Intraoperative radiographic localization within the cervical spine can be a challenge because of the anatomical relation of the musculoskeletal structures of the pectoral girdle. On standard cross-table lateral radiographs, these structures can produce shadowing that obscure the anatomical features of the cervical vertebrae, particularly at the caudal levels. Surgical guidelines recommend accurate intraoperative localization as a means to reduce wrong-level spine surgery, and unobstructed visualization is needed for fluoroscopy-guided placement of spinal instrumentation. In this article, the authors describe and evaluate a novel device designed to provide transient intraoperative caudal displacement of the shoulders to improve and simplify radiographic visualization of the cervical spine.
A 2-center prospective study was conducted to evaluate the device. The study included a total of 80 patients undergoing cervical spine surgery. The device was evaluated in a cohort of 50 patients undergoing elective single-level anterior discectomy and fusion and also in a second cohort of 30 patients at an independent institution. The patients in this second cohort were undergoing a variety of cervical spine procedures for multiple indications and were included in the study to allow the authors to assess the effectiveness of the device in a general neurosurgical practice. After the patients were anesthetized and positioned, consecutive standard cross-table lateral radiographs or intraoperative fluoroscopic were obtained before and after use of the device. The images were compared in order to determine the difference in lowest vertebral level visible.
There was an average difference in cervical spine visualization of +2.8 ± 0.9 vertebral levels in the first cohort, while in the second the improvement was +1.2 ± 0.7 levels (p < 0.0001 between cohorts, unpaired t-test). There was one complication, a minor shoulder abrasion, which required no specific management.
This device is safe and effective for increasing the radiographic visualization of the cervical spine for intraoperative localization.
Clinical factors show promise for predicting fractures, but until they’re validated, all such patients should undergo C-spine computed tomography.
Both the National Emergency X-Radiography Utilization Study (NEXUS) and Canadian cervical spine (C-spine) rules have demonstrated that clinical exam is sufficient to clear the cervical spine for certain trauma patients. However, the sensitivity and specificity of these rules for patients with major trauma are not adequate, and many centers perform C-spine computed tomography (CT) for all patients with major trauma. In this prospective single-site study, investigators evaluated the correlation between findings on C-spine CT and presence of any of 18 combined NEXUS and Canadian C-spine criteria in 5812 trauma patients.
All patients met criteria for major trauma requiring trauma team activation, which included Glasgow Coma Scale (GCS) score <14, systolic blood pressure <90 mm Hg, respiratory rate <10 or >20 per minute, significant obvious anatomic injury (e.g., flail chest; two or more long-bone fractures; crushed, degloved, or mangled extremity; amputation; pelvic fractures; open or depressed skull fractures; paralysis), and significant mechanism of injury (e.g., falls >20 feet, high-risk motor vehicle collision).
Fracture incidence was 6.3%. Clinical exam had 100% sensitivity and 0.62% specificity for detecting fractures. Seven NEXUS/Canadian C-spine criteria were independent predictors of fracture: midline tenderness, GCS score <15, paresthesias, rollover motor vehicle collision, ejection from a motor vehicle, age 65, and not being able to sit up in the emergency department. Use of these seven factors increased specificity nearly 20-fold, to 11.6%.
Comment: Prospective multicenter validation of these factors is needed before practice changes. Until then, C-spine computed tomography should continue be the study of choice to evaluate patients with major trauma for possible cervical spine fracture.
Source: Journal Watch Emergency Medicine
Como JJ et al. – Spinal cord injury without computed tomography evidence of trauma (SCIWOCTET) is mainly a disease of adults, and its subset Spinal cord injury without radiographic abnormality (SCIWORA), a disease of children, is much less common. Adults with this disease have computed tomographic (CT) scans showing canal stenosis and significant degenerative changes in the cervical spine; thus, it is not accurate to state that they have SCIWORA. The characteristics of this patient population are important as SCIWOCTET is the concern when clearing the cervical spines of trauma patients with a CT scan of the cervical spine negative for injury.
Source: Journal of Trauma