Subluxation Of Spine Research Articles

The changing epidemiology of traumatic spine injuries: a trends analysis of 26 years of patients at a major level 1 trauma center in the United States

BACKGROUND CONTEXTTraumatic spinal injuries (TSI) are associated with high morbidity, mortality, and resource utilization. The epidemiology of TSI varies greatly across different countries and regions and is impacted by national income levels, infrastructure, and cultural factors. Further, there may be changes over time. It is essential to investigate TSI to gain useful epidemiologic information. However, there have been no recent studies on trends for TSI in the US, despite the changing population demographics, healthcare policy, and technology. As a result, reexamination is warranted to reflect how the modern era has affected the epidemiology of US spine trauma patients and their management. PURPOSETo determine epidemiologic trends in traumatic spine injuries over time. STUDY DESIGN/SETTINGRetrospective analysis; level 1 trauma center in the United States. PATIENT SAMPLEA total of 21,811 patients, between the years of 1996 and 2022, who presented with traumatic spine injury. OUTCOME MEASURESAge, sex, race, Injury Severity Score, mechanism of injury, injury diagnosis, injury level, rate of operative intervention, hospital length of stay, intensive care unit length of stay, discharge disposition, in-hospital mortality. METHODSData was collected from our institutional trauma registry over a 26-year period. Inclusion criteria involved at least one diagnosis of vertebral fracture, spinal cord injury, spinal subluxation, or intervertebral disc injury. Exclusion criteria consisted of patients with no diagnosed spine injury or a diagnosis of strain only. A total of 21,811 patients were included in the analysis. Descriptive statistics were tabulated and ordinary least squares linear regression was conducted for trends analysis. RESULTSRegression analysis showed a significant upward trend in patient age (+13.83 years, β=+0.65/year, p<.001), female sex (+2.7%, β=+0.18%/year, p=.004), falls (+10.5%, β=+0.82%/year, p<.001), subluxations (+12.8%, β=+0.35%/year, p<.001), thoracic injuries (+1.5%, β=+0.28%/year, p<.001), and discharges to subacute rehab (+15.9%, β=+0.68%/year, p<.001). There was a significant downward trend in motor vehicle crashes (-7.8%, β=-0.47%/year, p=.016), firearms injuries (-3.4%, β=-0.19%/year, p<.001), sports/recreation injuries (-2.9%, β=-0.18%/year, p<.001), spinal cord injuries (-11.25%, β=-0.37%, p<.001), complete spinal cord injuries (-7.6%, β=-0.24%/year, p<.001), and discharges to home (+4.5%, β=-0.27%/year, p=.011). CONCLUSIONSAt our institution, the average spine trauma patient has trended toward older females. Falls represent an increasing proportion of the mechanism of injury, on a trajectory to become the most common cause. With time, there have been fewer spinal cord injuries and a lower proportion of complete injuries. At discharge, there has been a surge in the utilization of subacute rehabilitation facilities. Overall, there has been no significant change in injury severity, rate of operative intervention, length of stay, or mortality.

SCIDISH – AN UNPREDICTED CASE OF T CELL LYMPHOPENIA, HYPOCALCEMIA, AND SKELETAL ANOMALIES

<h3>Introduction</h3> Biallelic pathogenic variants in <i>PAX1</i> lead to autosomal recessive otofaciocervical syndrome 2 (OTFCS2), characterized by facial and ear abnormalities, hearing loss, skeletal dysplasia, intellectual disability, branchial defects, and athymia. This rare case describes an infant who presented with T cell lymphopenia and hypocalcemia and was diagnosed with a novel homozygous PAX1 variant. <h3>Case Description</h3> A 6-day-old boy born to consanguineous parents was admitted for an abnormal newborn screen (TREC=0) and primary immunodeficiency with T-B+NK- immunophenotype (33/uL CD3+T-cells, 30/uL CD3/CD4/CD45RO cells, undetectable CD3/CD4/CD45RA cells, undetectable CD16/CD56NK-cells). Exam showed dysmorphic facial features, left preauricular pit, and sacral and should dimples. He received prophylactic antimicrobials, and immunoglobulin replacement for hypogammaglobulinemia. He developed seizures, attributed to hypocalcemia secondary to hypoparathyroidism. Further workup indicated presence of NK cells, absent thymic shadow, ASD and PFO on echocardiogram, failed hearing screen, mild laryngomalacia, kyphosis, and spinal subluxation of L5 on S1. FISH and microarray were negative for 22q11.2 deletion. Invitae Primary Immunodeficiency Panel revealed homozygous VUS (c.509C>A(p.Pro170His)) in PAX1, and parents are heterozygous carriers. Patient's clinical picture was most consistent with OTFCS2 with athymia. He was referred for thymus transplantation. <h3>Discussion</h3> Primary thymic defects should be considered in patients with abnormal SCID NBS, specifically in those with hypoparathyroidism. We suggest early genetic testing, as identification of the underlying defect is crucial for prognosis and management. As T-cell dysfunction in OTFCS2 is due to aberrant thymic development, allogeneic thymus transplantation is the expected curative treatment, whereas patients with PAX1 defects who underwent hematopoietic stem cell transplantation failed to gain T cell reconstitution.

만성 요통 환자의 골반 교정 운동이 척추부 변위 변화와 요통 장애 지수에 미치는 영향

이 연구는 부정렬 증후군을 동반한 만성 요통 환자를 대상으로 골반 교정 운동이 요통 장애 지수(ODI), 다리 길이 차이(LLD) 및 척추부 변위 변화에 어떠한 영향을 주는지를 밝히는데 그 목적이 있다. 연구의 대상은 부정렬 증후군을 동반한 만성 요통 환자 16명을 대상으로 운동군(EG, n=8), 통제군(CG, n=8)으로 분류하여 EG는 1회 60분, 주 3회, 12주간의 재활운동을 시행하였다. ODI, LLD 및 척추부 변위 변화(요추 전만각, 천골 경사각, 요추 너비, 천골 너비, 장골 길이 및 장골 너비)는 운동 전과 운동 12주 후 각각 측정하였다. ODI, LLD, 요추 전만각, 천골 경사각, 요추 너비, 천골 너비 및 장골 너비는 CG과 비교해서 EG에서 운동 후에 각각 유의하게 감소하였다(p.001). 이상의 결과, 이 연구에서 부정렬 증후군을 동반한 만성 요통환자의 골반 교정 운동은 ODI, LLD 및 척추부 변위 변화에 효과적인 사실을 증명하였다. 추후 만성 요통 환자를 위한 효율적인 운동방법으로 제시하고자하며 다른 관절부위에도 교정운동 프로그램 구성이 더 필요할 것으로 사료된다.

An epidemiology of paediatric cervical spine injuries at the Red Cross War Memorial Children's Hospital over a ten-year period

Background: Paediatric cervical spine injury (CSI) is rare compared to adult CSI. Very little has been published regarding the epidemiology and outcome of CSI in children in South Africa. The objective of this retrospective study is to characterise the epidemiology and report on the outcome of CSI in children <13 years at a tertiary referral centre for paediatric trauma. Methods: We performed a retrospective study of CSI at our hospital over a ten-year period. The Picture Archiving and Communication System (PACS) of our institution was searched for patients with CSIs. Search terms included: cervical spine fracture, subluxation, dislocation, contusion, SCIWORA (spinal cord injury without radiographic abnormality) and retroclival haematoma. Demographic and clinical data were obtained from hospital records. Injury-related variables were compared for children ≤8 and >8 years due to anatomical and biomechanical differences observed. Outcome was assessed using the Frankel grading. Results: Sixty-six children were identified with a cumulative incidence of 0.1%. The median age was 7 years (inter-quartile range 4–8.8) and 65% were male. All injuries were caused by blunt trauma. Passenger motor vehicle injury (MVA) accounted for 52% of injuries. Injuries due to physical abuse, and recreational and sporting activities did not occur. Children ≤8 years of age incurred more injuries than those >8 years (74.2% vs 25.8%). Ninety-eight per cent of injuries occurred in the upper cervical spine (C1–C4) of children ≤8 years. Of the 13 (19.6%) children with neurologic injury, five (7.5%) had complete spinal cord injury, four (6%) had incomplete neurology, and three (4.5%) died. SCIWORA occurred in six (9%) children with variable outcome. Seven patients (10.6%) were operated for instability. An injury severity score (ISS) of 25 (13–34) was associated with poor outcome. The mortality rate was 4.5% and all children who died were ≤8 years with upper CSIs and closed head injuries (CHIs) related to MVA. Conclusion: CSI occurred in 0.1% of patients evaluated following trauma. MVAs, either pedestrian or passenger, were responsible for the majority of these injuries. Children ≤8 years were more frequently injured and sustained injuries to the upper cervical spine. The majority of paediatric CSIs are stable injuries that can be managed conservatively; however, urgent surgical stabilisation is indicated for unstable injuries. CSI with associated CHI caused by MVAs in young children is associated with death. Even though our patients are referred from high violence communities, no CSIs were attributed to physical abuse or penetrating injury. Level of evidence: Level 4

Clinical analysis of postoperative complications of lumbosacral selective posterior rhizotomy for the treatment of spastic cerebral palsy

Objective To study the complications of lumbosacral selective posterior rhizotomy (SPR) for the treatment of spastic cerebral palsy and to provide the prevention strategies. Methods We retrospectively reviewed the surgical outcome and postoperative complications of 508 patients with spastic cerebral palsy who underwent SPR surgery at Department of Neurosurgery of Beijing Fengtai Hospital, The First Hospital of Peaking University from March 2003 to November 2016 and were followed up for more than one year. The complications were divided into 2 main categories: perioperative complications (from post operation to discharge) and medium to long-term (follow-up of over 1 year) complications. Incidence, causes, treatment approaches of complications as well as outcomes were analyzed. Results A total of 508 patients were included in this cohort. The overall response rate (modified Ashworth spasm scale≤2 grade) was 93.7% (476/508). Perioperative transient complications included lower extremity weakness in 76 (15.0%) cases, abdominal pain in 39 (7.7%), lower extremity sensory deficit in 29 (5.7%), headache related to low intracranial pressure in 18 (3.5%), transient urinary retention in 9 (1.8%), slow incision healing in 5 (1.0%), cerebrospinal fluid leakage in 3 (0.6%), incision infection in 2 (0.4%), and aspiration pneumonia in 2 (0.4%). All patients were followed up for 17-36 months, with an average of 22.5±5.4 months. Medium to long-term complications during follow-up included chronic back pain in 51(10.0%) cases, instability or subluxation of spine in 38 (7.5%), lower extremities dyskinesia in 31 (6.1%), scoliosis in 29 (5.7%), and lower extremity sensory deficit in 25 (4.9%). Conclusions The operation of SPR seems to be highly effective for the treatment of spastic cerebral palsy. Perioperative complications are mostly transient and can be resolved within 2 weeks following proper treatment. Medium to long-term complications usually have no significant negative effect on the patient's quality of life. Key words: Cerebral palsy; Postoperative complications; Selective posterior rhizotomy

Rapid resolution of high-output chylothorax with reduction of spinal subluxation

Rapid resolution of high-output chylothorax with reduction of spinal subluxation

A Diagnostic Imaging Case of Cervical Spinal Subluxation for Chuna Mannual Therapy: Cervical Malposition with OPLL

A Diagnostic Imaging Case of Cervical Spinal Subluxation for Chuna Mannual Therapy: Cervical Malposition with OPLL

Advances in Functional Spine Neuroimaging

Several imaging modalities are currently being used to obtain diagnostic information in patient with spinal cord injuries. Among them, magnetic resonance imaging, computed tomography myelography, and plain radiography are the most widely used. Magnetic resonance imaging or MRI is a non-invasive imaging method that uses magnetic fields and radio frequency (RF) waves and provides soft tissue contrast of the spinal cord and surrounding tissues within the spinal canal. On the other hand, computed tomography or CT is based on x-rays, to provide excellent bone contrast, and is the first line of diagnostic imaging performed following a traumatic injury in both adults and kids to evaluate for fractures and spinal subluxation. Subsequently, MRI is performed to evaluate for the presence of spinal cord compression, spinal cord edema and/or hemorrhage, epidural/subdural hemorrhage, prevertebral edema, and ligamentous injury. Although still not widely available, in addition to providing good structural information, MRI has evolved in the recent years to provide functional characteristics of the spinal cord. These include information such as diffusion of the water molecules within the spinal cord providing functional information of white matter based on diffusion tensor imaging (DTI), and neuronal activation sites within the gray matter of the spinal cord based on Blood oxygenation level dependant (BOLD) imaging. In our center at Jefferson we are utilizing these functional neuroimaging biomarkers to potentially help us to understand the mechanisms of spinal cord injury (SCI) as well as guide and track changes of new therapeutic procedures. In the following sections we will discuss the methodologies underlying these techniques.

Odebode-Agaja adult cervical traction device

This technical note describes a new simple, cheap and affordable adult cervical traction device that is especially suitable for use in resource-poor third world countries because of its cost-effectiveness. While the widely used imported Gardner-Wells tongs cost over N250,000 (Nigerian) naira (approximately $1630 USD), the new equally effective, durable and locally readily available Odebode-Agaja traction device sells for N35,000 naira (approximately $220 USD). The device does not require scalp incision or skull drilling. It is designed for bedside application in patients with cervical spine injuries, including subluxation and fracture-dislocation of the cervical spine from the atlanto-occipital joint to T1.

Computed tomography reconstruction artifact suggesting cervical spine subluxation

Use of computed tomography (CT) imaging for evaluation of the cervical spine following blunt trauma is both an efficient and reliable method for detecting injury. As a result, many trauma centers and emergency departments rely exclusively on CT scans to acutely clear the cervical spine of injury. Although quite sensitive for detecting bone injury, CT may be associated with a low sensitivity for detecting herniated discs, injured soft tissue or ligaments, and dynamic instability. In addition, CT-generated artifact may obscure pathological findings. In this case report, we describe the course of a patient whose CT scan harbored CT-generated artifact that suggested traumatic subluxation of the cervical spine. Clinicians should be aware of such artifact and how to recognize it when basing clinical management on such studies.

Cervical Spine Subluxation in Marfan Syndrome

Subluxation of the cervical spine may occur in patients secondary to trauma. Patients with Down syndrome and rheumatoid arthritis can have spontaneous cervical spine subluxation. Although cervical spine abnormalities are common in patients with Marfan syndrome, clinical problems are rare1. Lumbar subluxation is rarely seen in patients with this condition2 and, in an extensive review of cervical spine involvement in patients with Marfan syndrome, Hobbs et al. noted no cases of cervical subluxation1. We describe the clinical features and surgical treatment of a patient with Marfan syndrome who had progressive multilevel cervical subluxation. The patient was informed that information concerning this case would be submitted for publication. Athirteen-year-and-four-month-old boy presented to the Spine Service with right-sided neck pain associated with decreased range of motion. There was no history of trauma or recent illness. The medical history was unremarkable. The range of neck motion was flexion to 45°, extension to 10°, left axial rotation to 60°, and right axial rotation to 20°. The patient had mild upper cervical spine tenderness and had normal findings on neurological examination. Initial radiographic examination revealed anterior subluxation of C2 on C3, with marked segmental kyphosis (Fig. 1). Magnetic resonance imaging revealed disc-space changes at C2-C3 that were consistent with infection. The facet joints were aligned. Given the patient's complaints of pain and the finding of cervical subluxation on plain radiographs, the patient was admitted for evaluation and treatment. Computed tomography revealed no evidence of fracture. A bone scan with SPECT (single photon emission computed tomography) imaging showed slight posterior uptake at C2-C3 consistent with trauma. The findings of the laboratory evaluation were unremarkable and included a normal white blood-cell count, erythrocyte sedimentation rate, and C-reactive protein level. The patient was managed with skeletal traction with use of tongs, with easy …

It is time to think in different terms: re-considering subluxation

: “A complex of functional and/or struc-tural and/or pathological changes that compromise neu-ral integrity and may influence organ system functionand general health” (5).I was present at the Houston Conference, (6) and fol-lowing that conference, Joe Howe and I wrote the sec-tion on radiographic manifestations of spinal subluxa-tion. (7) The drawings were mine and the radiographscame from my office. We did this work and submitted itbecause there was a “political need” for this kind ofevidence. Neither Joe Howe nor I were convinced thatthis was a good direction to take, because it placed us ina legislative box, which neither of us could support fromany kind of scientific evidence.I remember the development of the ACC definition verywell because it happened that I offered the followingdefinition: “A subluxation is any articular change thatalters the ability of the nervous system to integrateorgan systems.” Naturally, our group could not let it bethat simple, though I surely wish we had. Regardless,what we have done during the past century is adopt aword that has specific meaning to the rest of the scien-tific and health care community and tried to change itsmeaning into something much more complex than theword itself implies.By simple word breakdown, the word must mean onlyone thing; “

Rotatory subluxation of the cervical spine — when is odontoid lateral mass asymmetry benign?

Rotatory subluxation of the cervical spine is a rare but serious condition in the adult. The condition is suspected radiologically in the presence of odontoid-lateral mass asymmetry on open mouth view. The application of ATLS principles in the initial assessment of trauma patients has resulted in a significant increase in the number of radiological examinations performed. This has led inevitably to an increase in the number of anomalies identified. An average of 400 cervical spine X-rays per year are performed for trauma in our casualty department.

Anterior subluxation of the cervical spine

Anterior subluxation (AS), or hyperflexion sprain, generates a disproportionate level of concern in emergency medicine. Anxiety related to this injury arises from the fact that AS may produce delayed mechanical instability of the cervical spine, with resultant pain and neurological impairment. Furthermore, its radiographic presentation may be very subtle, and it may be impossible to reliably diagnose or exclude this injury using standard screening radiographs. Additional studies, such as flexion–extension (FE) radiography and magnetic resonance (MR) imaging, are often used in the acute setting to assess injury status and radiographically exclude AS injury. There are a number of reasons to discourage this latter practice, which can represent an impossible attempt to “radiographically clear the cervical spine” of blunt trauma patients with “100 % certainty.” This is because AS is an uncommon lesion, and the neurological deficits secondary to delayed instability are almost always minor and transient. Furthermore, AS is usually not entirely occult on screening plain films (which are typically “abnormal” even if in nonspecific ways). Finally, FE imaging, done acutely in the presence of spasm, is probably unable to exclude this diagnosis reliably, even when plain films are normal, and emergent MR, probably the most accurate technique, is not widely available. Risk stratification provides a rational alternative approach for assessing injury status. Low-risk patients may be spared further imaging provided they are given appropriate precautionary return instructions. High-risk patients require emergent evaluation by an experienced spine specialist, and may benefit from advanced imaging. Patients at moderate risk may be best managed with symptomatic treatment, warnings to avoid significant physical activity, and delayed FE imaging and evaluation by a spinal specialist. They should also be instructed to seek immediate medical attention if they develop any indications of delayed instability, including severe pain and /or neurological signs. This stratified approach not only increases the likelihood that delayed subluxation will be recognized before it leads to chronic instability, but frees clinicians and radiologists from the quixotic burden of trying to “clear” the cervical spine with 100 % certainty in the acute setting.

A History of Manipulative Therapy Through the Ages and Up to the Current Controversy in the United States

Joint manipulation is an ancient art and science that can trace its origins to the earliest medical and lay practitioners. Today, it is practiced principally by physical therapists and chiropractors and to a lesser degree, by osteopathic and medical physicians. Self-manipulation of both joint and soft tissues is also a common practice in those who “crack” their own knuckles and spines. This article traces the history and development of manipulation from its origins to the present with a special emphasis on developments in the United States as a background for understanding current licensure and practice issues.Since the beginning of this century, physical therapy has enjoyed a close relationship with medicine and has developed its knowledge base and practice in spinal and extremity manipulation from the medical profession. Manipulation in physical therapy has become a significant part of its rehabilitation practice, often encompassed in the terms therapeutic exercise, active and passive movement, or manual therapy. Instruction in manipulation begins with pre-professional education; for those who wish to specialize in this field, instruction continues at the post-professional level, following the medical model of specialization. Since the 1960's, physical therapists have developed their own body of knowledge in manipulation, emphasizing pain relief and enhanced physical function.By contrast, since its independent origins in the late 19th century, chiropractic has practiced manipulation for most of its history as a primary therapeutic tool to correct spinal subluxation. It provides spinal adjustments to facilitate the free flow of nerve energy, which, in turn, relieves many human ailments. Unlike physical therapy, chiropractic has not been practiced in cooperation with medicine but has existed as an alternative during most of its history. In recent years, the chiropractic profession has divided along philosophical lines: those who strongly defend the subluxation theory (straights) to those who do not (mixers), with the later group now holding sway. This change in chiropractic philosophy and practice has brought practitioners into a practice model more closely aligned with the comprehensive model of rehabilitation therapy modeled by physical therapists. Consequently, many chiropractors now use physical therapy procedures even though they are prohibited from calling themselves physical therapists. As a result, competition in the market place has heightened, with concomitant licensure and political challenges.This article discusses the history and evolution of the practice of manipulation against a background of other key developments in health care; as such, it should provide understanding for today's current practice scene.

Recovery from Cruciate Paralysis Due to Axial Subluxation from Metastatic Breast Carcinoma: A Case Report.

Cruciate paralysis is an uncommon and potentially life-threatening myelopathy thought to arise from injury to the corticospinal tracts at a high cervical spinal level. The authors report on the case of a woman who developed cruciate paralysis secondary to axial subluxation of the cervical spine due to invasion by metastatic breast carcinoma. Correct bedside diagnosis, prompt spinal alignment via halo traction, and surgical spinal decompression with fusion stabilization reversed the paralysis completely. Postoperative antiestrogen medication, spinal radiation, and chemotherapy promoted local tumor control, allowing the patient longevity and good quality pain control. The prompt diagnosis and treatment of cruciate paralysis could effect a good prognosis in a seemingly terminal patient with metastatic spinal breast carcinoma by resolving life-threatening myelopathy, promoting longevity, and assisting with pain control.

The prevalence of cervical spondylolisthesis.

This study assessed the prevalence of cervical spondylolisthesis in patients undergoing radiographic studies for reasons unrelated to their cervical spine. Scout lateral cervical spine radiographs of 174 patients who had barium swallows were reviewed for the degree and level of cervical spondylolisthesis. Nine patients were found to have >2 mm of anterior subluxation of the cervical spine for a prevalence of 5.2%. Two patients had involvement at the C2-C3 level, one patient at C3-C4, four patients at C4-C5, one patient at C5-C6, and one patient at C7-T1. Subluxation ranged from 2 to 4 mm. Posterior subluxation (retrolisthesis) was not found in any patient. None of the nine patients with spondylolisthesis had complaints of neck pain or upper extremity symptoms, and none had a history of rheumatoid arthritis or cervical trauma.

Evaluation of Fracture and Subluxation of the Cervical Spine by 2D and 3D Reconstruction CT Imaging

It is still controversial whether 2D and 3D reformation CT could present spatial information not readily available from axial CT images in complex cervical spine injuries. We collected thirty-five cases of cervical spine trauma. Thin-section 2–3 mm continuous axial section images or spiral volumetric images were obtained by Picker PQ2000 CT scanner, than, 2D and 3D reconstruction images were created of the entire spine through the area of interest. The radiological findings were classified to cervical subluxation (atlantoaxial 7, C2 to C7 subluxation 8) and post-traumatic fracture (atlas 3, odontoid process 8, bipedicular axis 4, C3 to C7 13). Associated imaging findings included spinal stenosis, basilar invagination, rotatory and facet dislocation. In our experience, 2D and 3D reconstructions are capable of detecting injuries not visualized by conventional radiography or axial CT, in particular, 3D CT has the advantage of clear depiction of the spatial relationships of the complex anatomy and traumatic pathology in the cervical spine injuries.

Pediatric Emergency Physician Interpretation of Plain Radiographs: Is Routine Review by a Radiologist Necessary and Cost-Effective?

Study objective: To determine the concordance rate of plain radiograph interpretations by pediatric emergency physicians and pediatric radiologists, to evaluate the effect of incorrect radiologic diagnosis on patient management, and to evaluate the necessity and cost-effectiveness of routine follow-up review of all plain radiographs by a radiologist. Methods: We assembled a prospective series of all patients who presented to the emergency department of an urban tertiary care children's hospital and underwent plain radiography between October 1 and October 31, 1994. Pediatric emergency physicians documented their interpretations. Within 24 hours, films were reviewed by a pediatric radiologist. The two interpretations were classified as concordant or discordant and were further assessed for medical significance and subsequent change in management. Results: During the study period, 707 radiographic examinations were performed: chest, 56%; skeletal excluding spine, 20.1%; abdomen, 11.9%; sinus, 4.2%; spine, 3.6%; and other, 4%. The accuracy or concordance rate was 90.2% (638 of 707) for pediatric emergency physician interpretations; clinical management was unchanged in 96.9% (685 of 707) of the cases. Of the 69 discordant interpretations, 48 were clinically significant, with 22 requiring changes in management. They included 9 false-negative interpretations by pediatric emergency physicians: (5 fractures, 2 cases of pneumonia, 1 case of sinusitis, 1 case of cardiomegaly); 10 false-positive interpretations by pediatric emergency physicians (5 fractures, 4 cases of pneumonia, 1 case of sinusitis), and 3 false-positive interpretations by radiologists (1 case of C-2 spine subluxation, 1 retropharyngeal abscess, and 1 case of necrotizing enterocolitis). No adverse outcomes resulted from these misinterpretations. Routine review of all plain radiographs by a radiologist represents an estimated $210,000 annual cost to the patients and payers. Conclusion: Radiograph interpretations by pediatric emergency physicians were generally accurate, and no adverse outcomes occurred as a result of misinterpretation. Clinical assessment probably assisted these physicians in interpreting the radiographs of high-risk patients. Judicious consultation with a radiologist during the initial presentation of a high-risk patient, when deemed warranted by the pediatric emergency physician, will help the emergency physician deliver high-quality, cost-effective health care. Given the overall clinical accuracy rate of radiograph interpretations by the pediatric emergency physicians and the cost of routine review of all plain radiographs in the ED by a radiologist, routine review versus selective specialty consultation must be further evaluated. [Simon HK, Khan NS, Nordenberg DF, Wright JA: Pediatric emergency physician interpretation of plain radiographs: Is routine review by a radiologist necessary and cost-effective? Ann Emerg Med March 1996;27:295-298.]

The “open” exit foramen: A new sign of unilateral interfacetal dislocation or subluxation in the lower cervical spine

The purpose of this study was to describe the “open” exit foramen as a new sign associated with unilateral interfacetal dislocation or subluxation (UID/S) of the cervical spine. Three blinded observers evaluated 20 randomly ordered axial imaging examinations (9 with UID/S and 11 traumatized control patients) assessing for presence or absence of the open exit foramen sign at the level of injury. The clinical observations were then quantified by measuring the width of the involved cervical exit foramen at the level of injury on axial computed tomography or magnetic resonance imaging in nine patients with UID/S. These measurements were also compared to the width of contralateral uninvolved exit foramen at the level of UID/S and to ipsi- and contralateral exit foramen measurements of 20 control patients with acute cervical spine injuries but no UID/S. Measurements were analyzed using Student’st-test. Calculated sensitivity and specificity for blinded reviewer detection of the open exit foramen sign in cases of UID/S vs. traumatized controls were 78% and 79%, respectively. Quantitative measurements indicate the involved exit foramen was enlarged by an average of 3.9 mm compared to the contralateral exit foramen at the levels of UID/S, whereas controls demonstrated only 0.9 mm of foraminal asymmetry (P<0.01). In cases of UID/S, asymmetric widening of the exit foramen occurs in the axial plane, resulting in the open exit foramen sign. Blinded review confirms that this sign is clinically helpful in identifying the level and side of UID/S on axial imaging studies.