P49. Cervical spine CT scans can miss fractures when football equipment is in place

Abstract

<h3>BACKGROUND CONTEXT</h3> Iatrogenic worsening of a spinal injury can result in significant harm to football athletes and complicate its management when equipment is removed in the acute setting by inexperienced personnel. Spine imaging before removal of protective equipment mitigates this risk. There is a controversy regarding the ideal timing of equipment removal and whether current diagnostic imaging modalities are effective to detect these injuries without equipment removal. Prior data suggests that CT is a diagnostic modality for this purpose, however, radiologists' accuracy in detecting specific fractures must be investigated. However, there is no established modality to perform imaging in these patients with protective equipment in place. <h3>PURPOSE</h3> 1) Does the introduction of football equipment result in a reduction in sensitivity for cervical spine fracture detection? (2 What proportion of images that were determined to be of adequate diagnostic quality by experienced radiologists contained missed fractures that were previously identified in the images without football equipment? <h3>STUDY DESIGN/SETTING</h3> Diagnostic Study. <h3>PATIENT SAMPLE</h3> A total of 13 cadaveric specimens were used for testing to replicate a clinical setting. <h3>OUTCOME MEASURES</h3> 1) Sensitivity of CT for c-spine fracture 2) Proportion of fractures missed in CT studies with football equipment on that were deemed diagnostic by participation radiologists. <h3>METHODS</h3> A pendulum device was engineered to deliver a measured axial load to the crown of cadavers [PM1] to produce a variety of cervical spine fractures. The cadavers were then imaged using a standardized CT protocol first without and then with protective football equipment. The images were presented to three board-certified radiologists [SSL3] to identify all fractures from the occiput to T1 and assess their diagnostic quality. A sensitivity analysis was performed against a reference standard of fractures produced by the consensus of all radiologists in this study to determine if there was any reduction in radiologists' ability to detect fractures once football equipment was in place. <h3>RESULTS</h3> The radiologists in this study observed a 26.7% reduction in sensitivity for spine fracture detection once football equipment was in place (Overall, we observed a 26.7% reduction in sensitivity (51.3% (1.54/3) versus 78.0% (2.34/3), 95% CI 40.2% to 62.4%; p = 0.0032). Although the study radiologists considered 92% (72/82) of the CT images in the presence of football equipment to be of diagnostic quality, they failed to identify 51 (40.0%) total cervical spine fractures once the football equipment was introduced. <h3>CONCLUSIONS</h3> The sensitivity of cervical spine fracture detection using CT is diminished in the setting of protective football equipment. These findings contradict previous studies that determined CT to be a diagnostic imaging modality to image the cervical spine through equipment. Although the interpreting radiologists consistently deemed CTs performed in the presence of helmets and shoulder pads to have subjectively diagnostic quality, numerous fractures that had been detected in the absence of equipment were missed in their presence. The sensitivity of cervical spine fracture detection using CT is diminished in the setting of protective football equipment. Furthermore, this study established that subjective approval of the appearance of an imaging study based on the ability to recognize anatomic landmarks is insufficient to reliably determine the diagnostic quality of a CT image. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.