Ruling out spinal fractures in trauma
CMAJ 1997;157:1018
Judging by the number of references in "Variation in emergency department use of cervical spine radiography for alert, stable trauma patients" (CMAJ 1997;156:1537-44 [abstract / résumé]), by Dr. Ian G. Stiell and associates, the issue of missed cervical spine trauma remains a hot topic in emergency medicine.
The yield of standard 5-view cervical spine screening films in suspected neck trauma is clearly extremely low. Unfortunately, this observation does nothing to reassure emergency physicians faced with identification of fractures that threaten the spinal cord. No physician wants to be held accountable for missing such a potentially catastrophic injury. As a result, the responsibility for detecting such an injury has been arbitrarily transferred to the radiology service in each of the major trauma centres across the country. Thus, until the spine has been "cleared" by the neuroradiologist, all patients suffering trauma are treated as if a spine fracture exists. On more than a few occasions, this has resulted in unacceptable delays, an excessive number of radiographs and inappropriate application of protective devices for inordinate periods. Why this situation continues unresolved strikes at the heart of the inadequacies in our current teaching programs across Canada concerning the spine and musculoskeletal system. We do not teach how to examine the cervical spine in suspected trauma; instead, we preach inappropriately that "all will be revealed" if only the correct diagnostic imaging test is ordered. As a result, when a physician has little, if any, confidence in his or her ability to examine the neck, he or she relies on someone else's opinion or a diagnostic test. This explains the inordinate number of screening spine radiographs taken.
In a conscious, alert, cooperative patient whose attention has not been distracted by mood-altering drugs, alcohol or analgesics, physical examination of the neck is a far more sensitive way of screening for the presence of any cervical spine fracture than plain radiography.1
I propose that, rather than developing extensive guidelines for ordering radiographs, we should develop a teaching program to instil the principles of physical examination of the neck. Only when physicians gain confidence in their ability to examine the neck is radiographic screening of the spine likely to diminish.
Richard D. Dewar, MD
University of Calgary Spine Program
Calgary, Alta.
Reference
- Velmahos GC, Theodorou D, et al. Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: Much ado about nothing? J Trauma 1996;40:768.
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