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Thu, 24 Apr 2003 20:19:42 EDT

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In a message dated 4/24/2003 3:03:02 PM Eastern Daylight Time, 
mmcbridemd@yahoo.com writes:

> This pretty plainly states that CT is diagnostic for soft tissue injury. So 
> this brings me back to my original question with regards to a previous 
> comment by ERF: "If a patient is tender, or is unevaluable, the 3 views (or 
> what is becoming increasingly clear, CT) is only the first step--the collar 
> cannot be removed unless the patient is then documented to have no pain on 
> passive AND active exam, or, if persisitently unevaluable or tender, an MRI 
> or uprite flex-ex is normal."
>  
> Is there new data in the pipeline that CT is not adequate for diagnosis? 
> Wondering if our practice of using CT is showing some weaknesses...
>   
> 

Meredith--
I'm not sure what the basis of your question is--I am in full agreement that 
CT should now be considered the gold standard for C-spine screening, and 
plain films ar superfluous and not nearly as accurate.  We just presented at 
EAST our series of 1199 patients receiving both that supports this, as does 
virtually every other paper on the issue--will be published later this year 
in J of Trauma.  Carl Hauser presented compelling data of the same being true 
for T and L spine.   All I was saying above is that NO imaging test, 
regardless of what you use, in and of itself EXCLUDES c-spine injury reliably 
enough to allow removing the collar just on that basis, at least in the early 
postinjury period.  THAT is not disputed (see EAST Practice Managment 
Guidelines)--perhaps you are not aware of this?  If the CT of the c-spine is 
negative, then the collar must continue until there is no further tenderness 
or pain on active motion in the awake patient, or until the unevaluable 
patient gets whatever you believe is the appropriate final excluder (too 
little data here for any final conclusions to be made, so we all have our own 
protocols). Of course, in the absence of tenderness in the awake fully 
responsive patient, no imaging is necessary--that alone "clears" the c-spine 
and allows removal of the collar. The consensus is quite clear that even CT 
does not provide enough info as to ligamentous instability.  Sorry if that 
was not clear
ERF

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<HTML>In a message dated 4/24/2003 3:03:02 PM Eastern Daylig=
ht Time, mmcbridemd@yahoo.com writes: 
 
<BLOCKQUOTE TYPE=3DCITE style=3D"BORDER-LEFT: #0000ff 2px solid; MARGIN-LEFT=
: 5px; MARGIN-RIGHT: 0px; PADDING-LEFT: 5px">This pretty plainly states that=
 CT is diagnostic for soft tissue injury. So this brings me back to my origi=
nal question with regards to a previous comment by ERF: "If a patient is ten=
der, or is unevaluable, the 3 views (or what is becoming increasingly cle=
ar, CT) is only the first step--the collar cannot be removed unless the=20=
patient is then documented to have no pain on passive AND active exam, or, i=
f persisitently unevaluable or tender, an MRI or uprite flex-ex is normal."<=
BR>
 
Is there new data in the pipeline that CT is not adequate for diagnosis? Won=
dering if our practice of using CT is showing some weaknesses... 
&nbsp; 
</BLOCKQUOTE> 
 
Meredith-- 
I'm not sure what the basis of your question is--I am in full agreement that=
 CT should now be considered the gold standard for C-spine screening, and pl=
ain films ar superfluous and not nearly as accurate.&nbsp; We just presented=
 at EAST our series of 1199 patients receiving both that supports this, as d=
oes virtually every other paper on the issue--will be published later this y=
ear in J of Trauma.&nbsp; Carl Hauser presented compelling data of the same=20=
being true for T and L spine.&nbsp;&nbsp; All I was saying above is that NO=20=
imaging test, regardless of what you use, in and of itself EXCLUDES c-spine=20=
injury reliably enough to allow removing the collar just on that basis, at l=
east in the early postinjury period.&nbsp; THAT is not disputed (see EAST Pr=
actice Managment Guidelines)--perhaps you are not aware of this?&nbsp; If th=
e CT of the c-spine is negative, then the collar must continue until there i=
s no further tenderness or pain on active motion in the awake patient, or un=
til the unevaluable patient gets whatever you believe is the appropriate fin=
al excluder (too little data here for any final conclusions to be made, so w=
e all have our own protocols). Of course, in the absence of tenderness in th=
e awake fully responsive patient, no imaging is necessary--that alone "clear=
s" the c-spine and allows removal of the collar. The consensus is quite clea=
r that even CT does not provide enough info as to ligamentous instability.&n=
bsp; Sorry if that was not clear 
ERF</HTML>

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