C-spine X-rays Research Articles

Utility of Magnetic Resonance Imaging for Ligamentous Injury in Cervical Spine Trauma: A 2-Year Consecutive Case Cohort

Magnetic resonance imaging (MRI) is increasingly used as an adjunct to spinal soft tissue evaluation in cervical spine (C-spine) trauma; however, the utility of this information remains controversial. In this consecutive observational study, we reviewed the utility of MRI in patients with C-spine trauma. We identified patients in real time over a 2-year period as they presented to our level 1 trauma center for C-spine computed tomography (CT) scan followed by MRI. MRI was obtained by the trauma team prior to the spine service consultation if (1) they were unable to clear the C-spine according to protocol or (2) if the on-call radiologist reported a concern for ligamentous integrity from the CT findings. Thirty-three patients, including 19 males (58%) and 14 females, with a mean age of 54 years, were referred to the spine service for concerns of ligamentous instability. The most common mechanisms of injury were motor vehicle accidents (n= 13) and falls (n= 11). MRI demonstrated ligamentous signal change identified by the radiologist as potentially unstable in all patients. Fifteen patients (45%) had multiple C-spine ligaments affected. The interspinous ligament was involved most frequently (28%), followed by the ligamentum flavum (21%) and supraspinous ligament (15%). All patients underwent dynamic upright C-spine X-rays that were interpreted by both the ordering surgeon and radiologist. There was no evidence of instability in any patient; concurrence between X-ray interpretation was 100%. The cervical collar was successfully removed in all cases. No patients required late surgical intervention, and there were no return visits to the emergency department of a spinal nature. MRI signal change within the ligaments of the C-spine should be interpreted with caution in the setting of trauma. To physicians less familiar with spinal biomechanics, MRI findings may be perceived in an inadvertently alarming manner. Bony alignment and, when indicated, dynamic upright X-rays remain the gold standard for evaluating the ligamentous integrity of the C-spine.

Analysis of self-initiated visits for cervical trauma at urgent care centers and subsequent emergency department referral

BackgroundFollowing trauma involving the cervical spine (c-spine), patients often seek care at urgent care centers (UCCs) or emergency departments (EDs). PurposeThe purpose was to assess whether UCCs could effectively image acute self-selected c-spine trauma without referral to the ED as well as to estimate costs differences between UCC and ED imaging assessment. Materials and methodsThis retrospective study identified patients receiving c-spine imaging at UCCs affiliated with a large academic hospital system from 5/1/-8/31/2021. Patients receiving c-spine X-rays with an indication of trauma following low acuity injury, at UCCs were compared to patients receiving any c-spine imaging in the main campus ED. Medical record numbers were cross-referenced to identify patients receiving imaging at both a UCC and ED within 24 h and within 7 days. Work relative value units (wRVUs) for each UCC and ED imaging type were calculated. For the hypothetical scenario of patients presenting to the ED in the absence of UCC, patients were assumed to receive c-spine computed tomography (CT) without contrast per “usually appropriate” designation by the American College of Radiology Appropriateness Criteria®. ResultsAmong 143 self-selected, low acuity, patients who received c-spine X-rays at UCCs with an indication of trauma, one required referral to the ED within 24 h and two required referrals to the ED within 7 days. During the 4-month study period, 105.94 wRVUs ($3696.25) were saved by performing a c-spine X-ray in an UCC instead of a CT in the ED, extrapolated to 317.82 wRVUs ($11,088.74) per year. Using the average total costs of an UCC visit versus an ED visit, a total $145,976 was estimated to be saved during the study period or $437,928 per year. ConclusionOffering access for patient-initiated visits at UCCs for low-acuity c-spine trauma may help reduce the need for an ED visit, reducing imaging and healthcare visit costs. Summary statementUrgent Care Centers (UCCs) reduced the need for an Emergency Department (ED) referral visit in nearly 100% of self-selected, low acuity, patients with cervical trauma. Key results•Only 1.4% of patients required referral to an ED after a UCC visit for acute cervical trauma in this specific population.•In our system, UCCs are estimated to result in a savings of $437,928 over the course of a year in reduced ED visit costs, and $11,088.74 in wRVUs for this specific population.

131 Characterizing atlanto-occipital dissociation and its association with pediatric traumatic cardiac arrest: A descriptive case series

Abstract Primary Subject area Emergency Medicine - Paediatric Background Atlanto-occipital dislocation (AOD) is a type of cervical spine injury (CSI) that is commonly fatal or associated with severe neurologic consequences. Although rare, AOD is now more commonly recognized in children as improved prehospital care allows for more patients to reach trauma centres and undergo definitive imaging. Patients with AOD often present with cardiorespiratory instability and prompt diagnosis is crucial. However, diagnosis may be delayed due to variation in imaging practices and lack of literature on this topic. Objectives Primary objective: Describe the demographic characteristics, clinical presentation, and long-term outcomes of children with AOD, compared to other upper CSI. Secondary objective: Describe the frequency of AOD and other upper CSI in pediatric traumatic cardiac arrest (PTCA) and the utility of a lateral c-spine radiograph in this setting. Design/Methods This was a retrospective, single-centre case series of all pediatric trauma patients age < 16 years diagnosed with upper CSI seen at a tertiary pediatric trauma centre from 2000-2020. Patients were included if they had evidence of bony or ligamentous injury from C0-2. The diagnosis of upper CSI was ascertained on autopsy, when available, then cross-sectional imaging, then plain radiographs, when the other modalities were unavailable. Data was obtained from manual chart review and analyzed using descriptive statistics. Results Thirty-six patients were excluded for not meeting upper CSI criteria. Of 93 patients with upper CSI, 24 had AOD: 14 (15%) complete and 10 (11%) incomplete (Table 1). The mechanism of injury was motor-vehicle-collision in 23 (96%) of these patients, and a fall in one (4%). All patients with complete AOD presented in PTCA and only one (7%) survived. Of seven patients with AOD who received a lateral c-spine x-ray during resuscitation, 5 (71%) had identifiable injuries. In contrast, of the 10 patients with incomplete AOD, only 1 (10%) presented in arrest and none died. Only one patient received an x-ray during resuscitation, which showed the injury but went undetected, and 100% of final diagnoses were made through CT. The majority of incomplete AOD patients were managed non-operatively and had minimal to mild disability. Conclusion In our study population, complete AOD was highly fatal with all patients presenting in PTCA. In contrast, incomplete AOD carried a more favorable prognosis with 100% survival and minimal-mild disability. If there is suspicion for AOD, a lateral c-spine XR in the trauma bay can aid in early diagnosis, guiding neurosurgical management and/or goals of care discussions.

Correlation of Soft tissue Projection in Injured NEcks (CSPINE) - Prevertebral soft tissue measurement in paediatric cervical spine trauma

Background: In paediatric trauma, measured increase in prevertebral soft tissue thickness on a lateral cervical spine (C-spine) X-ray is interpreted as swelling, raising suspicion of C-spine injury. Defining swelling in absolute measurements is cumbersome – children’s sizes vary. Published recommendations are largely lacking in evidence. There may be potentially more consistent tools, for example, to measure soft tissue thickness as a ratio of vertebral body width. The aim of this study was to determine whether consistent, measurable prevertebral soft tissue to vertebral body width ratios exist for use as simple diagnostic tools in the assessment of swelling and injury in paediatric C-spine trauma. Patients and methods: C-spine trauma X-rays taken at a South African children’s hospital were randomly sampled. Seventy-one unintubated X-rays from 85 controls were used to identify normal ratios. The authors measured vertebral bodies and soft tissue at each level, created all possible ratios, then chose the two least variable – one for the upper and one for the lower C-spine. Twenty cases aided in determining diagnostic accuracy for C-spine injury. Results: Mean soft tissue at the second cervical vertebral level (c2) was 38% of the seventh vertebra (C7) (95% confidence interval [CI]: 34–41.9%, standard error [SE]: 2.0%). Mean c6 soft tissue was 65.6% of C7 vertebra (95% CI: 61.9–69.3%, SE: 1.9%). In diagnosing C-spine injury, a receiver operating characteristic (ROC) curve calculation gave an empirical optimal cut-point of 53.9% and 74.4% respectively. Using practical cut-offs of 55% at c2 and 75% at c6 yielded specificities of 93.8% (95% CI: 84.8–98.3%) and 81.8% (95% CI: 70.4–90.2%), with negative predictive values of 90.9% (95% CI: 81.3–96.6%) and 91.5% (95% CI: 81.3–97.2%) respectively. Conclusion: Consistent and specific ratios exist in the upper and lower paediatric C-spine. Both ratios have poor sensitivities and positive predictive values and so are poor screening tools; however, a positive result can raise suspicion of C-spine injury in high-risk individuals. This can help to motivate for further investigations such as computer tomography (CT) or magnetic resonance imaging (MRI), which may not be easily accessible in under-resourced settings. However, further research is required to validate the diagnostic value of these ratios. Level of evidence: Level 4

Adequacy of trauma c-spine X-rays: a case for ;straight to CT?’

Category: MSK.

A Clinical Study on Axial Symptoms and Imaging Changes in Paraspinal Muscles after Cervical Posterior Open-door Laminoplasty.

This research aimed to gain a better understanding of the relationship between cervical posterior open-door laminoplasty on axial symptoms, the net cross-sectional area of paraspinal muscles, and the degree of pimelosis. A retrospective study was conducted on a consecutive series of 37 patients who had underwent cervical posterior open-door laminoplasty + lateral mass fixation and bone graft fusion between January 2015 and July 2015. All patients received postoperative examinations at 6 months and 18 months after the operation. For each follow-up visit, the VAS Rating Scale and ODI Function Index Questionnaire were filled out. Meanwhile, a C-Spine X-ray and MRI of the patients were taken. In the measurements taken with ImageJ 1.51 K Software, the cervical vertebra MRI T2-weighted image cross-section for each segment was measured separately, mainly including the mean T2 signal value of the contour area and the net area of the paraspinal muscles. Differences between VAS and ODI (%) at three different time points were of statistical significance (p < 0.01). Pairwise comparisons of the results showed that VAS and ODI (%) at different times were clearly different (p < 0.01). Differences in the mean T2 signal value and net area at different times were of statistical significance (p < 0.01). Pairwise comparisons of the results indicated that the mean T2 signal value and net area at different times were clearly different (p < 0.01). The corresponding analytical results for VAS, ODI (%), and the mean of the T2 signal value and net area demonstrated that VAS6 months after surgery was positively correlated to the net area of C3/4 and C4/5 (r = 0.352, p < 0.05; r = 0.338, p < 0.05). The analogous analytical results for the mean T2 signal value and net area were of no statistical significance (p > 0.05). We believe that axial symptoms after cervical spine surgery does not affect the recovery of neurological function. There is a process of acute or subacute enlargement of paraspinal muscles on segments C3/4 and C4/5 after the operation, while the results of the follow-up visits show that there is a gradual process of atrophy in local posterior muscles, which may be related to axial symptoms. The degree of pimelosis of the neck paraspinal muscles may have no relationship with axial symptoms.

A Comparison of Mean Models and Clustering Techniques for Vertebra Detection and Region Separation from C-Spine X-Rays

A Comparison of Mean Models and Clustering Techniques for Vertebra Detection and Region Separation from C-Spine X-Rays

Isolated tracheal injury after whiplash

Whiplash, a sudden acceleration–deceleration movement that can cause diverse symptoms such as neck pain, cervicogenic headache, restricted neck movement, tingling of the arms (central cord syndrome), and dizziness. However, laryngotracheal injuries after whiplash are extremely rare. We report the case of a 25-year-old Taiwanese female who presented to the emergency department with severe posterior midline neck pain after a rear-end motorcycle collision. Her C-spine X-ray showed no definite fracture; furthermore, her neck noncontrast-enhanced CT scan revealed paratracheal free air. She was discharged uneventfully after a 12-h observation period. Laryngotracheal injuries after whiplash, a hyperextension–hyperflexion movement, are potentially life-threatening and could lead to airway obstruction. Such injuries should not be overlooked. To the best of our knowledge, this is the first case report of isolated laryngotracheal injury after whiplash.

Diagnostic Accuracy of Clinical Examination in Cervical Spine Injuries in Awake and Alert Blunt Trauma Patients

Study DesignObservational, case series.PurposeTo determine the sensitivity and specificity of clinical judgment as compared to the use of X-ray images in detecting cervical spine injuries in trauma patients presenting in the emergency department of Aga Khan University Hospital, Karachi.Overview of LiteratureCross-table cervical spine views are important in patients with signs and symptoms relating to cervical spine, but asymptomatic patients constitute a different subgroup. Accuracy of clinical examination in these patients has not been subjected to scrutiny.MethodsAll patients with blunt trauma who presented to the emergency department and underwent cross-table X-rays as part of their trauma workup were included. The X-rays were read by a radiologist not aware of the history of the patients. We recorded demographic data along with mechanism of injury, associated neck signs or symptoms whether present or not, cervical spine range of motion, associated injuries and X-ray findings. The history and examination were carried out by the on-call neurosurgery team member. The sensitivity and specificity along with negative and positive predictive value of the clinical examination were calculated. Data were analyzed using SPSS ver. 16.0.ResultsOf 50 patients with positive signs and symptoms, 4 (8%) had positive X-rays while only 1 out of 324 (0.3%) with no associated signs and symptoms had positive X-ray findings.ConclusionsThe clinical examination is 80% sensitive and 73.98% specific in detecting true cervical spine injuries as compared to C-spine X-rays in alert and awake patients with blunt trauma.

Diagnosis and treatment of craniocervical dissociation in 48 consecutive survivors

Study type: Case seriesIntroduction: 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.1Figure 1 Initial lateral C-spine radiograph obtained as part of the initial ATLS survey demonstrating an occiput C1 distractive injury.Figure 2 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).Figure 3a–b Preoperative coronal T2 MRI sequences demonstrating increased signal intensity on the occiput-C1 and C1-2 joints.Figure 4 Postoperative lateral C-spine x-ray showing rigid posterior instrumented fusion from occiput to C2.Figure 5 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.Table 1Delay in diagnosisNo. of patients from previous study (%)No. of patients from current study (%)Less than 24 hours4 (24%)23 (74.2%)Between 24 and 48 hours9 (52%)7 (22.6%)More than 48 hours4 (24%)1 (3.2%)

Traumatic Retropharyngeal Hematoma of Delayed Onset in an Anticoagulated Patient

The development of a retropharyngeal hematoma following a trivial blunt trauma is a rare occurrence. A lateral c-spine X-ray or a cervical CT image that shows marked widening of the prevertebral space is sufficient evidence for the clinical diagnosis of retropharyngeal hematoma. When this complication does occur, it can become life-threatening if the airway is compromised. But the diagnosis is obscure and initially veiled in complaints of sore throat or hoarseness, suggesting infection. Thorough investigation of such complaints is necessary especially in patients receiving anticoagulation therapy. We now report a case of retropharyngeal hematoma that occurred as a delayed-onset consequence of a trivial blunt trauma with no evidence of a bony cervical spine injury. It occurred in a 52-year-old man who had been taking warfarin. We also reviewed the literature.

Neck Pain In A Discus Thrower

HISTORY: A 20yo female collegiate discus thrower with acute onset of shooting pain in her left neck when she abruptly extends her neck and turns it to the left. She develops simultaneous numbness on her left tongue and face. She has difficulty speaking transiently. Episodes last 20 to 30 seconds. They are followed by a left-sided headache which lasts all day. It is a shooting sensation radiating up from the neck and "feels like getting hit in the funny bone." The athlete denies any weakness or sensation deficits in extremities, seizures, dizziness, or visual changes. Symptoms began in high school but have increased in severity since she joined the collegiate discus team. Family history is negative. Negative review of systems. PHYSICAL EXAMINATION: Full range of motion in neck, with significant hyperextension. No C-spine tenderness. Negative bilateral Spurling's. Cranial nerves intact. Speech within normal limits. Sensation intact to pinprick. Normal pupillary and funduscopic exams. Reflexes are 2+ and strength 5/5 in all extremities. Coordination intact. Normal gait. Negative Rhomberg's. No clonus. Negative bilateral Babinski. DIFFERENTIAL DIAGNOSIS: Vascular insufficiency/occlusion. Transient ischemia to isolated cranial nerves. Mass compressing cranial/ cervical nerves. Nerve compression from disc hernition or spinal stenosis. TEST AND RESULTS: Laboratory testing - Normal complete blood count, erythrocyte sedimentation rate, comprehensive metabolic panel, thyroid simulating hormone. Negative anti-nuclear antibody (<1:40) and rheumatoid factor (<17). C-spine X-rays - Mild reversal of the normal cervical lordosis. 2-3mm anterolistheses of all cervical bodies C2-C6 with neck flexion, which revert to mild retrolistheses with extension. No spinal stenosis or degenerative disease. There is mild instability throughout the cervical spine. C-spine MRI - No cervical mass, disc herniation, spinal stenosis, or neuroforaminal narrowing. Brain MRI with contrast - Negative. FINAL WORKING DIAGNOSIS: Neck-Tongue Syndrome TREATMENT AND OUTCOMES: 1. Neck strengthening and postural training to stabilize neck. 2. Patient declines acetaminophen and NSAIDs. 3. She stops discus throwing without specific plans to resume it. 4. Referred to a spine surgeon. 5, Continues to follow-up with her neurologist.

Shoulder Pain-Weight Lifting

HISTORY: 22yo male recreational weightlifter and triathlete p/w several month h/o progressive L shoulder pain of insidious onset. He reported weakness in his shoulder, particularly with weight training, and described intermittent numbness and paresthesias radiating from the shoulder into the forearm and hand. He denied swelling or discoloration of the LUE. PMH: (+)RLE DVT with PE, approx. 1 year earlier, after immobilization in CAM walker following RLE injury. Extensive hypercoagulability work-up was (−). Meds: coumadin 5 mg daily, ASA 81 mg daily. (+)rare ETOH use. (−) tobacco/recreational drug/anabolic steroid use. FH: (−) thromboembolic/neurologic disease. ROS: no constitutional sx. PHYSICAL EXAMINATION: Gen: healthy-appearing, muscular, young male. No LUE edema/discoloration. L shoulder: no atrophy/deformity, (+)full ROM, (+)pain with shoulder elevation >130°, (+)Hawkin's test, (−)apprehension test. RUE strength 5/5, including RTC. Sensation intact to soft touch/pinprick. Reflexes +2 symmetric. Normal pulses LUE. (−)Spurling's maneuver, (−)Adson's test, (−)Roos test, (−) costoclavicular maneuver. DIFFERENTIAL DIAGNOSIS: Shoulder impingement syndrome Cervical radiculopathy Thoracic outlet syndrome Upper extremity deep vein thrombosis Brachial plexopathy TEST AND RESULTS: Shoulder MRI: small fluid collection in subdeltoid bursa and subcoracoid region, small effusion in glenohumeral joint, small subcortical cysts in posterior humeral head laterally. Os acromiale present. LUE EMG/NCS: abnormal insertional activity, denervation potentials and membrane instability c/w with active C6 radiculopathy. C-spine x-rays: normal C-spine MRI: normal Brachial plexus MRI: thrombosis of L subclavian vein with inflammation of nearby brachial plexus in cervical vascular and subclavicular regions. FINAL WORKING DIAGNOSIS: C6 radiculopathy secondary to subclavian vein thrombosis TREATMENT AND OUTCOMES: Given duration of sx, pt not considered candidate for thrombolytic tx. INRs in preceding months had been in 2.0-2.4 range. Hematology consultant who had been involved with pt's prior care for DVT/PE. advised increasing coumadin dosing to achieve INR in 2.5-3.0 range. Pt referred for surgical evaluation for consideration of thoracic outlet decompression.

Two Heads Better Than One? An Unusual Calcified Mass Discovered on Lateral C-Spine X-Ray Study

Two Heads Better Than One? An Unusual Calcified Mass Discovered on Lateral C-Spine X-Ray Study

Atypical Headache in a College Football Player

HISTROTY: A 20 y/o AA defensive end presented in June with c/o severe headache and early AM N/V. Over the past 24°, he c/o a mild HA and neck pain following an abrupt neck rotation. He was dx. with a mild HA 2° to cervical muscle spasms. He was treated with Tylenol and PT which improved his neck sx., but his HA worsened. His pain was described as throbbing pain in the L temple which was exacerbated by exertion or flexion of the neck. He c/o photophobia but no visual disturbances. He denied parasthesia. Pt. had no hx of migraines. PHYSICAL EXAMINATION: BP 147/77, P 60, Temp 97.2, Pulse Ox 97%. PERRLA. EOMI. Fundoscopic exam WNL. Neck was supple with full ROM with pain. Further exam WNL. HISTROTY cont.: Pt. was given NSAIDS/PT for his neck and improved for 2 days but had return of severe HA with N/V and was seen in the ER. He was treated for migraine with opiates, antiemetics, and IV hydration. He improved for 4 days, but he presented again with return of sx and was treated. He improved for 8–10 hours, but he came in to our office the next day with return of sx. He was then admitted to the hospital. PHYSICAL EXAMINATION cont.: BP 133/59, P50, R 16, Temp 99.0. PERRLA. EOMI. Fundoscopic exam WNL. Mild meningismus present. Further exam WNL. DIFFERENTIAL DIAGNOSIS: Cervical Muscle Strain with 2° HA Migraine Meningitis Intracranial Hemorrhage Intracerebral Artery Aneurysm M.O.L. Other cerebrovascular abnormality TEST AND RESULTS: Noncontrast Axial CT - Slightly increased attenuation along L edge of tentorium attributed to vasculature, otherwise WNL MRA - Moderate tortuosity of the cervical segments of the internal carotid arteries bilaterally, L>R, otherwise WNL C-Spine XRAYS - Reversal of cervical lordosis, otherwise WNL MRI - Thrombosis of the superior sagittal sinus, L transverse sinus, L sigmoid sinus, and a portion of the jugular vein near the skull base. No evidence of other hemorrhage/infarct LP - WNL, normal opening pressure Hypercoagulability Panel - Elevated Factor VIII (359), vWF (398) FINAL WORKING DIAGNOSIS: Cervical Muscle Strain Cerebral Venous Thrombosis TREATMENT AND OUTCOMES: The pt. was transferred to a tertiary care hospital for further eval/tx. The patient was started on a heparin drip and converted to PO Coumadin/Subcutaneous Lovenox at d/c. His sx gradually improved. He was maintained on Coumadin for 6 mos.

Cervical Spine Fractures in the Elderly

Objectives: Physicians obtain an estimated 800,000 C-spine x-rays annually with cervical spine injury (CSI) occurring 2.4% of the time. Of these, it has been found that geriatric patients experience more falls than their younger counterparts. Studies indicate that the elderly population falls due to decreased proprioception, vertigo, cardiac etiology leading to syncope, or mechanical falls. Combined with the conditions of an aging body (osteoporosis, decreased elasticity, decreased muscle mass, and decreased coordination), a simple fall can become a life-threatening event.

Cranio-cervical stabilization of traumatic atlanto-occipital dislocation with minimal resultant neurological deficit

Our purpose is to describe a case of atlanto-occipital dislocation and discuss treatment approaches to minimize subsequent neurological deficits. Traumatic atlanto-occipital dislocation, has traditionally been considered rare and lethal, due to resulting high levels of spinal cord injury. Outcomes are generally expected to be poor. However, recent case reports indicate that survival is increasing. Of patients who survive cranio-cervical dislocation, many endure resulting neurological deficits. We present a rare case of a 23-year-old male, who sustained an atlanto-occipital dislocation in a motor vehicle accident. The patient presented with a Glasgow Coma Scale (GCS) of 11T. Lateral C-spine x-ray and thin-section slices CT delineated a C1 ring fracture on the left side with approximately 1 cm anterior and superior subluxation of the occipital condyles of the cranium in reference to C1. The patient was completely awake, alert, and was following commands. The patient underwent a cranio-cervical stabilization from occiput to C3, using lateral mas screws (C1-C3) and transarticular screws (C2-C3). The Vertex (Medtronics) system used included longitudinal bars connected to the lateral mas plating system, which was subsequently used to place screws within the keel of the occipital bone. Motor strength and sensation remained intact following surgery. One-week post-operation, the patient was ambulating 140 feet, conversationally appropriate, and had a GCS of 15. This case illustrates the possibility for neurosurgical intervention of cranio-cervical dislocations to achieve optimal outcome and demonstrates that survival from this injury is not only conceivable, but recovery of function is also possible.

Does the Canadian C-Spine Rule Miss Unstable Injuries?

Unstable cervical-spine injuries, while uncommon, are potentially devastating if missed; thus, c-spine x-rays are ordered frequently. Researchers at a community teaching hospital in Australia assessed whether mandated use of the Canadian C-Spine Rule (a clinical decision rule intended to reduce unnecessary orders for x-rays) affected x-ray ordering rates and length of time patients wore hard …

Reducing the time to clear the cervical spine of trauma patients in the emergency department

Abstract Objectives This study was conducted to determine if the time taken to exclude cervical spine (c-spine) injury in Emergency Department (ED) trauma patients could be reduced by having the full series of c-spine x-rays performed in the resuscitation room as part of the routine trauma series x-rays. The quality of c-spine x-rays taken in the resuscitation room was also evaluated. Methods Any patient with a suspected cervical spine injury presenting on a weekday was triaged to the resuscitation room. A full cervical series of three x-rays were obtained in the resuscitation room together with the trauma series of radiographs as clinically indicated. The time taken to remove cervical spine immobilisation devices following x-ray clearance from the medical staff was recorded. The quality of the x-ray images were formally assessed and reported by a consultant radiologist. The results were compared with matched historical controls obtained from the trauma service database. Results There were 21 consecutive patients in the study which was conducted over a three month period. The mean time taken for patients in the control group to have their cervical spine immobilisation device removed following cervical spine x-ray clearance was 262 minutes (median 186 minutes), and in the study group 100 minutes (median 80 minutes). This decrease in time was statistically significant: p=0.007. There was no significant difference in the adequacy of x-ray films undertaken in the ED. Conclusion Cervical spine x-ray imaging performed in the resuscitation room as part of the initial trauma series panel, considerably reduces the length of time trauma victims spend in a cervical spine immobilisation device, awaiting clearance of cervical spine injury, without compromising quality of care.

Paper reports overview: Sepsis, insulin and noninvasive ventilation

commentary reflects on the paper reports published in the Critical Care Forum between 6 November 2001 and 8 January 2002 The paper reports presented here reflect the current leading issues in the intensive care the search for the 'magic bullet' in sepsis being an obvious example. Many of the trials in sepsis that are currently being reported were presented at recent conferences [1]. is the case for the KyperSept Antithrombin III Study [2]. The summary of this paper highlights the disappointment of the study: ATIII [antithrombin III] joins a long list of promising experimental agents for sepsis that failed to show a significant benefit in a multicentre, randomised phase III clinical trial. Although some success has been reported with 'magic bullet' studies [3], the paper by Rivers and colleagues [4] puts these to shame by demonstrating a superlative outcome benefit with essentially good early resuscitative care in severe sepsis and septic shock. Goal-directed therapy in the emergency department for patients with severe sepsis and septic shock improved survival from 46.5% (control) to 30.5% (goal-directed therapy). was achieved by targeting central venous saturation – an investigation that could easily be performed in most modern emergency departments – and the resultant treatment was by no means complicated or expensive: increased fluids and/or blood, and occasionally dobutamine for inotropic support. That study mirrors the already impressive and abundant evidence for goal-directed therapy in another patient population – the high-risk surgical patient [5]. It is incredible, yet disconcerting, that a relatively basic but successful and cheap treatment for the high risk or critically ill patient is not current practiced in many intensive care units. However, the expensive practice of magic bullets will no doubt be enthusiastically received, despite the fact that the results are far less impressive. The report of Rivers and colleagues [4] emphasizes the enormous benefits that may be achieved by early, good, basic critical care management. The benefits of noninvasive ventilation once again feature prominently in our paper reports [6]. Patients with acute hypoxaemic respiratory failure following lung resection were randomized to standard care with or without nonintermittent positive pressure ventilation. Not surprisingly, the need for extubation was significantly higher in the control group, as was hospital and 120-day mortality. It would be interesting to know whether this mortality benefit remained significant if the randomization had been to nonintermittent positive pressure ventilation versus invasive ventilation. Hormone therapy has always been popular in the critically ill, and one report [7] investigated intensive insulin therapy in nondiabetic surgical and critically ill patients. Crude hospital mortality was 7.2% in the intensive therapy group versus 10.9% in the control group (P = 0.01), and this benefit was associated with a 46% reduction in bloodstream infections. Finally a Canadian study [8] derived the 'Canadian C-spine rule' in order to allow more selective and specific ordering of C-spine X-rays in trauma patients who are alert and stable. The derived rule had a sensitivity of 100% and specificity of 42.5%. As was highlighted in the first paper report overview published back in November 1999 [9], there has been an exponential growth in the amount of literature specific to intensive care and related fields. This is set against the background of an ever-increasing service commitment and so time is at a premium to reflect on important breakthroughs in the literature, it said. Our paper reporters, who are few in number as compared with the amount of evidence based literature out there, are not immune to these time constraints. If you, the reader, would like more papers critiqued, or even to join our 'merry band of reporters', contact us on editorial@ccforum.com.