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There are several approaches to imaging the cervical spine in the patient with
multiple trauma, and there is little consensus on a single consistent approach.1
When deciding if and how to image the cervical spine, consider the following:
The first question to address is whether the patient needs imaging at all. At least
two validated systems can identify patients at very low risk of c-spine injury.
NEXUS Criteria
The first is the NEXUS (National Emergency X-Ray Utilization Study) Criteria,2
which is based on a large (35 000 patient) multicenter study done in 1992. NEXUS
criteria that define a low-risk patient are as follows:
In order to meet the standard for low risk, all 5 criteria must be met.
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These have been reported as 92% to 99% sensitive in defining a population of
patients who do not need imaging.3,4
The evidence supporting the validity of these two different criteria for evaluation
is not perfect, and it may not be possible to directly compare the sensitivities and
specificities of the two systems.3 As with all clinical decision rules, these criteria
must be applied from the perspective of the physician’s practice setting as well as
taking into account individual patient considerations. Use of either of these
criteria, plus clinical judgment, is considered acceptable, high-quality practice.
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Types of Imaging
As noted previously, once it has been decided to image the c-spine, a wide
variety of practices are utilized to rule out significant, unstable c-spine injury.
Several approaches are outlined here:
CT: This has become a popular modality, with higher sensitivity and
specificity than plain film. CT is also convenient in conjunction with CT scans
of other areas commonly scanned in the trauma patient. Ideally, the scanner
should be able to do reconstructions in various planes (axial, sagittal). This is
dependent on the age and type of scanner. Check with your radiologist
and/or technician about any limitations of your scanner. Other considerations
include increased cost and radiation exposure with CT vs plain radiographs.
MRI: This is the only modality that can directly image ligaments. Neither
plain films nor CT can directly identify ligamentous injury. Theoretically, a
patient may have an unstable c-spine due to ligamentous injury with normal
x rays and CT. However, MRI is not commonly available on an emergency
basis and may be difficult to carry out in the acute setting of a patient with
multiple trauma. Once again, apply clinical judgment to determine which
patient remains at risk of unstable c-spine injury after normal x-rays and/or
CT. If a patient is determined to be in this risk category, he or she must
remain in c-spine immobilization until an MRI has been completed and
interpreted.
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REFERENCES
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