Resuscitation lateral cervical spine X-ray (LSCX): A useful mandatory screening tool in acute trauma? Poster No.: C-2397 Congress: ECR 2010 Type: Topic: Authors: Keywords: DOI: Scientific Exhibit Musculoskeletal S. B. Perumal, S. M. V. Reddy, S. Muly, S. Dalavaye, P. Evans; Swansea/UK Cervical spine, Portable radiographs, Trauma 10.1594/ecr2010/C-2397 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 14
Purpose Cervical spine injuries can cause serious disabilities or death if failed to diagnose early and it is vital to clear the cervical spine in the management of a trauma patient. The Advanced Trauma Life Support (ATLS) [1] guidelines recommend portable Lateral Cervical Spine X-ray (LCSX) as part of trauma series radiographs during the initial assessment of all trauma patients. The aim of our study was to assess the adequacy and efficacy of protocol-driven portable LCSX as a diagnostic tool in the trauma resuscitation. Methods and Materials The setting for this retrospective study was a busy emergency department in a teaching hospital. Over a 2 year period, 171 trauma patients who had portable LCSX performed in the resuscitation area were identified from computerised radiology records and included in the study. An experienced musculoskeletal radiologist reviewed the LCSX for their adequacy, fractures and also subsequent cervical spine imaging performed if any in the radiology department. LCSX radiographs including occiput to upper border of first thoracic (T1) vertebra were considered adequate. The case notes of patients with no follow-up imaging performed after portable LCSX were reviewed. Page 2 of 14
Results LCSX were inadequate in 135/171 (79%) patients. Further cervical spine imaging was performed in 147/171(86%) cases in the radiology department. These included 76 plain radiographs, 69 CT scans and both imaging modalities in 2 cases. Case notes were available in 18/24 patients with no follow-up imaging after LCSX. In this group, cervical spine was clinically cleared in 12 patients and 3 deaths were noted during resuscitation while no documentation could be found in the remaining 3 cases. LCSX revealed fractures in 6/171(3.5%) cases who had follow up CT scan for further evaluation. LCSX failed to identify 3 fractures which were subsequently identified in the CT scan. Page 3 of 14
Fig.: Pie chart showing number of inadequate and adequate LCSX References: S. B. Perumal; Accident and emergency, ABM University, Swansea, UNITED KINGDOM Page 4 of 14
Fig.: Pie chart showing subsequent cervical spine imaging References: S. B. Perumal; Accident and emergency, ABM University, Swansea, UNITED KINGDOM Page 5 of 14
Fig.: Pie chart showing fractures missed by LCSX References: S. B. Perumal; Accident and emergency, ABM University, Swansea, UNITED KINGDOM Page 6 of 14
Images for this section: Page 7 of 14
Fig. 1: Adequate portable LCSX of a 31 year old patient Page 8 of 14
Fig. 2: CT scan showing C6/C7 facet joint fracture not evident on portable LCSX (fig.1) Page 9 of 14
Fig. 3: Inadequate portable LCSX of a 53 year old patient Page 10 of 14
Fig. 4: CT scan shows C6 fracture not evident on portable LCSX (fig.3) Page 11 of 14
Conclusion Our study clearly demonstrates the inadequacy of routinely performed portable LCSX in the vast majority (79%). The practical difficulties of performing portable radiographs in resuscitation area can contribute to inadequate and poor quality x-rays. Moreover, 86% of patients had further imaging of cervical spine in the radiology department reflecting the poor reliability of the LCSX as a diagnostic tool. Studies suggest that even the anatomically complete lateral films interpreted by an expert will miss 15% of cervical spine injuries and 50% of these are inadequate [2]. Lateral films are especially not helpful to review upper and lower cervical spine areas which are notorious for concealing injuries. In patients with severe head trauma covering craniocervical junction during CT imaging will reveal about 10% injuries missed by plain films [2]. Portable LCSX is mostly inadequate and can delay resuscitation while contributing little as a mandatory reliable diagnostic tool in suspected cervical spine injuries Therefore in clinically suspected cervical spine injuries, it may be more appropriate to obtain complete plain radiographic studies in radiology department or CT scan once life-threatening injuries are addressed with standard neck immobilisation. This will speed up patient evaluation, and avoid unnecessary radiation exposure to patient and department staff. This will contribute to the effective use of resources in providing quality health care [3, 4]. We propose that it may be appropriate to eliminate standard portable LCSX in resuscitation area and instead perform either plain cervical spine radiographs in the radiology department or a CT scan guided by local trauma protocols for suspected neck injuries. References 1. Advanced Trauma Life Support (ATLS) course manual,7th edition, 2004; 1:20. Page 12 of 14
2. Morris C G T, McCoy E. Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening. Anaesthesia, 2004; 59:464-482. 3. Spain DA, Trooskin SZ, Flancbaum L, Bovarsky AH, Nosher JL. The adequacy and cost effectiveness of routine resuscitation-area cervical-spine radiographs. Ann Emerg Med. 1990; 19(3):276-8. 4. Mirvis SE, Diaconis JN, Chirico PA, Reiner BI, Joslyn JN, Militello P. Protocol-driven radiologic evaluation of suspected cervical spine injury: efficacy study. Radiology, 1989; 170(3 Pt 1):831-4. Personal Information Corresponding author: Dr Sounder Babu Veeran Perumal Morriston Hospital, Swansea, SA6 6NL Address for correspondence: 2, Llwyn Teg, Fforestfach, Swansea, SA5 4NF Page 13 of 14
Tel No: 00447817483740 E-mail: sounder6@yahoo.com Co-authors: 1. Dr Santhosh M.V. Reddy Morriston Hospital, Swansea, SA6 6NL 2. Dr Sudha Muly Morriston Hospital, Swansea, SA6 6NL 3. Dr Suresh Kumar Dalavaye FRCR Department of Radiology, Morriston Hospital, Swansea, SA6 6NL 4.Mr P A Evans Emergency Department, Morriston Hospital, Swansea SA6 6NL Page 14 of 14