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Original report |
1 Department of Diagnostic Radiology, Allegheny General Hospital, 320 E. North Ave., Pittsburgh, PA 15212-4772.
Received September 22, 1999;
accepted after revision April 17, 2000.
Address correspondence to R. H. Daffner.
Abstract
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CONCLUSION. Cervical radiography is a time-consuming procedure, which is a concern for trauma surgeons. A more efficient way for cervical evaluation of trauma patients needs to be adopted. Evidence now exists in the literature to suggest that helical CT can serve that purpose.
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Technologists were instructed to record the examination start time as soon as the patients were placed on the X-ray table and the time of examination completion, which was defined as the time the radiographs were processed and determined to be adequate for interpretation. Other data recorded included the patient's registration number, sex, age, and number and type of each repeated radiograph that was necessary. In addition, they recorded the reason or reasons for repeated radiographs using seven categories: film too dark, film too light, positioning error, patient size, patient uncooperative, patient motion, and other factors that affected interpretation such as the presence of foreign bodies. The database was constructed using Excel software (Microsoft, Redmond, WA).
A five-view radiographic examination was adequate for revealing the C7-T1 interval in 27 patients. In the other 100 patients, a swimmer's view was necessary. The initial data were collected on 100 consecutive patients, of whom 21 required only five radiographs. For consistency and reliability the only data that was finally analyzed was from patients who required the six-view radiographic examination. Therefore, I continued to gather data until I had 100 patients who required six views. This required adding 27 more patients to the study group. The final group included 57 males and 43 females who ranged in age from 16 to 92 years (average age, 39 years). In addition, 30 consecutive patients who required cranial CT underwent complete (occiput to T1) cervical helical CT, while they were still on the CT table. All these patients had previously undergone a full six-view cervical series and were examined because of less than satisfactory radiographic examinations (14 patients), fractures (13 patients), or questionable radiographic findings (3 patients). The times of their examinations were recorded from the time the cervical portion of the examination began until the examination was finished and the last image was reviewed on the monitor. This group comprised 20 males and 10 females who ranged in age from 10 to 89 years (average age, 49 years). Patients were scanned at 3-mm intervals, and images were reconstructed at 2-mm intervals, with a pitch of 1. Images were processed at bone and soft-tissue window settings and sagittal tomographic reconstruction. Completed, but unfilmed studies were made immediately available to the trauma team and emergency physicians on our picture archiving and communications system (PACS) in both the emergency department and trauma intensive care unit.
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The atlantoaxial radiograph needed to be repeated in 74 patients (74%). Fifty-seven patients (77%) required one, seven (9%) required two, nine (12%) required three, and one (1%) required four repeated radiographs. The swimmer's view needed to be repeated in 41 patients (41%). In 24 patients (59%), only one repeated radiograph was necessary. Fourteen patients (34%) required three repeated radiographs, and one patient each (2%) required two, four, and five repeated radiographs. Eighteen patients (18%) required a repeated oblique radiograph. Three of these required two repeated radiographs; the remainder, one. The lateral radiograph was repeated in 10 patients (10%). The anteroposterior radiograph was repeated in seven patients (7%).
The reasons for the repeated radiographs in 61 patients (61%) were positioning errors, of which 44 (72%) were of the atlantoaxial radiograph. Twenty-two radiographs (22%) were repeated because they were too dark. Eleven of these (50%) involved the swimmer's view. Fourteen radiographs (14%) were too light, of which eight (57%) were also the swimmer's views. In two patients (2%), repeated radiographs were required because of the patient's size. Both of these were swimmer's views. Three patients (3%), all of whom were under the influence of alcohol, were uncooperative. Patient motion occurred in one patient. Repeated examination was necessary for one patient because of mechanical error, one in whom a Bucky error occurred, and two in whom foreign bodies impeded radiographic interpretation.
Of the 127 patients, nine (7%) had fractures. Seven of these fractures (78%) involved C2 (hanged man's, n = 3; body, n = 2; dens, n = 2). One patient had a Jefferson fracture of C1 and one had a crush fracture of the articular pillar of C5. All of the C2 injuries were revealed on the lateral radiograph. The Jefferson fracture was seen on the atlantoaxial radiograph only. The C5 pillar fracture was visible on the supine oblique and lateral radiographs. All these patients underwent (helical) CT examination, which revealed all fractures. One patient with a C2 body fracture also had a fracture of the body of C5 that was not readily apparent on the radiographs.
The time for helical CT ranged from a low of 3 min to a high of 30 min. The average time for the cervical CT examination was 12 min. The longer times occurred in those patients who had fractures. The reason for this time delay was a result of more careful review of the images by the attending radiologist and the trauma team.
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Radiography has been an integral part of trauma resuscitation protocols. In many instances, surgeons will rely on an initial cross-table lateral radiograph and later perform the remainder of the cervical series when the patient is more stable [4], which may necessitate placing the patient in a restraining collar until "clearance" can be obtained. Vandemark [3] attempted to clarify the problem of determining which patients needed cervical radiography by listing the historic or physical findings that would indicate the patients who have a higher risk for cervical trauma.
My study indicates that obtaining cervical radiographs is a time-consuming process. Moulton and Griffiths [12], in a review of 120 patients studied with the three-radiograph cervical series, found that 45% of their patients required one or more repeated radiographs for satisfactory examination. As my data have shown, the radiographs that most likely need to be repeated are the open-mouth (atlantoaxial) and swimmer's view radiographs. It makes little sense to repeat films and consume time when another method, helical CT, is available for the same purpose.
The initial reports of the efficacy of helical CT in revealing cervical fractures were extremely encouraging. [5, 6]. Since those early reports, enough data have been accumulated, with experience in my institution, to suggest that helical CT should be used as the primary screening tool with anteroposterior and lateral radiographs [13] in high-risk patients. Examination times with CT are much shorter and the study may be obtained when the patient undergoes cranial CT. At my institution, screening the patient and viewing the images require the patient to remain on the CT table for an average of 12 additional minutes.
The atlantoaxial and swimmer's view radiographs are typically the most difficult to obtain and require repetition most often; however, both of these areas are easily examined with helical CT. At my institution we are now using CT to a greater extent for these purposes, particularly in obese patients.
How cost-effective is it to perform helical CT? Cost-effectiveness needs to be determined by analyzing data such as length of hospital stay, reduced morbidity from making earlier diagnoses, and actual savings of eliminating all or part of certain studies. Cost-effectiveness analysis cannot be based strictly on charges for studies, because those reimbursements are only at a fraction of the initial figure. Rather, they should be based on cost factors such as technologist's time, hourly equipment operating expense, and supplies such as film, chemicals, and IV-administered drugs. Blackmore et al. [14], showed that cervical screening with helical CT was, in fact, cost-effective. Furthermore, he and his group at the University of Washington proposed a revised set of criteria for identifying patients at high risk for cervical injury [15, 16]. Their criteria modify those previously published by Vandemark [3].
In summary, cervical radiography in trauma patients is often a time-consuming process. This study has shown that the average time for such an examination was 22 min and involved one or more repeated radiographs in 79% of our patients. The atlantoaxial and swimmer's view radiographs are the examinations most frequently requiring repeated images. Helical CT of the cervical region can be performed in nearly half the time of cervical radiography, when it accompanies a concomitant cranial study.
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