(Radiographics. 2000;20:S260.)
© RSNA, 2000
Invited Commentary
Frederick A. Mann, MD and
C. Craig Blackmore, MD, MPH
Department of Radiology, Harborview Medical Center, Harborview Injury Prevention and Research Center, Seattle, Washington
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Commentary
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As Dr Jelly et al
infer in their discussion of indications for screening for cervical spine injury, the choice of imaging strategy should be tailored to the likelihood or pretest risk of fracture. The specific strategy may vary because pretest risk for cervical spinal cord injury increases such that, in patients at low pretest risk, either no imaging or conventional radiography may be appropriate, whereas in patients at higher pretest risk, screening of the entire cervical spine with CT or MR imaging may be more effective. Simply put, as the possibility of spinal cord injury increases, the sensitivity of the screening test must also increase to minimize the deleterious consequences of false-negative diagnoses.
However, diagnostic accuracy is only one criterion for choosing a modality for imaging the cervical spine and represents only one measure of the impact of imaging on patient outcome. Other important criteria include time required, impact on subsequent care, mobility, and cost.
In the seriously injured polytrauma patient, minimizing the time between the traumatic event and definitive treatment of life-threatening injuries is the first priority. Given equivalent diagnostic accuracy, the faster diagnostic test is preferred. Rapid exclusion of spinal injury facilitates patient transport and can markedly reduce the prevalence of cranial decubitus ulcers caused by unnecessary use of protective cervical collars. Exclusion with radiography also allows improved pulmonary toilet through early patient mobilization to a sitting position. Finally, rapid exclusion of spinal injury may lower the cost of patient care by reducing the number of personnel required to reposition patients (eg, four persons are recommended for spinal protective logrolling).
Patient care, including surgical planning, depends on identification of all cervical spine injuries. In patients requiring surgical stabilization, multiple level injuries may lead to imaging of a significantly longer spinal segment and more complex fixation. Once injuries are detected, targeted imaging (eg, dedicated thin-section CT, MR imaging) may be used to precisely characterize all osseous and ligamentous involvement.
Transport of seriously ill polytrauma patients to the radiology suite is often a major undertaking that requires a multidisciplinary team, and technical limitations of bedside imaging may preclude definitive diagnostic studies. Thus, performing definitive cervical spine imaging while the patient is undergoing initial evaluation in the emergency department can help avoid the cost and potential morbidity of patient transfer. However, recent advances in miniaturization have promoted the development of mobile CT scanners, which allow cross-sectional diagnostic imaging of the head, neck, and torso nearly at bedside. Initial assessments of the cost-effectiveness of these spatially distributed technologies are promising, and in the future, the need for patient mobility will be further reduced by improvements in the mobility of these technologies.
Finally, can high-tech, labor-intensive imaging requiring large capital outlays provide superior results at a lower cost? Early CT of the cervical spine has proved effective in victims of serious polytrauma. For other trauma victims, conventional radiography remains an excellent and cost-effective diagnostic tool.
Related Article
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Radiography versus Spiral CT in the Evaluation of Cervicothoracic Junction Injuries in Polytrauma Patients Who Have Undergone Intubation
- Louise M. E. Jelly, David R. Evans, Marina J. Easty, Timothy J. Coats, and Otto Chan
RadioGraphics 2000 20: S251-S259.
[Abstract]
[Full Text]
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