Are You Playing Russian Roulette?

Dr. Tehranzadeh is Chief of Radiology at Long Beach VA, and Professor Emeritus and Vice Chair of Radiology, Department of Radiological Sciences, University of California,Irvine Medical Center, Orange, CA.

Are you playing Russian roulette when trying to “clear” the cervical spine trauma after injury using plain radiographs? Do you consider yourself a “super radiologist?” Are you still wasting time with plain radiographs to clear cervical spine trauma? The reality is that weare practicing in a highly litigious society and missing cervical spine fractures is a very serious concern.

Cervical spine injuries can lead to permanent disability, paralysis and loss of life. There is still a misconception that it is controversial as to whether radiographs should be the first line of examination in cervical spine trauma.¹ In numerous instances, the literature indicates that radiographs have a high false-negative rate in detecting cervical-spine fractures.

A false-negative rate of 23% on a single lateral view of the cervical spine was reported by Bachulis et al.² Acheson et al. claimed that only 26% of fractures had been correctly identified on the initial radiographic examination.³ And, Lee et al. reported even higher false-negative results of 67% based on radiographic interpretation.⁴ I personally have seen large numbers of cervical spine fractures on computed tomography (CT) that could not be found, even retrospectively, on radiographs.

There are additional reasons to start with CT in trauma cases. Most blunt polytrauma patients have multiple suspected regions of injury and require CT of the head, chest, abdomen and pelvis in order for us to obtain a faster, easier and more efficient work-up by using one test. By comparison with CT, radiographs are time-consuming to acquire and often inadequate for the diagnostic review. They often incompletely show the C6 to T1 levels. The odontoid process is often hard to visualize and may be obscured on a technically poor open-mouth view, obscured by an endotracheal or NG tube, or may be misinterpreted as fractured due to superimposition of the overlaying teeth, under the surface of the C1 ring, or at the posterior occipital base. All these factors delay the radiographic work-up, and even when an injury is discovered by plain radiographs, one may still need CT to determine the injury details and to exclude concurrent injuries not visible on radiographs. Occipital condyle fractures are occasionally unstable and can easily be missed on radiographs due to overlapping osseous structures.⁵ Considering that CT can allow prompt recognition of unstable cervical spine fractures and can prevent paralysis, it appears as a very cost-effective diagnostic method.⁵ The caveat remains that horizontally-oriented fractures can be missed on CT, though less often with high-resolution multichannel-detector reformatted images.

I am frequently consulted by defense attorneys on cervical spine fractures that were allegedly missed by radiologists. The radiologistis often found at fault, not because they missed the fracture (fractures were invisible on radiographs anyway), but because they failed to recommend CT examination as follow up in the appropriate clinical setting. To throw another monkey wrench into this dilemma, sometimes the patient has a history of neck pain, but the clinician and patient fail to communicate this history to the radiologist. Given this circumstance, I recommend that a disclaimer be included in all radiographic reports of the cervical spine that, given a history of trauma of any type, CT would be indicated.

The current policy in our medical center is to use CT as the first examination for clearing spine fractures in cases of trauma. If the CT examination is normal, but the patient has pain, lateral flexion-extension radiographs are obtained to detect possible ligament injury, which could be responsible for instability and subluxation/dislocation. If there is a serious ligament injury present, a neurological deficit or potential instability is suspected, magnetic resonance imaging should further assess the cervical spine.

Ultimately, the radiologist is responsible for diagnosing fractures or suspected instability, and recommending the best imaging study to further the work-up of an injury. Many cervical spine injuries could lead to paralysis and long-term disability and a potentially shortened life-span. Radiologists must maintain a high level of responsibility in interpreting these studies and abstain from accepting low-quality images, images that do not show the entire cervical spine or incomplete radiologic series. The stakes are too high for our patients and we are playing Russian roulette with our careers.

REFERENCES

1. Daffner RH. Controversies in cervical spine imaging in trauma patients. Emer Radiol.2004;11:2–8.
2. Bachulis BL, Long WB, Hynes GD, Johnson MC. Clinical indications for cervical spine radiographs in the traumatized patient. Am J. Surg.1987;153:473–478.
3. 3.Acheson MB, Livingston RR, Richardson ML, Stimac GK. High resolution CT scanning in the evolution of cervical spine fractures: Comparison with plain film examinations. AJR Am JRoentgenol.1987;148:1179–1185.
4. Lee HJ, Sharma V, Shah K, Gor D. The role of the spiral CT vs plain films in acute cervical spine trauma: A comparative study.Emer Radiol.2001;8:311–314.
5. Blacksin MF, Lee HJ. Frequency and significance of fractures of the upper cervical spine detected by CT in patients with severe neck trauma. AJR Am J Roentgenol.1995;165:1201–1204.
6. Blackmore CC, Ramsey SD, Mann FA, Deyo RA. Cervical spine screening with CT in trauma patients: A cost-effectiveness analysis. Radiology.1999;212:117–125.