![]() ![]() Many studies noted two important aspects of MRI evaluation: 13 Overall, care was changed for a significant number of patients based on these studies. 15 Another large study in 2011 showed that 2.8% of the patients receiving an MRI following a negative CT had injuries requiring surgery. In the Inaba study, all of the patients requiring surgery had a focal neurological finding, and two of the three had significant degenerative disease. 14,15 The authors discussed however, that those patients made up a small percentage (<4% and 1%) of their overall number. Both studies identified injuries requiring surgery with MRI that were not found on CT. Recently, two prospective, large, multi-center trials were completed to evaluate the utility of post-CT MRI. These studies argued that an important aspect of using MRI, the postulated gold standard, is its negative predictive value and its use to exclude unstable cervical spine injury in patients with persistent pain or coma. 9 Still less than 1% needed surgery based on new findings. Schoenfeld’s meta-analysis showed a higher percentage of patients affected by a post-CT MRI, with 6% of the patients requiring management changes. However, most changes to care involved using a collar and accounted for less than 1% of the study population. In recent meta-analyses, injuries that required surgically intervention 9 or prolonged rigid collar use 10-12 were found on MRI after normal CTs. Some studies suggest MRIs will catch important information missed by CT. Should awake, reliable patient with persistent midline tenderness after normal head CT undergo MRI? In Support of an ED MRI: The use of MRI in awake, reliable patients without identification of bony abnormality on CT is controversial, even amongst neurosurgical specialists. MRI is also the best diagnostic imaging for SCIWORA (spinal cord injury without radiographic abnormality) with studies documenting sensitivities of 89-100%.MRI is superior in its ability to evaluate for acute disc herniation, ligamentous injury, edema, contusions, bony compression of the spinal cord, and epidural and subdural hemorrhage when compared to CT.If an injury is strongly suspected, per the American College of Radiology, reconstructions should be completed. 3D-CT reconstructions allow for visualization in multiple planes and provide superior injury detection when compared with plain x-ray.CT is highly sensitive, fast, practical, not limited by a patient’s pre-existing hardware, and is less claustrophobic for patients than MRIs.Sensitivity approaches 97-100% and specificity 99-100% in detecting injury. CT is excellent for evaluationof spine alignment, detection of bony injuries, and hematomas involving the paravertebral soft tissues, craniocervical junction injuries, and signs of subcutaneous soft tissue trauma.If a patient fulfills the NEXUS or Canadian C-Spine criteria: Initial Imaging of the Cervical Spine: X-ray, CT, or MRI? 4 When assessing for these injuries, the literature is clear: both CT and MRI can be critical modalities in evaluating for unstable cervical spine injuries. 3 For ED patients, a missed or delayed diagnosis of unstable cervical spine injuries is ten times more likely to be associated with neurological sequelae than injury diagnosed on initial evaluation. Litigation concerning missed cervical spine injuries is often severe, and the average payout in the United States is $2.9 million. 2 Morbidity and mortality from cervical injuries are high. 1,2 Injuries have a bimodal distribution, with an initial peak between ages 15 and 29 years old and the second peak after age 65. What is the role of magnetic resonance imaging (MRI)? When is it appropriate to discharge a patient in a rigid or soft cervical collar?Ĭervical spine injuries occur in 3% of major trauma patients. What are the next steps for a patient with persistent C-spine tenderness, a negative CT, and no neurological deficits? In spite of pain medication, the patient continues to have point tenderness to his cervical spine. ![]() A non-contrast computed tomography (CT) is completed, which shows no obvious bony abnormality. The patient denies sensory deficits or subjective feelings of weakness. His initial survey showed point tenderness to his cervical spine, with no other focal physical exam findings. He required extrication by the fire department and did not ambulate prior to arrival in the ED. Author: Kathy Staats, MD EM & EMS Attending Physician, Stanford University) // Edited by: Alex Koyfman, MD and Brit Long, MD CaseĪ 28-year-old male with no past medical history is brought in by EMS in a C-collar with spinal precautions for neck pain after a rollover motor vehicle collision prior to arrival. The patient was driving at highway speed prior to the accident, did not have loss of consciousness, was a restrained driver, and airbags deployed. ![]()
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