and RW analyzed the data. PAC chaired the steering committee. HMA drafted the article, and all authors contributed substantially to editing and revision. HMA and PAC take responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Funded by the Transport Accident Commission, Victoria, Australia (grant No. NV16).
Earn CME Credit: Continuing Medical Education is available for this article at www.ACEP-EMedHome.com.
Publication date: Available online August 5, 2011.
Please see page 522 for the Editor's Capsule Summary of this article.
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