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Original Report |
1 Department of Diagnostic Radiology, Allegheny General Hospital, 320 East North Ave., Pittsburgh, PA 15212-4772.
Received January 2, 2001;
accepted after revision March 9, 2001.
Address correspondence to R. H. Daffner.
Abstract
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CONCLUSION. Performing a cervical CT examination in conjunction with a cranial CT examination added an average of 12 min to the overall study time. The time for performing a primary cervical examination was 11 min on average. These times are approximately half of those required for a six-view radiographic evaluation. Helical CT has been suggested as a replacement for the more traditional radiographic evaluation of the cervical spine in trauma victims. Evidence now exists to support that recommendation.
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One hundred patients underwent cervical examination immediately after undergoing cranial CT examination, while they were still on the CT table. That group included 73 men and 27 women, whose ages ranged from 10 to 92 years old (average, 47 years). The remaining group of 56 patients, 37 men and 19 women ranging in age from 16 to 90 years (average, 53 years), underwent a primary cervical study. The first 30 patients in the current study were part of the original radiography study group [3].
All CT studies were performed on a Plus 4 helical scanner (Siemens Medical Systems, Iselin, NJ) in our emergency department. The technologists were instructed to begin recording the time of the examination for the first group when they repositioned the patient from the cranial portion of the examination. Our cranial examination typically has the angle of the gantry parallel to the skull base. The gantry was reoriented to a position that would be more perpendicular in relationship to the cervical spine. In addition, the patient was repositioned, and the computer program was reconfigured to begin the examination at the skull base. All patients were studied from the skull base through T1 at 3-mm intervals, and images were reconstructed at 2-mm intervals, using a pitch of 1. Images were processed at bone and soft-tissue window settings that included sagittal tomographic reconstruction. Completed but unfilmed studies were made immediately available to trauma surgeons and emergency medicine physicians on our PACS (picture archiving and communication system), in both the emergency department and trauma intensive care units. The end point of the examination was determined when the last axial image was reviewed on the technologist's console and a decision was made by a trauma team physician to move the patient off the table.
For those patients who had the cervical examination only, the technologists were instructed to begin recording the time when the patient was satisfactorily placed on the CT table and positioned in the gantry. They were not instructed to record the time it took to move the patient to the CT table because this time varies greatly, depending on the patient's size, extent of injuries, and amount of life support equipment to be transferred. An additional reason for not recording the total time of examination was that the goal of this study, similar to that of the study on radiography [3], was to determine how much time the actual CT examination took, once the patient was positioned. In theory, the time to move the patient from the stretcher to either the radiography table or the CT table should be identical. In other words, our concern was whether, once a CT study was ordered, it did, in fact, save time. The end point of the examination for those patients who underwent the cervical study only was the same as for those patients who had the combined study. The same scanning parameters were used for the cervical examination in both groups.
Our trauma team consists of a senior attending surgeon, several surgical residents, two registered nurses, and a physician's assistant. A senior attending radiologist and the radiology resident on call are consulting members of the trauma team and are frequently called for image interpretation once such studies have been obtained. After-hours coverage is via teleradiology.
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Of particular note is the fact that of the 65 patients who were studied because of unsatisfactory radiographs, 14 patients (21.5%) had fractures that were detected only by the CT examination. Of these 14, nine were determined to have minor fractures and five were determined to have major fractures by a previously established criterion [10].
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"The golden hour" is the term trauma surgeons use for the critical period of time needed to begin definitive treatment of patients who have suffered serious trauma [12, 13]. A goal of resuscitation for patients within this golden hour is to reestablish respiratory and hemodynamic stabilization, according to the American College of Surgeons Committee on Trauma [14]. Anything that delays treatment, such as prolonged times of radiographic or CT examinations, can adversely affect the patient. The author's previous study [3] showed that the average time needed to perform a six-view radiographic evaluation in a group of trauma patients was 22 min and that 79% of those patients required one or more repeated radiographs.
Ample evidence in the radiology literature indicates that helical CT should be used as the primary screening tool for evaluating the cervical spine in trauma victims [1, 5,6,7, 9, 14]. However, three questions need to be addressed: Should helical CT replace radiography for screening the cervical region in trauma patients? How cost-effective is helical CT in this regard? Is there still a role for radiography of the cervical spine in trauma patients, and if so, how extensive should it be?
The first question is the easiest to answer. Helical CT has certainly shown itself to be not only a more rapid method for evaluating the cervical spine but also more efficient for identifying fractures [5, 7, 9, 10] (Fig. 1A,1B,1C,1D). As our study has shown, using CT can reduce the time required for the examination by as much as half when compared with a complete radiographic examination. In addition, CT routinely shows the atlantoaxial and cervicothoracic junction much more easily than does radiography. These are two areas that are more likely to require repeated radiographs [3]. Once the newer fast scanners become more commonplace, we may see a further reduction in time of examination.
The question of whether helical CT is cost-effective compared with radiography has been addressed by several authors. True cost-effectiveness should be determined by analyzing data that include cost factors such as the technologists' time and hourly equipment operating expense, as well as supplies such as film and chemicals. Blackmore et al. [6] performed such an analysis and determined that screening with helical CT was cost-effective. In another study, Blackmore et al. [1] proposed a revised set of criteria for identifying patients at high risk for cervical injury. Most recently, Hanson et al. [15] established a clinical decision rule for determining whether helical CT should be used for cervical spine injury screening. Their criteria modify those previously published by Vandemark [9]. Finally, Rhea et al. [16], using a methodology developed for studying patients with appendicitis at the Massachusetts General Hospital, showed that the cost differential between helical CT and radiography for screening patients with suspected cervical injury was negligible (Rhea JT, presented at annual meeting of the Radiological Society of North America, Chicago, November 2000).
If helical CT is much more efficient at revealing cervical fractures than radiography, is there still a role for the older technology? In the opinion of this author, there definitely is. My recommendation is that we continue to perform the lateral and anteroposterior radiographs only. Because of the greater accuracy of CT in revealing injuries, it is not necessary to obtain multiple repeated radiographs to cover the cervicothoracic junction. For the same reason, we can abandon the open-mouth view because this area is adequately covered by CT, and it also may be portrayed with coronal tomographic reconstruction.
Why should we continue to obtain radiographs? The answer lies in the fact that the radiographs can provide an overall "road map" when identifying gross abnormalities. Furthermore, in those instances in which the patient has moved during the CT examination, motion artifacts may detract from the reconstructed tomographic images. Radiographs will be of use to determine proper alignment.
A possible weakness of this study, as well as that of the earlier one on radiography [3], is that the time needed to bring the patient into the CT or radiography room and place him or her on the examining table was not recorded. As mentioned, the author's purpose was to determine if there was any net saving in time between a radiographic and CT examination. Once the examination has been ordered, it should take the same amount of time to move any patient, no matter the type of examination.
In conclusion, our study has shown that the average time for performing a complete evaluation of the cervical spine in trauma patients using helical CT is 12 min for the patients who are undergoing concomitant cranial evaluations and 11 min for those requiring a cervical examination only. This technique reduces the actual examination time of the cervical region by nearly 50% when compared with the amount of time for radiography. In addition to being more rapid, helical CT is more efficient at identifying fractures. Sufficient evidence in the radiology literature now exists to recommend that helical CT replace traditional radiography as the screening tool for patients with suspected cervical injury.
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