(Radiographics. 2000;20:S251-S259.)
© RSNA, 2000
Radiography versus Spiral CT in the Evaluation of Cervicothoracic Junction Injuries in Polytrauma Patients Who Have Undergone Intubation1
Louise M. E. Jelly, FRCR,
David R. Evans, MB,BS,
Marina J. Easty, FRCR,
Timothy J. Coats, FRCS and
Otto Chan, FRCR
1 From the Departments of Radiology (L.M.E.J., D.R.E., M.J.E., O.C.) and Accident and Emergency (T.J.C.), The Royal London Hospital, Whitechapel, London E1 1BB, England. Presented as a scientific exhibit at the 1999 RSNA scientific assembly. Received February 9, 2000; revision requested March 28 and received April 25; accepted April 28. Address correspondence to L.M.E.J. (e-mail: louisejelly@hotmail.com).
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Abstract
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A prospective study was performed over a 1-year period in patients who had sustained blunt trauma, mostly in motor vehicle accidents. All 73 patients (56 male and 17 female; age range, 2–94 years; mean age, 35.2 years) in the study had undergone intubation and ventilation at the trauma site (mean Glasgow Coma Score, 9.9 [range, 3–15]; mean Injury Severity Score, 30.4 [range, 8–75]) and subsequently underwent three-view radiography of the cervical spine and thin-section spiral computed tomography (CT) of the cervicothoracic junction. Spinal fractures were detected in 20 patients and involved the cervicothoracic junction region in 12 cases. In all 12 patients, the fractures were visualized at CT, whereas in seven of 12 patients, conventional radiography failed to demonstrate injuries (transverse process fracture of T1 [n = 1], pedicle and vertebral body fracture of C7 [n = 1], fractures of the first and second ribs [n = 5]). Thus, routine CT of the cervicothoracic junction in a highly select group of severely injured patients helped detect occult fracture in seven of 73 patients (10%); however, most of these fractures were not clinically significant. Larger studies involving a high-risk patient population are needed to confirm these findings.
Index Terms: Spine, CT, 31.12115 • Spine, fractures, 31.41 • Spine, injuries, 31.41 • Spine, radiography, 31.11
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Introduction
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Cervical spine trauma accounts for almost two-thirds of all spinal cord injuries (1–3). Early recognition and treatment of trauma to the cervical spine is essential for optimal neurologic outcome, and the consequences of missed or delayed diagnosis can be devastating. In the conscious patient without any distracting injury, clinical examination is highly accurate in excluding cervical spine trauma (4–9). However, in the unconscious patient with multiple injuries, clinical examination is unreliable, and exclusion of injury to the cervical spine relies on imaging.
The Advanced Trauma Life Support guidelines set forth by the American College of Surgeons (10) have increased awareness of the problems surrounding the clinical management of trauma and have greatly influenced trauma care. For patients with suspected cervical spine injury, the American College of Surgeons routinely recommends a single cross-table lateral radiograph in polytrauma patients; unfortunately, however, the specifics of further cervical spine imaging have not been defined and are left to the discretion of the trauma team.
Controversy exists regarding optimal imaging in patients with suspected cervical spine injury. Radiographic series consisting of one, three, five, or even seven views have been advocated for use in the trauma setting (11–19). Previous studies have suggested that radiographic evaluation alone is inadequate, and this may be particularly true in high-risk trauma patients (11–13,20–22). Computed tomography (CT) is used as an adjunct to conventional radiography at many institutions, some of which even recommend routine CT of the entire cervical spine in cases of multiple trauma (20,23). Studies performed at our institution have shown that up to 66% of injuries at the craniocervical junction may be missed at conventional radiography but are subsequently detected at CT (24).
Between 9% and 18% of all cervical spine injuries occur at the cervicothoracic junction (25–27). Radiographs of this region that allow adequate visualization may be technically difficult to obtain, and in at least 26% of all trauma patients the C7-T1 space is not visualized on the three-view series (28). This is particularly true in patients with obtundation who have undergone intubation.
Although previous studies have assessed the accuracy of conventional radiography and CT in the detection of lower cervical spine injury, none was based solely on the evaluation of unconscious, severely injured patients with a high risk of injury. In the light of our findings at the craniocervical junction, we were concerned that we were missing significant injury at other levels, particularly the cervicothoracic junction.
In this article, we compare the findings at three-view radiography of the cervical spine with those at routine spiral CT of the cervicothoracic junction in polytrauma patients who have undergone intubation. We also discuss the significance of occult injuries at conventional radiography that are subsequently detected at CT.
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Materials and Methods
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A prospective study was performed over a 1-year period from January 1, 1998 to December 31, 1998. The study included 73 of 204 trauma patients who underwent both conventional radiography and CT of the cervicothoracic junction during the 1-year period. Mechanisms of injury included motor vehicle accidents (51% of cases), jumps or falls (44%), and other mechanisms including assault (5%). Associated injuries are shown in Table 1. All 73 patients (56 male and 17 female; age range, 2–94 years; mean age, 35.2 years) in the study underwent intubation and ventilation at the trauma site (mean Glasgow Coma Score, 9.9 [range, 3–15]; mean Injury Severity Score, 30.4 [range, 8–75]). In the majority of cases, the Helicopter Emergency Medical Service was the route of admission.
All patients initially underwent a three-view radiographic series of the cervical spine. At our institution, this series consisted of a cross-table lateral radiograph and two supine oblique radiographs. The latter were performed with a 55° angulation from horizontal and a 10°–15° cranial angulation. T2 or below was depicted on the supine oblique radiographs in all 73 patients (100%), and many radiographs allowed visualization as low as T4. Only 25 of 73 cross-table lateral radiographs (34%) depicted the C7-T1 space. All patients subsequently underwent CT of the cervicothoracic junction regardless of whether this region was visible at conventional radiography. CT was performed from the lower border of C6 to the upper border of T2 with a Siemens Somatom Plus 4A scanner (Siemens Medical Systems, Erlangen, Germany). Typical scan parameters were 140 kV and 146 mAs. Spiral CT was performed with a 2-mm section thickness, a 1.5 pitch, and a 2-mm reconstruction interval. Bone images were reconstructed with an edge-enhancement kernel and viewed with bone windowing (window level, 250 HU; window width, 2,000 HU). Twelve sagittal and 12 coronal reconstructions were routinely obtained. Examinations were performed at the same time as CT of the brain.
Clinical details including mechanism of injury, Glasgow Coma Score, and Injury Severity Score were obtained from the Helicopter Emergency Medical Service database or from clinical notes. Associated injuries outside the cervical spine were also documented.
All radiographs were interpreted by at least two radiologists (L.M.E.J., D.R.E., O.C., M.J.E.), and a consensus opinion was obtained. Interobserver variability was not assessed. Findings at radiography and CT were combined to provide the standard of reference.
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Results
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Fractures were detected in 20 of 73 patients (27%). Four of these patients had only rib fractures, whereas the remaining 16 patients (22%) had fractures of the vertebrae. Twelve of 20 patients had fractures involving the cervicothoracic junction region and included all four patients with rib fractures. The remaining eight cases involved fractures at higher spinal levels, including occipital condyle fractures, and were not analyzed further. In all 12 patients with lower cervical spine fractures, the fractures were visualized at CT. Conventional radiography demonstrated injury in only five of 12 patients (42%) (Table 2) (Figs 1–3) despite adequate visualization down to C7-T1 on the cross-table lateral view in eight of 12 patients (67%) and down to T2 on all of the supine oblique views. Thus, seven patients had fractures that were not detected at conventional radiography but were subsequently detected at CT (Figs 4–7) (Table 3). Of these seven fractures, five involved the first or second rib, one involved the transverse process of T1 (Fig 4), and one involved the pedicle and vertebral body of C7 (Fig 5). In the latter case, there were also fractures of C5 and C6. In four of these seven patients, the C7-T1 space was visualized on the cross-table lateral view.
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TABLE 2. Fractures Detected at Conventional Radiography in 12 Patients with Lower Cervical Spine Fractures Seen at CT
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Figure 3a. (a) Cross-table lateral radiograph shows C2 and C7 spinous process fractures (arrows). (b) Spiral CT scan obtained at the level of C2 demonstrates spinous process and right lamina fractures (arrows). (c) Spiral CT scan obtained at the level of C7 helps confirm the spinous process fracture (arrow).
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Figure 3b. (a) Cross-table lateral radiograph shows C2 and C7 spinous process fractures (arrows). (b) Spiral CT scan obtained at the level of C2 demonstrates spinous process and right lamina fractures (arrows). (c) Spiral CT scan obtained at the level of C7 helps confirm the spinous process fracture (arrow).
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Figure 3c. (a) Cross-table lateral radiograph shows C2 and C7 spinous process fractures (arrows). (b) Spiral CT scan obtained at the level of C2 demonstrates spinous process and right lamina fractures (arrows). (c) Spiral CT scan obtained at the level of C7 helps confirm the spinous process fracture (arrow).
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Figure 5a. (a) Cross-table lateral radiograph demonstrates spinous process and lamina fractures of C5 and C6 (arrows). C7 appears normal. (b, c) On left (b) and right (c) supine oblique radiographs, the cervicothoracic junction is well demonstrated. (d) Spiral CT scan obtained at the level of C5 demonstrates left lamina and spinous process fractures (arrow). (e) Spiral CT scan shows an unsuspected fracture of the right pedicle of C7 extending into the vertebral body (arrow).
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Figure 5b. (a) Cross-table lateral radiograph demonstrates spinous process and lamina fractures of C5 and C6 (arrows). C7 appears normal. (b, c) On left (b) and right (c) supine oblique radiographs, the cervicothoracic junction is well demonstrated. (d) Spiral CT scan obtained at the level of C5 demonstrates left lamina and spinous process fractures (arrow). (e) Spiral CT scan shows an unsuspected fracture of the right pedicle of C7 extending into the vertebral body (arrow).
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Figure 5c. (a) Cross-table lateral radiograph demonstrates spinous process and lamina fractures of C5 and C6 (arrows). C7 appears normal. (b, c) On left (b) and right (c) supine oblique radiographs, the cervicothoracic junction is well demonstrated. (d) Spiral CT scan obtained at the level of C5 demonstrates left lamina and spinous process fractures (arrow). (e) Spiral CT scan shows an unsuspected fracture of the right pedicle of C7 extending into the vertebral body (arrow).
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Figure 5d. (a) Cross-table lateral radiograph demonstrates spinous process and lamina fractures of C5 and C6 (arrows). C7 appears normal. (b, c) On left (b) and right (c) supine oblique radiographs, the cervicothoracic junction is well demonstrated. (d) Spiral CT scan obtained at the level of C5 demonstrates left lamina and spinous process fractures (arrow). (e) Spiral CT scan shows an unsuspected fracture of the right pedicle of C7 extending into the vertebral body (arrow).
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Figure 5e. (a) Cross-table lateral radiograph demonstrates spinous process and lamina fractures of C5 and C6 (arrows). C7 appears normal. (b, c) On left (b) and right (c) supine oblique radiographs, the cervicothoracic junction is well demonstrated. (d) Spiral CT scan obtained at the level of C5 demonstrates left lamina and spinous process fractures (arrow). (e) Spiral CT scan shows an unsuspected fracture of the right pedicle of C7 extending into the vertebral body (arrow).
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Figure 6a. (a) Cross-table lateral radiograph shows spinous process fractures of C4, C5, and C6 (arrowheads). The C7-T1 space is also seen. (b) Spiral CT scan helps confirm the spinous process fracture of C5 (arrowhead). (c) Spiral CT scan obtained at the level of T1 shows an unsuspected fracture of the left first rib (arrow).
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Figure 6b. (a) Cross-table lateral radiograph shows spinous process fractures of C4, C5, and C6 (arrowheads). The C7-T1 space is also seen. (b) Spiral CT scan helps confirm the spinous process fracture of C5 (arrowhead). (c) Spiral CT scan obtained at the level of T1 shows an unsuspected fracture of the left first rib (arrow).
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Figure 6c. (a) Cross-table lateral radiograph shows spinous process fractures of C4, C5, and C6 (arrowheads). The C7-T1 space is also seen. (b) Spiral CT scan helps confirm the spinous process fracture of C5 (arrowhead). (c) Spiral CT scan obtained at the level of T1 shows an unsuspected fracture of the left first rib (arrow).
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Figure 7a. (a) Cross-table lateral radiograph demonstrates no fracture. (b) Spiral CT scan obtained at the level of T2 shows an unsuspected fracture of the right second rib (arrowheads).
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Figure 7b. (a) Cross-table lateral radiograph demonstrates no fracture. (b) Spiral CT scan obtained at the level of T2 shows an unsuspected fracture of the right second rib (arrowheads).
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TABLE 3. Fractures Not Detected at Conventional Radiography in 12 Patients with Lower Cervical Spine Fractures Seen at CT
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Discussion
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Injury to the cervical spine can result in neurologic or spinal cord damage in up to 39%–50% of cases (1–3) and accounts for approximately 1%–3% of all trauma cases (29,30). Early diagnosis of cervical spine injury is imperative because delayed diagnosis and treatment can result in neurologic deterioration (31), with devastating consequences for the patient.
Studies have shown that radiography rarely depicts cervical spine injury in alert, asymptomatic patients without distracting injuries (4–9). However, these patients are at the lowest risk for injury.
The situation is different in patients who are at high risk for injury and in those who cannot be examined due to obtundation. Factors that help identify those at a higher risk for cervical spine injury have been described in the literature and include both clinical criteria (Glasgow Coma Score less than 14 [32], neck tenderness, loss of consciousness, neurologic deficit [4,11,33], drug ingestion [4]) and specific mechanisms of injury (motor vehicle accident [4,34], fall from a height greater than 3 m [34]).
We purposely chose to study a highly select group of severely injured patients because we believed that such a group would yield the highest number of fractures. Therefore, only patients who underwent intubation and ventilation at the trauma site for severe multiple injuries or obtundation were included because they were easily identifiable as the highest risk group. Indeed, an average Injury Severity Score of 30.4 is, to our knowledge, a higher figure than that reported in any similar study to date and helps confirm the severity of injury in these patients.
There is good evidence that conventional radiography is inadequate as an initial screening tool, and it is well documented that CT is superior to radiography in the detection of bone injury to the cervical spine (11–13,20,21). CT does have some limitations (35,36), particularly in cases involving subluxation-dislocation or fractures oriented in the axial plane. However, the advent of spiral CT and multiplanar reformatting has improved the detection of even these injuries (1,12), and CT now plays a complementary role to conventional radiography.
It is widely accepted that significant injury to the craniocervical region can be missed even when this area is well seen at conventional radiography. Many institutions (including our own) perform routine CT of the craniocervical region concurrently with head CT in polytrauma patients who are undergoing ventilation (6,22).
Evidence exists to indicate that a high number of fractures in the distal cervical spine are missed at radiography, but it is less clear whether routine CT of the cervicothoracic junction is warranted in these cases. The prevalence of injury to this area is also high, and there are problems in obtaining high-quality radiographs that include the cervicothoracic junction. This is particularly true in the unconscious patient, in whom other diagnostic and therapeutic procedures may take precedence. Most institutions perform focused CT of the cervicothoracic junction to clarify suspicious or equivocal findings or to further evaluate a definite fracture if this region is not adequately seen at conventional radiography. However, the central question in our study was whether CT of the cervicothoracic junction should be performed routinely. Tehranzadeh et al (37) evaluated CT of the cervical spine in 100 trauma cases with nonvisualization of C7 and T1 at radiography and found three patients with fractures, all of which were stable. Two of these patients had undergone intubation, and one had obtundation. A recent study by Berne et al (23) evaluated routine CT of the entire cervical spine in 58 unconscious patients who were undergoing ventilation. The authors found 20 fractures, eight (40%) of which involved C6, C7, or T1. Of these eight fractures, six were not fully detected at conventional radiography and three were unstable. In two of the latter cases, however, the cervicothoracic junction was not visualized at conventional radiography, and the patients would therefore have undergone CT of the cervicothoracic junction even without the screening protocol. Therefore, only one significant fracture was missed at conventional radiography but subsequently detected at CT. However, the exact level of this unstable fracture is not clear. Nunez et al (35) retrospectively reviewed conventional radiographs and CT scans obtained in 88 patients with cervical spine fractures and found that in 32 patients the fractures (n = 50) were not revealed or were incompletely demonstrated at radiography. Fourteen of 50 fractures (28%) were at the C6 and C7 level, and three of the affected patients had unstable fractures. However, the number of cases in which the cervicothoracic junction was visualized at conventional radiography is not documented, so that the true number of missed fractures at conventional radiography is not known. Mirvis et al (39) performed CT in 408 trauma patients, 235 of whom underwent CT of the cervicothoracic junction due to inadequate visualization at radiography. In 49 of these 235 patients, bedside examination was unreliable owing to obtundation. No fractures were seen in this group. Other investigators comparing CT with conventional radiography have presented their data in such a way that it is difficult to separate undetected injuries at the cervicothoracic junction from injuries at other levels (12,36). Few studies have focused specifically on the lower cervical spine or on very high risk patients.
Opinions (and subsequent practice) vary between institutions with regard to what constitutes optimal conventional radiography. The American College of Surgeons Advanced Trauma Life Support Manual (10) recommends cross-table lateral radiography in cases of multiple trauma, whereas the American College of Radiology Appropriateness Criteria for Imaging and Treatment Decisions (38) recommend conventional radiography based on different clinical variants. With both sets of guidelines, however, the extent and specifics of the radiographic evaluation remain controversial. Most institutions use a conventional radiographic series consisting of at least three views (11–15), including cross-table lateral and anteroposterior views and a collimated anteroposterior view of the odontoid peg. Other institutions advocate use of a five-view series that includes both right and left supine oblique views (16–18), although Freemyer et al (14) did not detect any injuries with the five-view series that were not detected with the three-view series. However, Turetsky et al (16) found that supine oblique views may help detect fractures or subluxations that are not identified with standard three-view series. Kaneriya
et al (28) found that the addition of oblique views reduced the number of CT scans required to exclude C7-T1 injury by 48%.
Our three-view series differs from that used at other institutions in that we are dealing specifically with patients with obtundation who have undergone intubation. Odontoid peg views are difficult to obtain, and we have found the anteroposterior view to be unhelpful because endotracheal tubes and other support lines tend to obscure the underlying structures. Consequently, we obtain right and left trauma oblique views along with a cross-table lateral view in patients who have undergone intubation to better assess alignment and to allow more consistent visualization of the cervicothoracic junction.
It is relatively difficult to accurately determine imaging costs in the British National Health Service. Each CT study would cost approximately 
400 ($600) if performed privately outside the National Health Service. Thus, the total cost of CT in our study would be 73 x $600, or $43,800.
Although we evaluated severely injured patients who were also at high risk for cervical spine injury, we found only one fracture that would have been clinically significant: that of the pedicle and vertebral body of C7 (Fig 5). The patient had fractures at other cervical spine levels that were seen at conventional radiography. CT would have included C7 in any case, even without the screening protocol, because we always image at least one normal vertebral body above and below a fracture.
We agree with the recommendations of the Eastern Association for the Surgery of Trauma (40), which has established practice parameters for identifying trauma-related cervical spine injuries. In patients with obtundation, a three-view conventional radiographic series (anteroposterior, cross-table lateral, and odontoid views) and thin-section axial CT through C1 and C2 are recommended. In addition, axial CT scans with sagittal reconstructed images should be obtained to evaluate possible spinal injury at any level or through the lower cervical spine if this area cannot be visualized on conventional radiographs. All of the injuries in our study would have been detected had this protocol been used.
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Conclusions
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CT of the cervical spine allows detection of fractures at the cervicothoracic junction that are not detected at radiography. In our highly select group of severely injured patients, routine spiral CT helped detect occult fractures in seven of 73 patients (10%), but most of these fractures were not clinically significant. However, the numbers involved in this study are too small to allow formulation of a policy for imaging the potentially injured spine. We cannot advocate routine CT of the cervicothoracic junction on the basis of our findings because there was only one significant injury, which would have been detected even without a screening protocol. Larger studies of a high-risk patient population will be needed to confirm our findings.
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Footnotes
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See the commentaries by Mann
and Zipser
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References
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Invited Commentary
- Frederick A. Mann and C. Craig Blackmore
RadioGraphics 2000 20: S260.
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Invited Commentary
- Stan Zipser
RadioGraphics 2000 20: S261-S262.
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Abstract
Introduction
