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1.  Are “Normal” Multidetector Computed Tomographic Scans Sufficient to Allow Collar Removal in the Trauma Patient? 
The Journal of Trauma  2010;68(1):103-108.
Background
Controversy continues as to the most safe and reliable method for clearing the cervical spine (C-spine) in a trauma patient who is rendered unable to participate in a clinical examination. Although magnetic resonance imaging (MRI) is the most sensitive test to detect soft-tissue injuries, it is impractical for routine use in every patient largely because of its cost and time of acquiescence. Recent studies have advocated the sole use of multidetector computed tomographic (MDCT) scans of the C-spine to decide if cervical collar immobilization can be discontinued. The current investigation retrospectively reviewed a series of MDCT scans obtained after an acute traumatic event that were used to direct treatment in the emergency department (ED) or intensive care unit.
Methods
Seven-hundred and eight trauma patients consecutively admitted to the ED between June 2001 and July 2006 underwent a computed tomographic scan of their C-spine as part of an institutional protocol. We identified 91 patients with MDCT scans that were officially recorded as adequate and negative by an attending ED radiologist who had also undergone an MRI during the same trauma admission period. Retrospectively, two fellowship-trained spine surgeons independently reviewed these MDCT studies to address the following questions: (1) Is the study adequate? (2) Is it suggestive of an acute injury? (3) Is there sufficient information to safely recommend collar removal? Institutional Review Board approval was obtained before the images were reviewed. Neither clinical examination findings nor MRI readings were made available to the surgeon evaluators.
Results
Both spine surgeons agreed that 76 of the 91 studies (84%) were adequate to evaluate for possible C-spine injuries. Seven of 91 MDCT scans (8%) were deemed inadequate by both surgeons (95% confidence interval, 2.3–13.1). Reasons for inadequacy included motion artifact, insufficient visualization of the cervical-thoracic or occipital-cervical junctions, incomplete reconstructive views, or poor quality. Three of the adequate MDCT scans had fractures that were identified by both of the spine surgeons; 4 additional fractures and 15 findings suspicious for instability were identified by at least one of the surgeons. Ultimately, 22 of 91 MDCT scans read as adequate and normal by attending radiologists were deemed suspicious for abnormality by the spine surgeons. Of these 22 cases, the official MRI reading was positive for a trauma-related abnormality in 17 cases.
Conclusions
C-spine clearance of patients without the ability participate in a clinical examination remains difficult. A multidisciplinary, algorithmic approach generally yields the most consistent results. However, our data highlight that reliance on a single imaging modality may lead to missed diagnosis of C-spine injuries. These data suggest that early involvement of the spine service for radiographic clearance may help identify occult injuries or suspicious findings necessitating further evaluation.
doi:10.1097/TA.0b013e3181b021da
PMCID: PMC3256247  PMID: 20065764
Cervical spine; Trauma; Clearance; Multidetector computed tomographic scan; Cervical collar
2.  Variation in emergency department use of cervical spine radiography for alert, stable trauma patients 
OBJECTIVE: To, assess the emergency department use of cervical spine radiography for alert, stable adult trauma patients in terms of utilization, yield for injury and variation in practices among hospitals and physicians. DESIGN: Retrospective survey of health records. SETTING: Emergency departments of 6 teaching and 2 community hospitals in Ontario and British Columbia. PATIENTS: Consecutive alert, stable adult trauma patients seen with potential cervical spine injury between July 1, 1994, and June 30, 1995. MAIN OUTCOME MEASURES: Total number of eligible patients, referral for cervical spine radiography (overall, by hospital and by physician), presence of cervical spine injury, patient characteristics and hospitals associated with use of radiography. RESULTS: Of 6855 eligible patients, cervical spine radiography was ordered for 3979 (58.0%). Only 60 (0.9%) patients were found to have an acute cervical spine injury (fracture, dislocation or ligamentous instability); 98.5% of the radiographic films were negative for any significant abnormality. The demographic and clinical characteristics of the patients were similar across the 8 hospitals, and no cervical spine injuries were missed. Significant variation was found among the 8 hospitals in the rate of ordering radiography (p < 0.0001), from a low of 37.0% to a high of 72.5%. After possible differences in case severity and patient characteristics at each hospital were controlled for, logistic regression analysis revealed that 6 of the hospitals were significantly associated with the use of radiography. At 7 hospitals, there was significant variation in the rate of ordering radiography among the attending emergency physicians (p < 0.05), from a low of 15.6% to a high of 91.5%. CONCLUSIONS: Despite considerable variation among institutions and individual physicians in the ordering of cervical spine radiography for alert, stable trauma patients with similar characteristics, no cervical spine injuries were missed. The number of radiographic films showing signs of abnormality was extremely low at all hospitals. The findings suggest that cervical spine radiography could be used more efficiently, possibly with the help of a clinical decision rule.
PMCID: PMC1227493  PMID: 9176419
3.  Missed upper cervical spine fracture: clinical and radiological considerations 
Objective:
This report presents a case of missed upper cervical spine fracture following a motor vehicle accident and illustrates various clinical and radiographic considerations necessary in the evaluation of post traumatic cervical spine injuries. Specific clinical signs and symptoms, as well as radiographic clues should prompt the astute clinician to suspect a fracture even when plain film radiographs have been reported as normal.
Clinical features:
A 44-year-old male was referred for an orthopaedic consultation for assessment of headaches following a high speed head-on motor vehicle accident eleven weeks prior to his presentation. Cervical spine radiographs taken at an emergency ward the day of the collision were reported as essentially normal.
Subsequent radiographs taken eleven weeks later revealed a fracture through the body of axis with anterior displacement of atlas. A review of the initial radiographs clearly demonstrated signs suggesting an upper cervical fracture.
Intervention and outcome:
Initially the patient was prescribed a soft collar which he wore daily until an orthopaedic consultation eleven weeks later. Fifteen weeks following trauma, the patient was considered for surgical intervention, due to persistent headaches associated with the development of neurological signs suggestive of early onset of cervical myelopathy.
Conclusion:
Cervical spine fractures can have disastrous consequences if not detected early. A thorough clinical and radiological evaluation is essential in any patient presenting with a history of neck or head trauma. Repeated plain film radiographs are imperative in the event of inadequate visualization of the cervical vertebrae. When in doubt, further imaging studies such as computed tomography or magnetic resonance imaging are required to rule out a fracture.
Images
PMCID: PMC2485171
upper cervical fracture; odontoid fracture; cervical spine trauma; chiropractic
4.  The adequacy of cervical spine radiographs in the accident and emergency department. 
One hundred and twenty radiographs of the cervical spine were performed at the request of the Accident and Emergency (A & E) department over a 6 week period. These consecutive films were reviewed for adequacy of anatomical demonstration of the complete cervical spine. The initial series of three films presented to the A& E staff achieved this objective in only 55% of cases overall, although further radiographic examinations requested before the patient left the department raised this figure to 75% for the lateral view and to 70% for the combined anteroposterior (AP) views. From the data it can be predicted that if every patient whose first 3 films were inadequate had received further investigation, the cervical spine would have been well visualized on approximately 90% of radiographs in each plane. The availability of radiologists for advice and their involvement with senior A & E staff in teaching are important factors in improving this situation.
PMCID: PMC1293902  PMID: 8459376
5.  Comparison of Three Prehospital Cervical Spine Protocols for Missed Injuries 
Introduction
We wanted to compare 3 existing emergency medical services (EMS) immobilization protocols: the Prehospital Trauma Life Support (PHTLS, mechanism-based); the Domeier protocol (parallels the National Emergency X-Radiography Utilization Study [NEXUS] criteria); and the Hankins’ criteria (immobilization for patients <12 or >65 years, those with altered consciousness, focal neurologic deficit, distracting injury, or midline or paraspinal tenderness).To determine the proportion of patients who would require cervical immobilization per protocol and the number of missed cervical spine injuries, had each protocol been followed with 100% compliance.
Methods
This was a cross-sectional study of patients ≥18 years transported by EMS post-traumatic mechanism to an inner city emergency department. Demographic and clinical/historical data obtained by physicians were recorded prior to radiologic imaging. Medical record review ascertained cervical spine injuries. Both physicians and EMS were blinded to the objective of the study.
Results
Of 498 participants, 58% were male and mean age was 48 years. The following participants would have required cervical spine immobilization based on the respective protocol: PHTLS, 95.4% (95% CI: 93.1–96.9%); Domeier, 68.7% (95% CI: 64.5–72.6%); Hankins, 81.5% (95% CI: 77.9–84.7%). There were 18 cervical spine injuries: 12 vertebral fractures, 2 subluxations/dislocations and 4 spinal cord injuries. Compliance with each of the 3 protocols would have led to appropriate cervical spine immobilization of all injured patients. In practice, 2 injuries were missed when the PHTLS criteria were mis-applied.
Conclusion
Although physician-determined presence of cervical spine immobilization criteria cannot be generalized to the findings obtained by EMS personnel, our findings suggest that the mechanism-based PHTLS criteria may result in unnecessary cervical spine immobilization without apparent benefit to injured patients. PHTLS criteria may also be more difficult to implement due to the subjective interpretation of the severity of the mechanism, leading to non-compliance and missed injury.
doi:10.5811/westjem.2014.2.19244
PMCID: PMC4100854  PMID: 25035754
6.  A 12 month clinical audit of cervical spine imaging in multiply injured and intubated patients 
The British Journal of Radiology  2010;83(987):257-260.
Previous work has questioned how plain films should be used when imaging the cervical spine of trauma patients. The authors wanted to identify whether the National Institute for Clinical Excellence (NICE) guidelines were being followed with respect to the imaging of patients presenting with cervical spine injury over a 1 year period. Data retrieved from the Electronic Digital Information Service (EDIS) computerised database records of all patients presenting with a triage code 1 or 2 between 1 September 2007 and 31 August 2008 were used to conduct a retrospective audit that identified multiply injured and intubated patients who did not undergo CT of the cervical spine and to highlight the use of plain films when the patient was to undergo CT of the head and cervical spine. A clinical record search identified 52 patients with a mean age of 32 years, of whom 73% were males, who had been admitted with multiple traumas and had undergone imaging of the cervical spine. Although no patient was intubated without undergoing CT of the cervical spine or head, seven patients had plain films when it was clear that they were to undergo CT. In conclusion, the audit emphasised the excellent work of emergency department and radiology staff in identifying and imaging multiple trauma patients, as all patients requiring CT of the cervical spine received this investigation. However, careful thought should be given to ordering plain films before CT, as some patients who clearly required CT of the cervical spine underwent unnecessary lateral plain films in the emergency department, delaying their progression to definitive care.
doi:10.1259/bjr/53146076
PMCID: PMC3473554  PMID: 20019171
7.  Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients 
European Spine Journal  2013;22(7):1467-1473.
Background
Flexion and extension radiographs are often used in the setting of trauma to clear a cervical spine injury. The utility of such tests, however, remains to be determined. We hypothesized that in patients who underwent a negative computed tomography (CT) cervical spine scan, flexion and extension radiographs did not yield useful additional information.
Methods
We conducted a retrospective chart review of all patients admitted to a Level I trauma center who had a negative CT scan of the cervical spine and a subsequent cervical flexion–extension study for evaluation of potential cervical spine injury. All flexion–extension films were independently reviewed to determine adequacy as defined by C7/T1 visualization and 30° of change in the angle from flexion to extension. The independent reviews were compared to formal radiology readings and the influence of the flexion–extension studies on clinical decision making was also reviewed.
Results
One thousand patients met inclusion criteria for the study. Review of the flexion–extension radiographs revealed that 80 % of the films either did not adequately demonstrate the C7/T1 junction or had less than 30° range of motion. There was one missed injury that was also missed on magnetic resonance imaging. Results of the flexion–extension views had minimal effects on clinical decision making.
Conclusion
Adequate flexion extension films are difficult to obtain and are minimally helpful for clearance of the cervical spine in awake and alert trauma patients.
doi:10.1007/s00586-012-2598-z
PMCID: PMC3698361  PMID: 23404352
Flexion extension; Cervical spine; Spine clearance
8.  The Swimmer's view: does it really show what it is supposed to show? A retrospective study 
Background
One of the basic principles in the primary survey of a trauma patient is immobilisation of the cervical spine till cleared of any injury. Lateral cervical spine radiograph is one of the important initial radiographic assessments. More than often additional radiographs like the Swimmer's view are necessary for adequate visualisation of the cervical spine. How good is the Swimmer's view in visualisation of the cervical spine after an inadequate lateral cervical spine radiograph?
Methods
100 Swimmer's view radiographs randomly selected over a 2 year period in trauma patients were included for the study. All the patients had inadequate lateral cervical spine radiographs. The radiographs were assessed with regards to their adequacy by a single observer. The criteria for adequacy were adequate visualisation of the C7 body, C7/T1 junction and the soft tissue shadow.
Results
Only 55% of the radiographs were adequate. None of the inadequate radiographs provided adequate visualisation of the C7 body and the C7/T1 junction. In 42.2% radiographs the soft tissue shadow was unclear. Poor exposure accounted for 53% of the inadequacies while overlapping bones accounted for the rest.
Conclusion
Clearing the cervical spine prior to removing triple immobilisation is essential in a trauma patient. This needs adequate visualisation from C1 to C7/T1 junction. In our study Swimmer's views did not satisfactorily provide adequate visualisation of the cervical spine in trauma patients. We recommend screening the cervical spine by a CT scan when the cervical spine lateral radiographs and Swimmer's views are inadequate.
doi:10.1186/1471-2342-8-2
PMCID: PMC2241593  PMID: 18197973
9.  Diagnosis and treatment of craniocervical dissociation in 48 consecutive survivors  
Study type: Case series
Introduction: Craniocervical dissociation (CCD) is an uncommon and frequently fatal injury with few reports in the literature of survivors. Advances in automobile safety and improved emergency medical services have resulted in increased survival. Timely diagnosis and treatment are imperative for optimal outcome. Regrettably, the presence of multiple life threatening injuries, low clinical suspicion, and lack of familiarity with the upper cervical radiographic anatomy frequently lead to missed or delayed diagnosis.
Objective: This paper represents the largest series of surgically treated CCD survivors. The goal of this study is to determine if any improvements have been made in the timely diagnosis of CCD while performing a complete patient evaluation.
Methods: Following institutional review board approval, a search of the Harborview Medical Center (HMC) trauma registry was conducted for all surgically treated CCD patients between 1996 and 2008. Forty-eight consecutive cases were identified. A retrospective review of the radiological and clinical results with emphasis on timing of diagnosis, modality used for diagnosis (Figures 1 and 2), clinical effect of delayed diagnosis, potential clinical or imaging warning signs, and response to treatment was performed. Thirty-one patients treated from 2003 to 2008 were compared to 17 patients that were treated from 1996 to 2002 and reported previously.1
Initial lateral C-spine radiograph obtained as part of the initial ATLS survey demonstrating an occiput C1 distractive injury.
Sagittal C-spine CT scan obtained as part of the initial ATLS survey demonstrating an occiput C2 distractive injury.
All patients sustained high-energy injuries and were evaluated according to standard Advanced Trauma Life Support (ATLS) protocols. Once CCD was identified or suspected, provisional stabilization was applied and MRI evaluation performed (Figure 3). Definitive surgical management with rigid posterior instrumentation and fusion was performed as soon as physiologically possible (Figures 4 and 5).
Preoperative coronal T2 MRI sequences demonstrating increased signal intensity on the occiput-C1 and C1-2 joints.
Postoperative lateral C-spine x-ray showing rigid posterior instrumented fusion from occiput to C2.
Postoperative sagittal C-spine x-ray showing rigid posterior instrumented fusion from occiput to C2.
Results: Craniocervical dissociation was identified on initial cervical spine imaging in 26 patients (84%). The remaining five patients (16%) were diagnosed by cervical spine MRI. Twenty-three patients (74.2%) were diagnosed within 24 hours of presentation, four (22.6%) were diagnosed between 24 and 48 hours, and one (3.2%) experienced a delay of greater than 48 hours (Table 1). In comparison, four (24%) of the previously treated 17 patients were diagnosed on initial cervical spine imaging. Four patients (24%) were diagnosed within 24 hours of presentation, nine (52%) were diagnosed between 24 and 48 hours, and four (24%) experienced a delay of greater than 48 hours.
There were no cases of craniocervical pseudarthrosis or hardware failure during a mean nine-month follow-up period. Four patients expired during their hospital course. The mean American Spinal Injury Association (ASIA) motor score of 47 improved to 60, and the number of patients with useful motor function (ASIA Grade D or E) increased from eight (26%) preoperatively to 17 (55%) postoperatively.
Conclusions: Improvements have been made in time to diagnosis of CCD in recent years. Increased awareness and the routine use of CT scan as part of the initial ATLS evaluation account for this progress. Expedited diagnosis has decreased preoperative neurological deterioration. However, differences in length of follow-up between the two groups preclude conclusions about its effect on long-term neurological outcome.
doi:10.1055/s-0028-1100920
PMCID: PMC3623094  PMID: 23637673
10.  Fractures of the cervical spine 
Clinics  2013;68(11):1455-1461.
OBJECTIVES:
The aim of this study was to review the literature on cervical spine fractures.
METHODS:
The literature on the diagnosis, classification, and treatment of lower and upper cervical fractures and dislocations was reviewed.
RESULTS:
Fractures of the cervical spine may be present in polytraumatized patients and should be suspected in patients complaining of neck pain. These fractures are more common in men approximately 30 years of age and are most often caused by automobile accidents. The cervical spine is divided into the upper cervical spine (occiput-C2) and the lower cervical spine (C3-C7), according to anatomical differences. Fractures in the upper cervical spine include fractures of the occipital condyle and the atlas, atlanto-axial dislocations, fractures of the odontoid process, and hangman's fractures in the C2 segment. These fractures are characterized based on specific classifications. In the lower cervical spine, fractures follow the same pattern as in other segments of the spine; currently, the most widely used classification is the SLIC (Subaxial Injury Classification), which predicts the prognosis of an injury based on morphology, the integrity of the disc-ligamentous complex, and the patient's neurological status. It is important to correctly classify the fracture to ensure appropriate treatment. Nerve or spinal cord injuries, pseudarthrosis or malunion, and postoperative infection are the main complications of cervical spine fractures.
CONCLUSIONS:
Fractures of the cervical spine are potentially serious and devastating if not properly treated. Achieving the correct diagnosis and classification of a lesion is the first step toward identifying the most appropriate treatment, which can be either surgical or conservative.
doi:10.6061/clinics/2013(11)12
PMCID: PMC3812556  PMID: 24270959
Cervical Atlas; Cervical Vertebrae; Spinal Fractures; Classification; Therapeutics
11.  Interpretation of trauma radiographs by junior doctors in accident and emergency departments: a cause for concern? 
OBJECTIVES: To investigate how well junior doctors in accident and emergency (A&E) were able to diagnose significant x ray abnormalities after trauma and to compare their results with those of more senior doctors. METHODS: 49 junior doctors (senior house officers) in A&E were tested with an x ray quiz in a standard way. Their results were compared with 34 consultants and senior registrars in A&E and radiology, who were tested in the same way. The quiz included 30 x rays (including 10 normal films) that had been taken after trauma. The abnormal films all had clinically significant, if sometimes uncommon, diagnoses. The results were compared and analysed statistically. RESULTS: The mean score for the abnormal x rays for all the junior doctors was only 32% correct. The 10 junior doctors were more experience scored significantly better (P < 0.001) but their mean score was only 48%. The mean score of the senior doctors was 80%, which was significantly higher than the juniors (P < 0.0001). CONCLUSIONS: The majority of junior doctors misdiagnosed significant trauma abnormalities on x ray. Senior doctors scored well, but were not infallible. This suggests that junior doctors are not safe to work on their own in A&E departments. There are implications for training, supervision, and staffing in A&E departments, as well as a need for fail-safe mechanisms to ensure adequate patient care and to improve risk management.
PMCID: PMC1343093  PMID: 9315930
12.  Brown-Sequard syndrome after blunt cervical spine trauma: clinical and radiological correlations 
European Spine Journal  2007;16(8):1165-1170.
The objective of this study was to describe clinical and radiological features of a series of patients presenting with Brown-Sequard syndrome after blunt spinal trauma and to determine whether a correlation exists between cervical plain films, CT, MRI and the clinical presentation and neurological outcome. A retrospective review was done of the medical records and analysis of clinical and radiological features of patients diagnosed of BSS after blunt cervical spine trauma and admitted to our hospital between 1995 and 2005. Ten patients were collected for study, three with upper- and seven with lower-cervical spine fracture. ASIA impairment scale and motor score were determined on admission and at last follow-up (6 months–9 years, mean 30 months). Patients with lower cervical spine fracture presented with laminar fracture ipsilateral to the side of cord injury in five out of six cases. T2-weighted hyperintensity was present in seven patients showing a close correlation with neurological deficit in terms of side and level but not with the severity of motor deficit. Patients with Brown-Sequard syndrome secondary to blunt cervical spine injury commonly presented T2-weighted hyperintensity in the clinically affected hemicord. A close correlation was observed between these signal changes in the MR studies and the neurologic level. Effacement of the anterior cervical subarachnoid space was present in all patients, standing as a highly sensitive but very nonspecific finding. In the present study, craniocaudal extent of T2-weighted hyperintensity of the cord failed to demonstrate a positive correlation with neurological impairment.
doi:10.1007/s00586-007-0345-7
PMCID: PMC2200771  PMID: 17394028
Brown-Sequard; Cervical spine trauma; MRI; Prognosis; Spinal cord Injury
13.  Vertebral artery injury after cervical spine trauma: A prospective study using computed tomographic angiography 
Background:
Although the vertebral artery injuries (VAI) associated with cervical spine trauma are usually clinically occult, they may cause fatal ischemic damage to the brain stem and cerebellum.
Methods:
We performed a prospective study using computed tomographic angiography (CTA) to determine the frequency of VAI associated with cervical spine injuries and investigate the clinical and radiological characteristics. Between January 2005 and August 2007, 99 consecutive patients with cervical spine fractures and/or dislocations were prospectively evaluated for patency of the VA, using the CTA, at the time of injury.
Results:
Complete disruption of blood flow through the VA was demonstrated in seven patients with unilateral occlusion (7.1%). There were four men and three women with a mean age of 43 (range, 33-55 years). Unilateral occlusion of the right vertebral artery occurred in four patients and of the left in three. Regarding the cervical injury type, two cases were cervical burst fractures (C6 and C7), two had C4-5 fracture/dislocations, two had a unilateral transverse foraminal fracture, and one had dens type III fracture. All patients presented with good patency of the contralateral VA. None of the patients developed secondary neurological deterioration due to vertebrobasilar ischemia during the follow-up period with a mean duration of 23 months.
Conclusions:
VAI should be suspected in patients with cervical trauma that have cervical spine fractures and/or dislocations or transverse foramen fractures. CTA was useful as a rapid diagnostic method for ruling out VAI after cervical spine trauma.
doi:10.4103/2152-7806.78255
PMCID: PMC3086173  PMID: 21541205
Cervical spine; computed tomographic angiography; injury; vertebral artery
14.  Odontoid lateral mass asymmetry: do we over-investigate? 
Emergency Medicine Journal : EMJ  2005;22(9):625-627.
Objectives: This study aimed to evaluate the necessity for further radiological investigation in patients with suspected traumatic rotatory subluxation of the atlanto-axial complex on plain radiography following acute cervical trauma and outline guidelines for assessment of patients with atlanto-axial asymmetry on plain radiography.
Methods: A retrospective review of all patients who had undergone atlanto-axial CT scanning as a result of radiographic C1–C2 asymmetry following cervical spine trauma. The plain x ray and CT images were reviewed retrospectively and correlated with the clinical presentation and outcome.
Results and conclusion: Records of 29 patients (16 men, 13 women; age range 21–44 years) were reviewed. All patients were found to have atlanto-odontoid asymmetry on the initial plain x ray. CT images of none of the patients revealed rotatory subluxation. Ten patients (32%) were found to have congenital odontoid lateral mass asymmetry. All patients were treated conservatively without any further intervention. On review, in 19 patients the orientation of the x ray beam in combination with head rotation was found to be at fault. Approximately 1050 trauma cervical spine x rays were taken in the department where this study was conducted over the period 1999–2001. This study identified 10 patients out of a total of 29 as having congenital odontoid lateral mass asymmetry. This represents approximately 1% of the patients attending the emergency department. Thus congenital odontoid lateral mass asymmetry should be considered in the differential diagnosis following acute cervical trauma.
doi:10.1136/emj.2003.014100
PMCID: PMC1726904  PMID: 16113180
15.  A delayed diagnosis of bilateral facet dislocation of the cervical spine: a case report 
Objective:
To review the case of a patient suffering from bilateral facet dislocation of the cervical spine.
Clinical features:
A 53-year-old male was involved in a car accident and was transported to the hospital. Cervical radiographs were taken at the emergency department and interpreted as normal. Four days later, he consulted a chiropractor where radiographs of the cervical spine were repeated. The examination revealed bilateral cervical facet joint dislocation at C5–C6 as well as a fracture involving the spinous process and laminae of C6.
Intervention and outcome:
The patient was referred to the hospital and underwent surgery.
Conclusion:
Patients involved in motor vehicle accidents often consult chiropractors for neck pain treatment. A high index of suspicion due to significant history and physical examination findings should guide the clinician in determining the need for reviewing the initial radiographs (if taken and available) or request repeat studies, regardless of the initial imaging status.
PMCID: PMC3924504  PMID: 24587496
dislocation; cervical spine; radiographs; dislocation; colonne cervicale; radiographies
16.  Upper cervical spine injuries: a management of a series of 70 cases 
Traumatic injuries of the upper cervical spine are often encountered, and may be associated to severe neurological outcome. This is a retrospective study of 70 patients, admitted over a 14 years period (1996 to 2010), for management of upper cervical spine injuries. Data concerning epidemiology, radiopathology and treatment was reviewed, and clinical and radiological evaluation was conducted. Men are more affected than women, with traffic accidents being the major traumatic cause. A cervical spine syndrome of varied intensity was found in about 90% of patients; neurological deficit was noted in 10 patients (21%). Radiological analysis discovered varied and many combined lesions: C1-C2 dislocation (7 cases), C2-C3 dislocation (9 cases), C1 fracture (10 cases) and C2 fracture (44 cases) including 28 odontoid fractures. Orthopedic treatment was carried out exclusively for 31 patients, and surgical treatment for 38 patients. One patient died before surgery because of a polytraumatisme. Posterior approach was performed in 29 cases including hooks and rods in 18 patients, wiring in 9 cases, and 2 transarticular screw fixations. In 9 cases anterior approach was performed: 5 odontoid screwing and 4 cases of C2-C3 discectomy with bone graft. Nearly all patients were improved in post-operative. Elsewhere, the operating results were marked by a persistent neurological deficit in 2 cases, and infection in 2 cases controlled by medical treatment. Mean follow-up was 23 months and showed good clinical and radiological improvement. Early management of cervical spine injuries can optimize outcome. Treatment modalities are well codified; however controversy remains especially with type II odontoid fractures.
doi:10.11604/pamj.2013.15.57.2316
PMCID: PMC3801262  PMID: 24147183
Upper cervical spine; injury; surgical management; prognosis
17.  Clinical presentation of a traumatic cervical spine disc rupture in alpine sports: a case report 
Isolated non-skeletal injuries of the cervical spine are rare and frequently missed. Different evaluation algorithms for C-spine injuries, such as the Canadian C-spine Rule have been proposed, however with strong emphasis on excluding osseous lesions. Discoligamentary injuries may be masked by unique clinical situations presenting to the emergency physician. We report on the case of a 28-year-old patient being admitted to our emergency department after a snowboarding accident, with an assumed hyperflexion injury of the cervical spine. During the initial clinical encounter the only clinical finding the patient demonstrated, was a burning sensation in the palms bilaterally. No neck pain could be elicited and the patient was not intoxicated and did not have distracting injuries. Since the patient described a fall prevention attempt with both arms, a peripheral nerve contusion was considered as a differential diagnosis. However, a high level of suspicion and the use of sophisticated imaging (MRI and CT) of the cervical spine, ultimately led to the diagnosis of a traumatic disc rupture at the C5/6 level. The patient was subsequently treated with a ventral microdiscectomy with cage interposition and ventral plate stabilization at the C5/C6 level and could be discharged home with clearly improving symptoms and without further complications.
This case underlines how clinical presentation and extent of injury can differ and it furthermore points out, that injuries contracted during alpine snow sports need to be considered high velocity injuries, thus putting the patient at risk for cervical spine trauma. In these patients, especially when presenting with an unclear neurologic pattern, the emergency doctor needs to be alert and may have to interpret rigid guidelines according to the situation. The importance of correctly using CT and MRI according to both – standardized protocols and the patient's clinical presentation – is crucial for exclusion of C-spine trauma.
doi:10.1186/1757-7241-16-14
PMCID: PMC2596173  PMID: 19014511
18.  MDCT of acute subaxial cervical spine trauma: a mechanism-based approach 
Insights into Imaging  2014;5(3):321-338.
Injuries to the spinal column are common and road traffic accidents are the commonest cause. Subaxial cervical spine (C3–C7) trauma encompasses a wide spectrum of osseous and ligamentous injuries, in addition to being frequently associated with neurological injury. Multidetector computed tomography (MDCT) is routinely performed to evaluate acute cervical spine trauma, very often as first-line imaging. MDCT provides an insight into the injury morphology, which in turn reflects the mechanics of injury. This article will review the fundamental biomechanical forces underlying the common subaxial spine injuries and resultant injury patterns or “fingerprints” on MDCT. This systematic and focused analysis enables a more accurate and rapid interpretation of cervical spine CT examinations. Mechanical considerations are important in most clinical and surgical decisions to adequately realign the spine, to prevent neurological deterioration and to facilitate appropriate stabilisation. This review will emphasise the variables on CT that affect the surgical management, as well as imaging “pearls” in differentiating “look-alike” lesions with different surgical implications. It will also enable the radiologist in writing clinically relevant CT reports of cervical spine trauma.
Teaching Points
• Vertebral bodies and disc bear the axial compression forces, while the ligaments bear the distraction forces.
• Compressive forces result in fracture and distractive forces result in ligamentous disruption.
• Bilateral facet dislocation is the most severe injury of the flexion-distraction spectrum.
• Biomechanics-based CT reading will help to rapidly and accurately identify the entire spectrum of injury.
• This approach also helps to differentiate look-alike injuries with different clinical implications.
doi:10.1007/s13244-014-0311-y
PMCID: PMC4035495  PMID: 24554380
Biomechanics; Multidetector computed tomography; Cervical vertebrae; Cervical spine injury; Spinal cord injury
19.  Fibular allograft and anterior plating for dislocations/fractures of the cervical spine 
Indian Journal of Orthopaedics  2008;42(1):83-86.
Background:
Subaxial cervical spine dislocations are common and often present with neurological deficit. Posterior spinal fusion has been the gold standard in the past. Pain and neck stiffness are often the presenting features and may be due to failure of fixation and extension of fusion mass. Anterior spinal fusion which is relatively atraumatic is thus favored using autogenous grafts and cages with anterior plate fixation. We evaluated fresh frozen fibular allografts and anterior plate fixation for anterior fusion in cervical trauma.
Materials and Methods:
Sixty consecutive patients with single-level dislocations or fracture dislocations of the subaxial cervical spine were recruited in this prospective study following a motor vehicle accident. There were 38 males and 22 females. The mean age at presentation was 34 years (range 19-67 years). The levels involved were C5/6 (n = 36), C4/5 (n = 15), C6/7 (n = 7) and C3/4 (n = 2). There were 38 unifacet dislocations with nine posterior element fractures and 22 were bifacet dislocations. Twenty-two patients had neurological deficit. Co-morbidities included hypertension (n = 6), non-insulin-dependent diabetes mellitus (n = 2) and asthma (n = 1). All patients were initially managed on skull traction. Following reduction further imaging included Computerized Tomography and Magnetic Resonance Imaging. Patients underwent anterior surgery (discectomy, fibular allograft and plating). All patients were immobilized in a Philadelphia collar for eight weeks (range 7-12 weeks). Eight patients were lost to follow-up within a year. Follow-up clinical and radiological examinations were performed six-weekly for three months and subsequently at three-monthly intervals for 12 months. Pain was analyzed using the visual analogue scale (VAS). The mean follow-up was 19 months (range 14-39 months).
Results:
Eight lost to followup, hence 52 patients were considered for final evaluation. The neurological recovery was 1.1 Frankel grades (range 0-3) and two patients with root involvement recovered. At six months bony trabeculae at the graft-vertebrae interface were noted. There were 12 (20 %) cases of graft collapse and one case of angulation which showed no progression. At six months the VAS was 3 (range 0-6). There was no limitation of neck motion at six months in 47 patients.
Conclusion:
Fresh frozen fibular allografts are suitable and cost-effective for anterior fusion in cervical trauma.
doi:10.4103/0019-5413.38587
PMCID: PMC2759583  PMID: 19823661
Cervical spine trauma; fresh frozen allograft; fibular allograft; anterior fusion in cervical spine
20.  Number and cost of claims linked to minor cervical trauma in Europe: results from the comparative study by CEA, AREDOC and CEREDOC 
European Spine Journal  2008;17(10):1350-1357.
Comparative epidemiological study of minor cervical spine trauma (frequently referred to as whiplash injury) based on data from the Comité Européen des Assurances (CEA) gathered in ten European countries. To determine the incidence and expenditure (e.g., for assessment, treatment or claims) for minor cervical spine injury in the participating countries. Controversy still surrounds the basis on which symptoms following minor cervical spine trauma may develop. In particular, there is considerable disagreement with regard to a possible contribution of psychosocial factors in determining outcome. The role of compensation is also a source of constant debate. The method followed here is the comparison of the data from different areas of interest (e.g., incidence of minor cervical spine trauma, percentage of minor cervical spine trauma in relationship to the incidence of bodily trauma, costs for assessment or claims) from ten European countries. Considerable differences exist regarding the incidence of minor cervical spine trauma and related costs in participating countries. France and Finland have the lowest and Great Britain the highest incidence of minor cervical spine trauma. The number of claims following minor cervical spine trauma in Switzerland is around the European average; however, Switzerland has the highest expenditure per claim at an average cost of €35,000.00 compared to the European average of €9,000.00. Furthermore, the mandatory accident insurance statistics in Switzerland show very large differences between German-speaking and French- or Italian-speaking parts of the country. In the latter the costs for minor cervical spine trauma expanded more than doubled in the period from 1990 to 2002, whereas in the German-speaking part they rose by a factor of five. All the countries participating in the study have a high standard of medical care. The differences in claims frequency and costs must therefore reflect a social phenomenon based on the different cultural attitudes and medical approach to the problem including diagnosis. In Switzerland, therefore, new ways must be found to try to resolve the problem. The claims treatment model known as “Case Management” represents a new approach in which accelerated social and professional reintegration of the injured party is attempted. The CEA study emphasizes the fundamental role of medicine in that it postulates a clear division between the role of the attending physician and the medical expert. It also draws attention to the need to train medical professionals in the insurance business to the extent that they can interact adequately with insurance professionals. The results of this study indicate that the usefulness of the criterion of so-called typical clinical symptoms, which is at present applied by the courts to determine natural causality and has long been under debate, is inappropriate and should be replaced by objective assessment (e.g. accident and biomechanical analysis). In addition, the legal concept of adequate causality should be interpreted in the same way in both third party liability and social security law, which is currently not the case.
doi:10.1007/s00586-008-0732-8
PMCID: PMC2556470  PMID: 18704519
Minor cervical trauma; Cervical spine injury; Whiplash injury
21.  Evaluation of morbidity, mortality and outcome following cervical spine injuries in elderly patients 
European Spine Journal  2008;17(4):585-591.
We analysed the morbidity, mortality and outcome of cervical spine injuries in patients over the age of 65 years. This study was a retrospective review of 107 elderly patients admitted to our tertiary referral spinal injuries unit with cervical spine injuries between 1994 and 2002. The data was acquired by analysis of the national spinal unit database, hospital inpatient enquiry system, chart and radiographic review. Mean age was 74 years (range 66–93 years). The male to female ratio was 2.1:1 (M = 72, F = 35). The mean follow-up was 4.4 years (1–9 years) and mean in-hospital stay was 10 days (2–90 days). The mechanism of injury was a fall in 75 and road traffic accident in the remaining 32 patients. The level involved was atlanto-axial in 44 cases, sub-axial in 52 cases and the remaining 11 had no bony injury. Multilevel involvement occurred in 48 patients. C2 dominated the single level injury and most of them were type II odontoid fractures. Four patients had complete neurology, 27 had incomplete neurology, and the remaining 76 had no neurological deficit. Treatment included cervical orthosis in 67 cases, halo immobilization in 25, posterior stabilization in 12 patients and anterior cervical fusion in three patients. The overall complication rate was 18.6% with an associated in-hospital mortality of 11.2%. The complications included loss of reduction due to halo and Minerva loosening, non-union and delayed union among conservatively treated patients, pin site and wound infection, gastrointestinal bleeding and complication due to associated injuries. Among the 28.9% patients with neurological involvement, 37.7% had significant neurological recovery. Outcome was assessed using a cervical spine outcome questionnaire from Johns Hopkins School of Medicine. Sixty-seven patients (70%) completed the form, 20 patients (19%) were deceased at review and 8 patients (7%) were uncontactable. Functional disability was more marked in the patients with neurologically deficit at time of injury. Outcome of the injury was related to increasing age, co-morbidity and the severity of neurological deficit. Injuries of the cervical spine are not infrequent occurrence in the elderly and occur with relatively minor trauma. Neck pain in the elderly patients should be thoroughly evaluated to exclude C2 injuries. Most patients can be managed in an orthosis but unstable injuries require rigid external immobilization or surgical stabilization.
doi:10.1007/s00586-008-0603-3
PMCID: PMC2295275  PMID: 18196293
Elderly; Cervical spine injury; External immobilization; Outcome
22.  Emergency department intubation of trauma patients with undiagnosed cervical spine injury 
Emergency Medicine Journal : EMJ  2004;21(3):302-305.
Objectives: Some trauma patients have an undiagnosed cervical spine injury but require immediate airway control. This paper reports an emergency department's (ED) experience with these patients. In particular, is there a worse neurological outcome?
Methods: A retrospective study over 6.5 years, based on prospectively collected data from the Royal Perth Hospital trauma registry. Patients with a cervical spine injury were identified and clinical data were abstracted. The primary outcome measure was evidence of exacerbation of cervical spine injury as a result of intubation by ED medical staff.
Results: 308 patients (1.9%) of the 15 747 trauma patients were intubated by ED medical staff. Thirty seven (12%) were subsequently verified to have a cervical spine injury, of which 36 were managed with orotracheal intubation. Twenty five (69%) survived to have a meaningful post-intubation neurological examination. Fourteen (56%) of these 25 patients had an unstable cervical spine injury. Ninety per cent of all ED intubations were by ED medical staff. No worsening of neurological outcomes occurred.
Conclusions: Every ninth trauma patient that this ED intubates has a cervical spine injury. Intubation by ED medical staff did not worsen neurological outcome. In the controlled setting of an ED staffed by senior practitioners, patients with undiagnosed cervical spine injury can be safely intubated.
doi:10.1136/emj.2003.006619
PMCID: PMC1726318  PMID: 15107367
23.  Absent cervical spine pedicle and associated congenital spinal abnormalities - a diagnostic trap in a setting of acute trauma: case report 
BMC Medical Imaging  2010;10:25.
Background
Congenital spinal abnormalities can easily be misdiagnosed on plain radiographs. Additional imaging is warranted in doubtful cases, especially in a setting of acute trauma.
Case Presentation
This patient presented at the emergency unit of our university hospital after a motor vehicle accident and was sent to our radiology department for imaging of the cervical spine. Initial clinical examination and plain radiographs of the cervical spine were performed but not conclusive. Additional CT of the neck helped establish the right diagnosis.
Conclusion
CT as a three-dimensional imaging modality with the possibility of multiplanar reconstructions allows for the exact diagnosis and exclusion of acute traumatic lesions of the cervical spine, especially in cases of doubtful plain radiographs and when congenital spinal abnormalities like absent cervical spine pedicle with associated spina bifida may insinuate severe trauma.
doi:10.1186/1471-2342-10-25
PMCID: PMC2988693  PMID: 21062465
24.  Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial 
Objective To evaluate the effectiveness of an active strategy to implement the validated Canadian C-Spine Rule into multiple emergency departments.
Design Matched pair cluster randomised trial.
Setting University and community emergency departments in Canada.
Participants 11 824 alert and stable adults presenting with blunt trauma to the head or neck at one of 12 hospitals.
Interventions Six hospitals were randomly allocated to the intervention and six to the control. At the intervention sites, active strategies were used to implement the Canadian C-Spine Rule, including education, policy, and real time reminders on radiology requisitions. No specific intervention was introduced to alter the behaviour of doctors requesting cervical spine imaging at the control sites.
Main outcome measure Diagnostic imaging rate of the cervical spine during two 12 month before and after periods.
Results Patients were balanced between control and intervention sites. From the before to the after periods, the intervention group showed a relative reduction in cervical spine imaging of 12.8% (95% confidence interval 9% to 16%; 61.7% v 53.3%; P=0.01) and the control group a relative increase of 12.5% (7% to 18%; 52.8% v 58.9%; P=0.03). These changes were significant when both groups were compared (P<0.001). No fractures were missed and no adverse outcomes occurred.
Conclusions Implementation of the Canadian C-Spine Rule led to a significant decrease in imaging without injuries being missed or patient morbidity. Final imaging rates were much lower at intervention sites than at most US hospitals. Widespread implementation of this rule could lead to reduced healthcare costs and more efficient patient flow in busy emergency departments worldwide.
Trial registration Clinical trials NCT00290875.
doi:10.1136/bmj.b4146
PMCID: PMC2770593  PMID: 19875425
25.  The effect of introducing guidelines for cervical spine radiographs in the accident and emergency department. 
OBJECTIVE: To assess the effect of guidelines for x ray requests on requests for cervical spine x rays. SETTING: Accident and emergency (A&E) department of tertiary referral centre. METHODS: Guidelines for all x ray requests were introduced in the (A&E) department of the Royal Infirmary of Edinburgh in February 1992. The effect of the guidelines on requests for cervical spine x rays was assessed by retrospective review of all such x rays taken over two 30 d periods, before and after the introduction of the guidelines. Junior staff had been in post for 3 months during both periods assessed. Films were reviewed for quality by a consultant radiologist. RESULTS: Guidelines reduced the number of inappropriate requests significantly; however, 26% of requests were still unnecessary. The standard of radiography improved but 49% of x rays remained inadequate, usually because the C7/T1 level was not demonstrated on the lateral view. The A&E doctors correctly interpretated the radiographs in 95% of examinations. CONCLUSIONS: Guidelines reduce inappropriate x ray requests. Further improvements can be expected with continued education.
PMCID: PMC1342606  PMID: 8821225

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