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Wed Jun 30 08:07:43 BST 2010

You have given the hint to the answer in your own question. You posit a
trial no sane person would now undertake. The rate of pickup is small - let
us say for the sake of argument 1%. In one arm of the study you would have
plain films only and the other arm would be allowed augmented imaging. You
would need at least 10,000 patients in each arm to power such a study
properly and I cannot imagine any ethics committee agreeing to it as the
argument for CT is now so strong. 

CTPA is sort of analogous; you are dealing with a condition with a 2%
mortality that can be entirely silent until the patient collapses. However,
there is plenty of evidence that duplex Doppler of veins is as good at
detecting clot but that is only if you think of the diagnosis before the
catastrophe and you are making the diagnosis to stop the next clot. You are
already only dealing with survivors which is by definition a self-selected
group. With a neck injury you do at least have a history to help you.

  _____  

From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Rob Ojala
Sent: 30 June 2010 01:22
To: Trauma-List [TRAUMA.ORG]
Subject: RE: Occult cervical spine injuries

The acid test really is - has the advent of CT demonstrably decreased the
number of cases of patients where folk have developed neurological sequelae
after having had neck cleared on plain films and clinical exam [not talking
about unconscious patients]. CT has unequivocally detected more fractures,
some of which are technically unstable, and we treat them differently as a
result - BUT how would these same folk have done if we were oblivious. 

A parallel example is the advent of CTPA for PEs - we have conducted
millions more CTs looking for those elusive clots and detected a few more -
but haven't made any difference to the mortality from PE. - so who are we
treating when we do these things - the patient or ourselves?

R

  _____  

From: trauma-list-bounces at trauma.org on behalf of Blueflightmedic
Sent: Wed 30/06/2010 11:14 a.m.
To: 'Trauma-List [TRAUMA.ORG]'
Subject: RE: Occult cervical spine injuries

Quite agree; most clinical examinations are random physical sign generators.
It's about the risk you are prepared to take. Consider an ankle injury. If
you follow the Canadian ankle rules you will miss about 4% of broken ankles.
We know 1% of them will sue. That's about 4,000UKP - whatever in the States.
The cost to the organisation is one of these every couple of years. That's a
pretty low outlay. And to the patient? A bit of extra pain and morbidity,
but usually a no worse outcome eventually.

What about a neck injury? Appalling morbidity. Huge bills in care for the
rest of the life. Multimillion pound (or dollar) compensation. A disaster
none would wish on anyone.

That's why I'm unhappy with even a tiny miss rate - it really matters.

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Rob Ojala
Sent: 27 June 2010 23:08
To: Trauma-List [TRAUMA.ORG]
Subject: RE: Occult cervical spine injuries

Mmmm - in all the discussion I haven't heard of a Reference to a paper
or formal case series acknowledging situations where in the pre-CT days
[ie case control] patients with NORMAL complete series Cx plain films
developing neurology after RSI where CT would have demonstrated a
[truly] unstable fracture.
Or
I'm not concerned about 1 or 2 cases in the world literature - we are
talking about millions of trauma patients over decades who have not come
to harm. So the percentages are what matters.

Blue flightmedic - your suggestion that a miss rate of  0.001% only is
the acceptable limit - May I respectfully suggest you throw away your
stethoscope [grossly insensitive]; opthalmoscope [worse than random at
detecting raised ICP]; ECG [insensitive]; CT or any other investigation
you care to mention.

For the cases Dr Mattox describes may I speculate - If a significant
number of trauma patients had to undergo MRI to rule out this condition,
I suspect more harm than good might await this cohort as practitioners
hold off RSI or other definitive therapies while the magnet slowly
weaves it magic.

Rob Ojala

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Blueflightmedic
Sent: Saturday, 26 June 2010 12:37 a.m.
To: 'Trauma-List [TRAUMA.ORG]'
Subject: RE: Occult cervical spine injuries

Unfortunately there remain a cohort of patients who present with normal
cervical spine films and either an inapparent bony or soft tissue
critical
injury. MR is the gold standard imaging modality of choice, but far more
important is clinical history and examination. There is not enough to go
on
in your story to know the full mechanism of injury and I am not at all
reassured by the 'lack of signs' - how much pain is the tib/fib injury
causing at the time of examination and how much analgesia has the
patient
received?

Beware the painful distracting injury. However, how painful is painful
enough to distract? In my own practice I teach two rules of thumb:

'Pain everywhere likely fracture nowhere'
And
'If venepuncture hurts there isn't a distracting injury'

However there is absolutely no place for complacency and I have seen
several
disasters, one quite recently, with completely normal cervical spine
films.

The figure quoted by the ATLS manual is a sensitivity of 85% for a
single
lateral film and from memory several papers have demonstrated that rises
to
97% with 3 adequate films. That's 3% you'll miss, and that's at least
2.999%
too high for my liking.

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Rob Ojala
Sent: 24 June 2010 22:23
To: trauma-list at trauma.org
Subject: Occult cervical spine injuries

Colleagues- a couple of questions/request for papers...

Scenario....as pertains to occult cervical spine injuries...

68yr old male high speed MVA causing seemingly isolated tib-fib
fracture.

No cervical symptoms or associated signs and  GCS 15

Plain films of Cx spine - normal other than minor degen changes.

Question is to CT or not CT neck

I am aware that there is a rate of occult fracture in this setting,
but.....

1.      What is the rate of truly unstable occult fractures with normal
[adequate] Cx films? [papers would be good NB - we are not talking about
papers on obtunded/intubated patients]
2.      in the pre-CT era - what was the rate of folk in the setting of
normal and adequate plain films who were intubated for operative
management and woke up with 'new' neurological sequelae? [ie effectively
the control group]
3.      I am aware that the routine use of Cx spine CT is creeping in
especially in countries where litigation fears predominate - but would
this patient get Cx spine CT in most parts of the world??

Many thanks

Rob Ojala

New Zealand

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