The National Emergency X-radiography Utilization Study group, which is discussed in more detail later in regard to its CDR, found similar rates of injury: 2.4% of 34,069 patients in 21 U.S. medical centers involving 111,219 patients, 4.3% of patients had injuries, at similar rates, in both academic and nonacademic centers, regardless of trauma center type (I through III). designation) all encounter cervical spine injuries with similar frequency, and emergency physicians must be intimately familiar with the imaging required to diagnose these dangerous injuries. The incidence of cervical injuries is relatively independent of the setting-level I, II, and III trauma centers (the U.S. This evaluation differs from the evaluation in trauma, as fractures or other bony pathology may not be present. In addition, nontraumatic cervical spine pathology occasionally requires imaging in the emergency department. Let’s begin our discussion with the cervical spine, followed by a parallel discussion of the thoracic and lumbar spine.Ĭervical spine injuries occur in approximately 2% to 4% of blunt trauma cases, and diagnostic imaging plays a pivotal role in the evaluation of patients for these potentially life-threatening or seriously debilitating injuries. Consequently, an even greater emphasis should be placed on applying reliable CDRs. The new ACR recommendation for a CT-first strategy guarantees an increase in the radiation exposure resulting from any screening for cervical spine injury. We discuss the radiation burden and cost of cervical CT. The three-view radiograph that has been the long-standing screening test in the emergency department is now recommended by the ACR “only when CT is not readily available.” Radiography is described in this document as “not … a substitute for CT.” The ACR cites a lack of evidence for recommendations of CT or x-ray as the primary screening tool for suspected cervical spine injury in children. Remarkably, the latest version of the American College of Radiology (ACR) Appropriate Guidelines for Imaging of Suspected Spine Trauma (2009) advocates thin-section CT as the primary screening study for suspected cervical spine injury in adults, removing plain radiography (x-ray) from this position. We review the evidence for use of CT and x-ray, comparing their sensitivity for detection of fractures. Imaging of the spine has undergone a revolution with the advent of multidetector CT with multiplanar reconstructions. Similar decision instruments can identify patients who require thoracic and lumbar imaging. We review two well-validated clinical decision rules (CDRs) that can identify patients at low risk of cervical spine injury who do not require any imaging. In many ways, the more difficult task for the emergency physician is not the interpretation of the image but the decision to image the spine. Thoracic spine metastatic disease with cord compressionĭegenerative joint disease and disc herniation Thoracolumbar compression and burst fractures T2 corner avulsion fractures (extension teardrop) Three-dimensional CT reconstructions of the normal cervical spineĬervical facet fractures with spinal cord injury on MRIĪcute cervical ligamentous injuries with x-ray, CT, and MRI findings The list in Table 3-1 can guide you to the relevant figure, where diagnostic features are discussed in detail. The figures in the chapter span a range of important spinal pathology, moving from cephalad to caudad. The figure captions are designed to allow the figures to stand alone, so we spend relatively little time discussing specific fracture patterns in the text. Don’t be daunted by the number of figures in this chapter-we explore injuries and nontraumatic spinal pathology in many imaging planes and in multiple modalities to maximize your three-dimensional understanding. We correlate CT findings with x-ray when possible, and we demonstrate associated soft-tissue abnormalities identified on magnetic resonance imaging (MRI). Our discussion of all spinal regions starts with interpretation of images, with a focus on computed tomography (CT) scan. Although differences exist, many common themes are shared in both the selection and the interpretation of diagnostic studies for all regions of the spine. In this chapter, we discuss imaging of the cervical, thoracic, and lumbar spine.
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