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lrogers{at}ajroffice.org
And 30 years later, the CT revolution continues. CTs are spinning the world over. Computed tomography continues to improve and the indications for the use of CT continue to expand 24 years after Hounsfield's Nobel Prize. Where will it all end? No one knows. Just sit back and enjoy the ride.
The first CT scans were limited to examinations of the brain. Then in the mid 1970s, body CT was introduced. CT was initially reserved for the desperately ill and seriously injured. However, as the speed of CT increased, single breath-hold examinations of the entire chest or abdomen could be obtained in one exposure and pediatric patients could be examined without sedation. As a result, the clinical applications of CT expanded. And the patients examined were not always seriously ill.
Body CT proved to have remarkably high sensitivity and specificity. Talk about a revolution: intravenous pyelography, the time-honored IVP, was replaced by CT, and unenhanced CT at that. CT assumed a central role in the evaluation of the common acute abdominal illnesses: bowel obstruction, appendicitis, and diverticulitis. CT could reveal pulmonary emboli, decreasing the need for pulmonary angiograms and isotopic lung scans. CT had found a role in "everyday" illness.
Physicians quickly realized that body CT was a winner, and they did not hesitate to order CTs for their patients whenever diagnoses were in doubt. It quickly became evident to all that CT reduced diagnostic uncertainty and increased diagnostic certainty. And furthermore, radiologists using CT were often able to accurately identify alternative diagnoses at the same time that they reliably excluded original clinical diagnoses. These attributes have made CT indispensable. Indeed, CT has become essential for the present-day practice of medicine and surgery.
That is not to say that CT was without its critics. Not too long after CT was introduced, CT became the whipping boy for those who wished to restrain the growth and to control the costs of medical care. To these critics, CT ex-emplified "hi tech–hi cost" medicine: unnecessary expenditures of precious health care dollars for technology of questionable value to patients. These critics charged that monies allocated for the purchase of CT equipment were spent by money-grubbing physicians and hospitals for the sole purpose of reaping great profits. Such sentiments spawned the implementation of Certificate of Need legislation. We don't hear such talk these days. Try as they might, the critics failed to quash CT.
In fact, the clinical usefulness and importance of CT has led to much the opposite, a surfeit of CT. Nowadays, it seems every patient gets a CT! When in doubt, get a CT!
As far as performing a CT, radiologists are rarely damned if they do, but certainly may be damned if they don't (or won't). Try to discourage a clinician from ordering a CT these days. Tell them a CT is not necessary, or suggest an alternative examination. You are liable to hear an argument. It is easier—and quicker and less stressful—to do the CT, than to argue about it.
The main reason clinicians are so insistent on ordering a CT is that they have limited tolerance for diagnostic uncertainty. They will do whatever it takes to reduce the risks of living with uncertainty. And CT will likely reduce that risk. Besides, clinicians don't get any credit for deciding not to order a CT; in fact, they may be taking a finite risk if they choose not to order one. Clinicians end up ordering CT to assuage their strong desire to know precisely what is wrong with their patients. This need to know is played out against a backdrop of the specter of liability. Clinicians most certainly do not want to be subsequently subjected to the hassle of a malpractice suit for not obtaining a CT. Why bother taking that chance? Order the CT.
If you should need further evidence of the risks associated with not ordering a CT, be sure to read this month's offering by Lenny Berlin [2]. Berlin relates the misfortunes of physicians who did not obtain a CT examination of the cervical spine of a patient involved in an automobile accident. The case described exemplifies every radiologist's nightmare.
The patient was neurologically intact on admission and the initial three-film examination of the C-spine was interpreted as normal. Unfortunately, the patient subsequently became quadriplegic and CT then showed a fracture– dislocation of the C-spine. Berlin addresses these questions: "What is the present radiologic standard of care for patients with a suspected or potential injury of the C-spine? Is the standard of care still a three-film or five-film radio-graphic examination of the C-spine? Or is the standard of care now CT of the spine?" Berlin's article is a must-read for all radiologists who spend any part of their days or nights interpreting studies from an emergency department.
So the onward and upward march of CT continues. And in its wake, old radiographic rubrics like radiographs of the spine for cervical trauma fall by the wayside. I wonder what the good Sir Godfrey makes of all this? The wisdom of awarding Hounsfield the Nobel Prize in 1979 has certainly been confirmed many times over.
Well, what's next for CT? Where does CT go from here? We don't know, but it is bound to appear in the pages of your AJR! We will keep you in touch.
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