Examination Of Cervical Spine Research Articles

SU‐E‐I‐51: Use of Blade Sequences in Cervical Spine MR Imaging for Eliminating Motion, Truncation and Flow Artifacts

Purpose:To assess the efficacy of the BLADE technique to eliminate motion, truncation, flow and other artifacts in Cervical Spine MRI compared to the conventional technique. To study the ability of the examined sequences to reduce the indetention and wrap artifacts, which have been reported in BLADE sagittal sequences.Methods:Forty consecutive subjects, who had been routinely scanned for cervical spine examination using four different image acquisition techniques, were analyzed. More specifically, the following pairs of sequences were compared: a) T2 TSE SAG vs. T2 TSE SAG BLADE and b) T2 TIRM SAG vs. T2 TIRM SAG BLADE. A quantitative analysis was performed using the signal‐to‐noise ratio (SNR), contrast‐to‐noise ratio (CNR) and relative contrast (ReCon) measures. A qualitative analysis was also performed by two radiologists, who graded seven image characteristics on a 5‐point scale (0:non‐visualization; 1:poor; 2:average; 3:good; 4:excellent). The observers also evaluated the presence of image artifacts (motion, truncation, flow, indentation).Results:Based on the findings of the quantitative analysis, the ReCON values of the CSF (cerebrospinal fluid)/SC (spinal cord) between TIRM SAG and TIRM SAG BLADE were found to present statistical significant differences (p<0.001). Regarding motion and truncation artifacts, the T2 TSE SAG BLADE was superior compared to the T2 TSE SAG and the T2 TIRM SAG BLADE was superior compared to the T2 TIRM SAG. Regarding flow artifacts, T2 TIRM SAG BLADE eliminated more artifacts compared to the T2 TIRM SAG.Conclusion:The use of BLADE sequences in cervical spine MR examinations appears to be capable of potentially eliminating motion, pulsatile flow and trancation artifacts. Furthermore, BLADE sequences are proposed to be used in the standard examination protocols based on the fact that a significantly improved image quality could be achieved.

A Rare Cause of Scapular Pain

A 57-year-old male patient presented to an academic sports and spine clinic with acute scapular pain and what he described as “winging” of the scapula. Three weeks before his presentation, increasingly severe pain began to develop through his left shoulder; it radiated down the upper arm, and he had pain along his left ribcage. At the same time, a significant prominence of his left scapula abruptly developed. He experienced pain when leaning on the area and upon moving the extremity, and he felt weak when lifting objects. He denied numbness or any symptoms in his other extremities. He reported a previous history of chronic neck issues and an electrocution injury involving his cervical region and left arm that resulted in persisting upper back pain radiating down his left arm and intermittent tingling in the ring and long fingers; however, these symptoms were described as distinctly different and far milder than his presenting complaints. He had no other significant medical history other than a 30-pack-year smoking history. Upon examination, the patient appeared well and was in no apparent distress. The left scapular region protruded from the chest wall at rest (Figure 1). Palpation revealed a nontender prominence following the course of the scapula, but palpation of the scapular borders was difficult. Mild tenderness to palpation at the left lateral rib cage adjacent to the lower scapula was noted. His scapula did not wing further with resisted scapular protraction or a wall push-up. He had weak shoulder external rotation and shoulder abduction to a lesser degree with minimal pain. The results of a cervical spine examination and the remainder of the neurologic examination were normal. A workup was completed, including the images provided, magnetic resonance imaging, and computed tomography angiography (Figures 2 and 3, respectively), and open biopsy pathology results confirmed pleomorphic spindle cell sarcoma with evidence of myofibroblastic differentiation, high grade (Figure 4). Soft-tissue sarcomas (STS) are the most frequent sarcomas identified, with an incidence of 10,660 cases reported in the United States in 2009. They most commonly occur in the extremities (60%). At least 50 different histologic subtypes of STS exist; pleomorphic sarcoma (malignant fibrous histiocytoma) is one of the most common, with a predilection for the shoulder/shoulder girdle [1,2]. Surgery is the standard primary treatment for most sarcomas. Limb-sparing surgery is recommended for extremity STS to achieve local tumor control with minimal morbidity [1]. High-grade extremity sarcomas are at high risk for local recurrence and metastasis, and thus many patients are treated with radiation therapy and chemotherapy preoperatively or postoperatively [1,2]. Factors associated with decreased overall survival and local recurrence in patients are tumor characteristics, including stage, grade, size, depth, and anatomic location [3]. In a Mayo clinic study of 248 cases of intermediateor high-grade surgically treated STS of the extremities diagnosed between 1995 and 2008, the 5-year incidence of local recurrence was 4.1% [3]. Patients who had positive surgical margins or margins of less than 2 mm had 5-year survival rates of 47% versus 72% in patients with wide margins [3]. Cases of STS in the infraspinatus muscle itself are rare. Four previous cases of sarcoma located in the infraspinatus muscle were found in a review of the literature. The first case, published in 1897, was in an 8-year-old child who underwent excision of the scapula [4]. A second case published in 1938 described a 17-year-old male patient who underwent surgical excision of the tumor, as well as at least part of the scapula [5]. A more recent publication describes a 28-year-old Japanese woman who underwent surgical excision of the infraspinatus muscle, part of the teres minor and teres major, and near-complete resection of the scapular periosteum [2]. The fourth case was noted in a study of function after a subtotal scapulectomy for bony or soft-tissue tumors among patients presenting to a university musculoskeletal oncology unit

Clinical clearance of the cervical spine in patients with distracting injuries

The purpose of this study was to prospectively assess the sensitivity and efficacy of clinical examination for screening of cervical spine (c-spine) injury in awake and alert blunt trauma patients with concomitant "distracting injuries." During the 24-month period from December 2009 to December 2011, all blunt trauma patients older than 13 years were prospectively evaluated with a standard cervical spine examination protocol by the trauma surgery team at a Level 1 trauma center. Awake and alert patients with a Glasgow Coma Score (GCS) ≥14 underwent clinical examination of the cervical spine. Clinical examination was performed regardless of "distracting injuries." Patients without complaints of pain or tenderness on physical exam had their cervical collar removed, and the c-spine was considered clinically cleared of injury. All awake and alert patients with "distracting injuries," including those clinically cleared and those with complaints of c-spine pain or tenderness underwent computerized tomographic (CT) scanning of the entire c-spine. "Distracting injuries" were categorized into three anatomic regions: head injuries, torso injuries and long bone fractures. Patients with minor distracting injuries were not considered to have a "distracting injury." During the 24-month study period, 761 blunt trauma patients with GCS ≥14 and at least one "distracting injury" had been entered into the study protocol. Two-hundred ninety-six (39%) of the patients with "distracting injuries" had a positive c-spine clinical examination, 85 (29%) of whom were diagnosed with c-spine injury. Four hundred sixty-four (61%) of the patients with "distracting injuries"’ were initially clinically cleared, with one patient (0.2%) diagnosed with a c-spine injury. This yielded an overall sensitivity of 99% (85/86) and negative predictive value greater than 99% (463/464) for cervical spine clinical examination in awake and alert blunt trauma patients with "distracting injuries." In the awake and alert blunt trauma patient with "distracting injuries," clinical examination is a sensitive screening method for cervical spine injury. Radiological assessment is unnecessary for safe clearance of the asymptomatic cervical spine in awake and alert blunt trauma patients with "distracting injuries." These findings suggest the concept of "distracting injury" in the context of cervical spine clinical examination is invalid. Expanding the utility of cervical spine clinical examination to patients with "distracting injuries" allows for significant reduction of both healthcare cost and radiation exposure.

T2 radiculopathy: A differential screen for upper extremity radicular pain

Radicular pain in the upper extremity can have a cervical origin terminating at the cervicothoracic junction (C8, T1). Review of the literature suggests cutaneous representations of T2 nerve root to the axilla, posteromedial arm, and lateral forearm, suggesting yet another source of upper extremity radicular pain. A 53-year-old female experienced insidious right upper thoracic pain radiating into the right axilla, upper arm, and lateral forearm (10/10 numerical pain rating scale (NPRS)) of 1-week duration. Medical referral suggested cervical radiculopathy, however, cervical spine examination was unremarkable. She presented with mechanical dysfunction of C8, T1; T1, T2; and T2, T3 vertebral segments with restricted cervical extension. Firm compression over the right lateral aspect of the second and third thoracic vertebrae reproduced her symptoms markedly. There was a predominance of right axillary pain. Cervical extension reproduced local upper thoracic pain. Nine treatment visits for a period of 3 weeks addressed mechanical dysfunction at the cervicothoracic junction and upper thoracic region, comprising manual therapy, corrective exercise, and pain modalities. Reduction of local tenderness, and radiating axillary and right arm pain was observed (2/10 NPRS), with improved cervical extension. The second thoracic intercostal nerve and the adjoining intercostobrachial nerve, medial antebrachial cutaneous nerve, and the posterior brachial cutaneous branch of the radial nerve are speculated to be potential symptom mediators. They have a representation to the axilla, medial and posterior arm, and lateral forearm – a representation supporting the speculation of upper extremity radicular symptoms following mechanical dysfunction of the upper thoracic vertebrae.

Role of Greater Occipital Nerve Blocks and Trigger Point Injections for Patients With Dizziness and Headache

The trigeminocervical system is integral in cervicogenic headache. Cervicogenic headache frequently coexists with complaints of dizziness, tinnitus, nausea, imbalance, hearing complaints, and ear/eye pain. Controversy exists as to whether this constellation of symptoms may be cervically mediated. To determine whether a wider spectrum of cervically mediated symptoms exist, and to investigate a potential role of greater occipital nerve blocks (GON) and trigger point injections (TPI) in these patients. Retrospective review of GON/TPI performed in a tertiary otoneurology/headache clinic from May 2006 to March 2007 for suspected cervically mediated symptoms. Data included chief complaint, secondary symptoms, response to injection, pre-GON/TPI posterior vertex sensation changes to pinprick, cervical spine examination, and response to vibration of cervical and suboccipital musculature. Total number of 147 patients were included. Chief complaints in decreasing frequency: dizziness (93%), tinnitus (4%), headache (3%), and ear discomfort (0.7%). Overall symptoms in decreasing frequency: dizziness (97%), headache (88%), neck pain (63%), tinnitus (23%), and ear discomfort (22%). Improvements after GON/TPI: neck range of motion (71%), headache (57%), neck pain (52%), ear discomfort (47%), dizziness (46%), and tinnitus (30%). Dizziness responders had neck position asymmetries (84%), reproducible dizziness by cervical and suboccipital musculature vibration (75%), and preinjection posterior vertex sensory changes (60%). A wider spectrum of cervically mediated symptoms may exist by influence of trigeminocervical and vestibular circuitry through cervical afferent neuromodulation. Certain examination findings may help to predict benefit from GON/TPI.

Evaluation of dose to tooth enamel from medical diagnostic X-ray examinations at Mayak PA

Abstract The nuclear workers of the Mayak Production Association had regular check-ups including medical diagnostic X-ray examinations since start of the production lines in 1948. Doses from diagnostic examinations need to be considered in reconstruction of occupational doses of the workers with electron paramagnetic resonance (EPR) of tooth enamel. The numbers and types of examinations of an individual worker can be assessed from the Mayak PA archives but no information was available on doses delivered to teeth by a single specific examination. Of the twenty one applied examination procedures only three affected the teeth, these being X-ray examinations of teeth, skull and cervical spine. For these three kinds of examinations operational procedures and operating modes of X-ray units were compiled from the archive and photon spectra were obtained from a catalog of spectral data for diagnostic X-rays. Entrance doses in air kerma were calculated using the fluence of photon spectra and absorbed dose in tooth enamel for various tooth positions and exposure geometry was then calculated using dose conversion coefficients obtained from Monte Carlo simulations. Doses were calculated for examinations in 1948–2000. Except for examination of the skull, absorbed doses in enamel of incisors were found to be about twice as large as in enamel of molars. In the period before 1970 the largest mean absorbed doses in tooth enamel were due to X-ray examination of teeth, with 64 mGy and 34 mGy calculated for incisors and molars, respectively. In the same period the lowest mean doses were due to X-ray examination of the skull, with 11 mGy and 12 mGy calculated for incisors and molars, respectively. In the period from 1970 to 2000, largest mean doses in enamel were due to X-ray examination of cervical spine, with 23 mGy and 12 mGy calculated for incisors and molars, respectively.

Occipito-Atlanto-Axial Osteoarthritis

A cross-sectional clinico-radiologic evaluation of occipito-atlantoaxial (OC1C2) region of 2 population groups. Determine the prevalence of OC1C2 osteoarthritis in porters involved in carrying loads on the head and general male population. Describe its clinico-radiologic manifestations. In addition to age, head loading is a known cause of degeneration affecting the occipito-cervical region. The impact of head loading in the population aged between third and sixth decade is unknown. Head loading is a common custom in the developing countries. Study group (n = 107) included randomly selected male porters from railway stations who underwent computed tomography (CT) study of the OC1C2 region, plain radiographs of the cervical spine and detailed clinical examination. Control group (n = 107) included randomly selected male patients undergoing CT scan study for diseases of paranasal sinuses with coincidental screening of OC1C2 region along with clinical assessment. The data were analyzed using SPSS 15 software. Mean age for study group was 32.6 years and controls was 34.6 years (P = 0.156). In the study group, duration of occupational exposure was 10.9 (+/-8.7) years; 81.3% porters being symptomatic with an age of 33.4 (+/-9.6) years. Radiologic prevalence of OC1C2 osteoarthritis in study group was 91.6% and in control group was 6.8%; age of affected individuals was 33.4 (+/-9.3) and 47.9 (+/-8.0) years, respectively. Most common complaint was suboccipital neck pain (69.7%); while the CT finding was decreased joint space with sclerosis and irregularity of the margins (81.3%). No statistically significant association was found between presence of radiologic changes and symptoms. Age, duration of occupational exposure and its relationship with various clinico-radiologic manifestations was studied. This condition has significant prevalence in porters, beginning at an early age. Diagnosis is based on the clinico-radiologic presentation. CT is the investigation of choice. Resultant functional limitations make early identification of this condition imperative.

Letter to the Editor Re: Voice Recognition Dictation: Radiologist as Transcriptionist and Improvement of Report Workflow and Productivity Using Speech Recognition—A Follow-up Study

Letter to the Editor Re: Voice Recognition Dictation: Radiologist as Transcriptionist and Improvement of Report Workflow and Productivity Using Speech Recognition—A Follow-up Study

Post-traumatic c7-t1 spondyloptosis in a patient without neurological deficit: a case report

Traumatic cervical spondyloptosis has almost always been associated with disabling neurological deficit and we could only find one case without a neurological deficit reported in the literature. A 42 year old man suffering from severe neck pain following a high speed motor vehicle accident was admitted to our hospital. Magnetic resonance imaging (MRI) and computerized tomography (CT) of the cervical spine and neurologic examination of the patient were performed. The patient was treated with three-column fixation of the traumatic level. We aimed to report a unique case of traumatic C7-T1 total spondyloptosis without a neurological deficit and discuss possible mechanisms and treatment modalities.

Converting Dose-Length Product to Effective Dose at CT

To determine effective dose (ED) per unit dose-length product (DLP) conversion factors for computed tomographic (CT) dosimetry. A CT dosimetry spreadsheet was used to compute patient ED values and corresponding DLP values. The ratio of ED to DLP was determined with 16-section CT scanners from four vendors, as well as with five models from one manufacturer that spanned more than 25 years. ED-to-DLP ratios were determined for 2-cm scan lengths along the patient axis, as well as for typical scan lengths encountered at head and body CT examinations. The dependence of the ratio of ED to DLP on x-ray tube voltage (in kilovolts) was investigated, and the values obtained with the spreadsheet were compared with those obtained by using two other commercially available CT dosimetry software packages. For 2-cm scan lengths, changes in the scan region resulted in differences to ED of a factor of 30, but much lower variation was obtained for typical scan lengths at clinical head and body imaging. Inter- and intramanufacturer differences for ED/DLP were generally small. Representative values of ED/DLP at 120 kV were 2.2 microSv/mGy x cm (head scans), 5.4 microSv/mGy x cm (cervical spine scans), and 18 microSv/mGy x cm (body scans). For head scans, ED/DLP was approximately independent of x-ray tube voltage, but for body scans, the increase from 80 to 140 kV increased the ratio of ED to DLP by approximately 25%. Agreement in ED/DLP data for all three software packages was generally very good, except for cervical spine examinations where one software package determined an ED/DLP ratio that was approximately double that of the other two. This article describes a method of providing CT users with a practical and reliable estimate of adult patient EDs by using the DLP displayed on the CT console at the end of any given examination.

Sternoclavicular Stress Lesions In An Adolescent Gymnast

HISTORY: A 13 year old level 7 gymnast presented with a three week history of insidious onset of pain in the proximal clavicular area of his left, non-dominant shoulder. He had no pain at rest or at night. He had recently added a new maneuver to his routine on the parallel bars. Radiographs were normal but further study with CT scanning was performed. The clavicle healed over time. About 5 months after the initial injury he felt a pop in his sternoclavicular (SC) joint area while doing a routine on the parallel bars. He had immediate onset of pain and swelling and could not continue. He again sought an evaluation to determine the nature of this injury. He had been in good health with no previous history of shoulder problems, systemic health problems, previous fracture or tumors. PHYSICAL EXAMINATION: Upon physical examination the patient appeared younger than his stated age but was otherwise normal in appearance. He had no atrophy but did have swelling at his right SC joint area. The swollen area on the right was firm, not mobile and nontender. His cervical spine examination was normal with no limitations of motion. He had full range of motion and strength in both shoulders. He was neurologically intact for sensation, motor and reflexes for both upper extremities. He had normal vascularity to both upper extremities with normal pulses and capillary refill. No provocative maneuvers could reproduce his pain. DIFFERENTIAL DIAGNOSIS: Fracture proximal clavicle Stress lesion proximal clavicle Tumor proximal clavicle Systemic arthritis both SC joints Congenital abnormality both SC joints TEST AND RESULTS: Left shoulder: Plain radiographs normal MRI suggests proximal humerus lesion Blood studies normal including rheumatoid screen and small cell tumor screen Right shoulder: Plain radiographs suggest possible abnormality proximal humerus CT scanning suggests that nonunion of physeal stress lesion FINAL WORKING DIAGNOSIS: Healed physeal stress fracture left proximal clavicle Nonunion physeal stress fracture right proximal clavicle TREATMENT AND OUTCOMES: Left physeal injury curtailed gymnastics for a month and no subsequent symptoms Right physeal injury returned to gymnastics with no limitations; follow up CT scan one year later showed continued nonunion at two years after injury

Estimation of adult patient doses for common diagnostic X-ray examinations in Rio de Janeiro, Brazil

DoseCal software has been used to evaluate the Entrance Surface Dose (ESD) and Effective Dose (ED) of adult patients undergoing abdomen, cervical spine, chest, lumbar spine and skull diagnostic X-ray examinations in AP, PA and LAT projections. The survey was carried out in nine hospitals in Rio de Janeiro state with a total of 1917 radiographs. The mean values of ESD (mGy) and ED (mSv) were recorded. Although the results obtained are below the international diagnostic reference levels, they present large variations within and between hospitals which reflects the disparity of radiographic techniques used in the examinations. The results were compared with the European Community Reference Levels. Even though in Brazil there are specific legislations on radiation protection and implementation of Quality Assurance Programs (QAPs) in all medical institutions, there is still a need for personnel training and national guidance on good practice for optimization of patients' doses.

Sprengelʼs Deformity in Klippel-Feil Syndrome

A retrospective study. To address the role of congenitally fused cervical segments, the degree of cervical scoliosis, and other risk factors on the presence of Sprengel's deformity (SD) in young patients with Klippel-Feil syndrome (KFS). Numerous abnormalities are associated with KFS, one of the most common being SD. It has been postulated that more severe forms of KFS may be more associated with extraspinal manifestations, such as SD. Thirty KFS patients from a single institution were reviewed. Cervical neutral lateral/dynamic/anteroposterior and thoracic anteroposterior plain radiographs were assessed. Radiographically, occipitalization (O-C1), number of congenitally fused segments (C1-T1), classification type (Types I-III), degree of cervical scoliosis, and the presence of SD was assessed. Clinical chart review entailed patient demographics and evidence of the clinical assessment of SD. The threshold for statistical significance was P < 0.05. There were 11 males (36.7%) and 19 females (63.3%) with a mean age of 13.5 years (range, 2.7-26.3 years). Occipitalization was present in 10 (33.3%) individuals and C2-C3 was the most common level fused (70.0%). The mean number of congenitally fused segments was 3.3 (range, 1-6 levels). The mean degree of cervical scoliosis was 17.3 degrees (range, 0 degrees-67 degrees). There were 6 (20%) Type I, 15 Type II (50.0%), and 9 Type III (30%) patients. SD was noted in 5 (16.7%) of the patients. Four patients had unilateral, whereas 1 patient had bilateral SD. There was 4.0 and 3.1 mean number of congenitally fused segments in patients with or without SD, respectively. SD did not occur in Type I patients (single fused block). The presence of SD was found to be nonsignificant regarding sex type (P = 0.327), presence of occipitalization (P = 0.300), number of congenitally fused segments (P = 0.246), specific congenitally fused segments (P > 0.05), classification type (P > 0.05), and scoliosis (P = 0.702). SD occurred in 16.7% of KFS patients. Sex type, number of congenitally fused segments, specific fused patterns, occipitalization, classification type, and the degree of cervical scoliosis did not seem to be significantly associated with the presence of SD in KFS patients in our series. Thorough examination for the presence and degree of SD in KFS is necessary, irrespective of the extent of cervical abnormalities. Alternatively, the treating physician should not dismiss a thorough cervical spine examination in patients with SD, evaluating factors that may predispose the KFS patient to an increased risk of neurologic injury.

Management of headache disorders: design of a randomised clinical trial screening for prognostic patient characteristics

BackgroundTreatment of headache disorders is not always optimal. Patients are treated in multiple ways, and the lack of scientific arguments for referral and the insufficient implementation of guidelines result in unclear treatment strategies.The coexistence of headache and neck pain can lead to the referral to a musculoskeletal physiotherapist. This treatment can only be successful if an underlying cervical segmental dysfunction is present. In such cases a physical treatment can be a valuable option that should be considered.The aim of this study is to identify prognostic therapeutic patient characteristics and to increase the number of correct physiotherapy referrals.Methods/designThis trial is designed to identify patient characteristics which can influence the prognosis of the patient. Patients with recurrent headache and co-existent neck pain are recruited via a multicenter setup. After screening for eligibility, subjects are tested at baseline and randomly allocated to one of two treatment groups. Testing includes the administering of questionnaires (a Headache Diagnosis Questionnaire, Headache Inventory List and the Headache Impact Test (HIT-6)) and physical tests (Thermal Stimuli, Manual Cervical Spine Examination and Pressure Algometry). Treatment groups are a usual care group (UC) administered by the General Practitioner (GP) and a usual care plus musculoskeletal physiotherapy treatment group (UCMT). UC is based on the Dutch GP Guideline for Headache. UCMT consists of the UC plus a combination of exercises and spinal cervical mobilisations. Follow-up measurements consist of the completion of the Headache Inventory List, the HIT-6 and scoring of the global perceived effect (GPE). The latter allowing the distinction between responders (positive effect) and non-responders (no effect or worse). Logistic regression analysis will be used to identify the specific patient characteristics of the responders and the non-responders. The additional value of the musculoskeletal physiotherapy will be examined. Follow-up measurements up to 52 weeks are scheduled.DiscussionThis trial aims to identify prognostic patient characteristics, in order to supply a useful diagnostic tool for all health care workers, dealing with headache sufferers.

Ocena skuteczności leczenia pacjentów z szumami usznymi za pomocą krioterapii ogólnoustrojowej

The aim of the study was evaluation of effectiveness of whole-body cryotherapy in patients with tinnitus. The research was carried out in 120 patients (aged 20-68) with tinnitus, divided into two groups: I--80 patients treated by cryotherapy and II--40 patients non treated. There were: 73 women and 47 men. Among patients of I group: 39 reported bilateral tinnitus, 20 reported right tinnitus, 15 reported left tinnitus and 6 reported tinnitus in head. Duration of the ailment took from 1 month to 23 years. The methods included: taking a history, otolaryngological physical examination, audiometry establishing level of tinnitus, medical consultation, X-ray examination of chest and cervical spine and CT of head. After examinations and additional consultations the patients were qualified for cryotherapy unless there were some contraindications. The patients underwent 10 procedures in two cycles with the weekend break. They were in cryochamber in temperature of -110 degrees C for 3 minutes. After cryotherapy they used kinesitherapy for 45 minutes. Intensity and troublesomeness of tinnitus was evaluated using self-assessment chart (point scale 0-100) and audiometry establishing level of tinnitus before and after treatment. The results indicates complete elimination of tinnitus in 4 patients, decrease in their intensity in 47 patients, maintenance of the ailment on the same level in 13 people and slightly increase of tinnitus in 16 patients. In audiometry we could observe in I group changes in frequency of tinnitus in 138 ears and changes in intensity of tinnitus in 91 ears. After treatment decrease of average hearing loss and average hearing damage were observed. Treatment of tinnitus may be effective by using whole-body cryotherapy.

Optimisation of imaging technique used in direct digital radiography

The purpose of the study was to optimise the technique employed for AP shoulder andlateral cervical spine examinations following an investigation into image quality, based onclinical assessment, and effective dose, calculated from patient entrance surfacedose measurements. A study was therefore conducted in an attempt to determinewhether the increased radiation dose to the patient following the introduction of ananti-scatter grid was justified by the level of improvement in image quality. The study,involving 100 patients, was able to demonstrate that the increase in radiation dose tothe patient when using an anti-scatter grid for AP shoulder examinations is notjustified by the improved image quality. A poor level of inter-rater reliabilitybetween the consultants scoring the lateral cervical spine images prevented afirm conclusion from being reached. The fact that all images were of diagnosticquality, however, suggested that the use of the anti-scatter grid was unnecessary.Following completion of the project the hospital involved was informed of all findings.

Throat Trauma - Soccer

HISTORY: A 21-year-old female college soccer player sustained a throat injury. During the last eight minutes of a late season game, the soccer player jumped vertically to head the ball. At the same time, two opposing players from the front and back of the player were positioning themselves to also advance the ball. As all three players jumped simultaneously to head the ball, this soccer player was caught between the two opposing players. She suffered an anterior and posterior head-to-neck collision. There was no observed loss of consciousness. She complained of anterior neck pain that radiated to her posterior neck. No initial shortness of breath or hemoptysis but player complained of throat pain and hoarseness. The player denied any numbness or parasthesias in her upper or lower extremities. PHYSICAL EXAMINATION: Initial On-field examination; General: supine, alert and anxious Neck: (+) Anterior neck pain in Zone II. Trachea was midline and tender, no crepitus, no bleeding in the oropharynx or nasal mucosa, no visible obstruction, dentition intact. Cervical spine examination showed paraspinal muscle tenderness but no bony midline tenderness. Lungs: symmetric respiration, transmitted upper airway sounds, otherwise clear to auscultation bilaterally, no wheezing. Musculoskeletal: strength intact bilaterally in upper and lower extremities. Neurological: intact to tactile stimuli bilaterally in upper and lower extremities. Vital Signs per EMS: BP 110/70 HR 100 RR 28. DIFFERENTIAL DIAGNOSIS: Laryngeal edema Laryngeal spasm Vocal Cord paralysis Vocal Cord hematoma Foreign Body obstruction Bronchospasm TEST AND RESULTS: Pulse Oximetry: 99% RA FINAL WORKING DIAGNOSIS: Trauma induced Laryngeal injury with possible spinal column injury TREATMENT AND OUTCOMES: Cervical spine immobilized with rigid cervical collar and spinal board. Player was given supplemental oxygen via mask and transferred to outside Trauma Center. During EMS transport, hoarseness progressed into stridor with increased respiratory rate and increased shortness of breath. Upon arrival to the Trauma Center, player taken for emergent tracheotomy and further airway management. Cervical spine management per outside hospital protocol.

What Defines a Distracting Injury in Cervical Spine Assessment?

The National Emergency X-Radiography Utilization Study defined five criteria for obtaining cervical spine radiographic investigations in blunt trauma patients. Distracting injury was given as the indication for more than 30% of all x-ray studies ordered. The hypothesis of this study was that upper and lower torso injuries would have different effects on clinical cervical spine assessment. This is a single-center, prospective, observational study of admitted, alert, adult blunt-trauma patients. All patients underwent cervical spine plain-film radiography. Data were collected on all injuries, physical examination findings, narcotic administration, and radiograph results. Patients with upper and lower torso injuries were compared in their ability complain of pain or midline tenderness relative to a cervical spine fracture. In all, 406 patients participated. All patients received narcotic analgesics before examination. Forty patients (9.9%) had cervical spine fractures, of whom seven had a nontender neck examination. All seven patients with a nontender cervical spine and a neck fracture had at least one upper torso injury. None of the 99 patients with injuries isolated to the lower torso and a nontender neck had a cervical spine fracture (p < 0.05). The frequency of cervical spine fracture among patients with cervical spine tenderness was 19.8% (n = 33). The National Emergency X-Radiography Utilization Study definition of a distracting injury may be narrowed. Upper torso injuries may be sufficiently painful to distract from a reliable cervical spine examination. Patients may detect spine tenderness in the presence of isolated painful lower torso injuries. Patients with spine tenderness warrant imaging.

The Inefficiency of Plain Radiography to Evaluate the Cervical Spine After Blunt Trauma

Controversy persists regarding the most efficient and effective method of cervical spine evaluation after blunt trauma. Historic guidelines for patients undergoing computed tomography (CT) of the head advocate imaging the occiput-C2 as part of that study. For the remaining cervical spine, plain cervical spine radiographs (CSR) with supplemental CT are recommended. Many patients who require head CT also undergo supplemental cervical spine CT after plain CSR, which leads to separate, discontinuous cervical spine CT scans. We sought to determine the incidence of this in our population. We hypothesized that plain CSR alone often proves inadequate to evaluate the cervical spine in patients who require head CT. The Eastern Association for the Surgery of Trauma (EAST) guidelines for cervical spine evaluation after blunt trauma were previously adopted and followed during the study period from December 1, 2002 to July 1, 2003. Our protocol included cross-table lateral and anteroposterior CSR with the occiput-C2 imaged with the head CT. We used segmental cervical spine CT to supplement those regions inadequately visualized by plain films. The electronic charts of 848 consecutive blunt trauma victims were retrospectively reviewed. The data abstracted included demographics, injury severity score, and the use and results of head CT and radiographic evaluation of the cervical spine. Of 848 consecutive blunt trauma patients, 716 (84.4%) underwent head CT. Average age was 44 years old, and average Injury Severity Score was 9. Seventy-six patients (11.6%) had clinical cervical spine examination alone, whereas 640 (89.4%) underwent plain CSR. In 178 patients (27.8%), plain two-view CSR visualized the entire cervical spine. Plain CSR were inadequate to visualize the complete cervical spine in 462 patients (72.2%). Of these patients, segmental CT was performed in 400 (87.6%). The remaining 62 (13.4%) patients did not have radiologic completion of their cervical spine evaluation before clinical examination. Nineteen patients (3.0%) had cervical spine fractures diagnosed on CT, of which only 6 (31.6%) were seen on plain CSR. The sensitivity and specificity of CSR to detect fractures was 31.6 and 99.2%, respectively. Plain CSR are inadequate to fully evaluate the cervical spine after blunt trauma, and supplemental CT is commonly required. Complete cervical spine CT is available, efficient, and accurate. Our findings support a growing body of literature that suggests that this modality should be used for blunt trauma patients who require radiographic evaluation of the cervical spine. Plain cervical spine radiographs need not be obtained. The EAST guidelines for cervical spine evaluation after blunt trauma should be updated to reflect this evolving practice pattern.

Computed tomography for cervical spine trauma. The impact of MDCT on fracture detection and dose deposition

A multidetector computed tomography (MDCT) was installed in our department. Referral rates, examination protocols and detection rates of abnormal findings in CT examinations for cervical spine trauma 6 months before and 6 months after MDCT installation were compared to look for changes in practice. Retrospective analysis of all CT cervical spine examinations in patients with multiple trauma over two contiguous 6-month periods: from July 2003 to December 2003 (helical CT) and from January 2004 to June 2004 (MDCT). Variables recorded were number of CT examinations performed, scan plane coverage and traumatic abnormalities detected. Phantom dosimetry measurements for cervical spine examination in both helical CT and MDCT were compared. One hundred and fifty four patients underwent cervical spine CT during these periods. Helical CT period: of 91 patients undergoing CT cervical spine examination for trauma, 65 (71%) were complete cervical examinations and 26 (29%) were level-specific examinations. Eight patients (9%) had cervical spine fracture, six of which were apparent on radiographs. Dose estimations for thyroid, lens and breast were 24.76, 1.86 and 0.21 mGy, respectively, for complete cervical spine examinations. MDCT period: of 63 patients who underwent CT cervical spine examination for trauma, 61 (97%) were complete examinations and 2 (3%) were level-specific examinations. Six patients (11%) had cervical spine fracture, three of which were apparent on radiographs. Dose estimations for thyroid, lens and breast were 75.8, 9.7 and 0.7 mGy, respectively, for complete cervical spine examinations, which were notably higher than those for helical CT. After installation of MDCT, clinical requests for complete examination of the cervical spine following trauma increased. This changing trend resulted in a significantly higher radiation dose to thyroid, lens and breast.