Thurs., 10/16/08 Spine, Paper #2, 2:31 pm OTA-2008
Are Normal CT Scans Sufficient to Allow Collar Removal on the Trauma Patient?
Mitchel B. Harris, MD (a-DePuy, Medtronic, Synthes; a,b-Zimmer; e-Globus);
Josef Simon, MD (n); Christopher Bono, MD (a-DePuy, Medtronic, Stryker);
Lawrence Maciolek, MD (n);
Brigham and Women’s Hospital, Boston, Massachusetts, USA
Purpose: Controversy continues as to the most reliable method for clearing the cervical spine in the trauma patient who is rendered unable to participate in the clinical examination. The presence of distracting injuries, an associated head injury, narcotic pain management, or endotracheal intubation are all factors that compromise the patient’s ability to provide reliable feedback. While MRI is the most sensitive test to detect soft-tissue injuries, it is impractical for routine use largely because of its cost and time of acquiescence. Recent studies have advocated the sole use of multidetector CT (MDCT) scans of the cervical spine to direct collar removal. The current investigation retrospectively reviewed a series of MDCT scans obtained after an acute traumatic event that were used in the decision to remove the field collar in the emergency department (ED) or ICU.
Methods: As part of a different study, which required the identification of a subset of ED patients who had undergone both MDCT scans and MRI studies, we identified 92 MDCT scans read as adequate and negative by an attending ED radiologist. Three fellowship-trained spine surgeons and two spine fellows reviewed these studies. The following questions were addressed: Is the study adequate? Is the MDCT scan (+) or (–) for findings suggestive/suspicious of an acute injury? Is there sufficient information to safely remove the collar? Reasons for the studies to be judged inadequate included: motion artifact, insufficient visualization of the cervical-thoracic or occipital-cervical junctions, incomplete reconstructive views, or poor quality. IRB approval was obtained before the images were reviewed. Clinical examination findings were not provided to the evaluators.
Results: 7 of 92 MDCTs were deemed inadequate by all of the attending spine surgeons, 15 of 92 by at least one of the attendings, and 25 of 92 by an attending or fellow. Three of the “adequate” MDCT scans had fractures that were identified by the spine attendings and fellows; 7 additional fractures were identified by at least one of the readers. 15 of 92 scans had findings that were suspicious to at least one of the spine attendings. Therefore, 15 of 92 MDCTs read as adequate and normal by the radiologists were felt to require continued use of the collar by the spine attendings due to fracture or abnormality. Three additional studies were felt to have suspicious findings by the spine fellows.
Conclusions: Cervical spine clearance without clinical feedback remains a difficult task. A multidisciplinary algorithmic approach generally yields the most consistent results. However, our data highlight the different interpretations of experienced spine surgeons, fellows in training, and experienced ED radiologists. When radiographically evaluating the cervical spine in a trauma patient, involving the spine service early may help identify occult injuries or abnormal/suspicious findings necessitating further work-up.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant