Is the lateral cervical spine x-ray obsolete during the initial evaluation of patients with acute trauma?

BACKGROUND: Clearing the cervical spine is a vital part of the treatment of trauma patients, and the failure to accurately diagnose an injury to the cervical spine can result in paralysis and even death. For decades, plain film imaging, primarily LCSX, was the standard imaging method used to initially evaluate the cervical spine, with CSCT used as an adjunct. With advancements in CSCT over the past decade, it is generally accepted that CSCT should be used as the screening method for clearance of the cervical spine in patients with trauma. In this study our goal was to determine whether lateral cervical spine radiographs (LCSX) are warranted in the initial evaluation of trauma patients or whether they should be eliminated completely in favor of CSCT scans as the initial method of evaluating the cervical spine in trauma patients.

METHODS: This is a retrospective study using a prospectively maintained computerized database of all trauma admissions to a level II American College of Surgeons verified trauma center. Patients who were identified to have both LCSX and CSCT on admission were analyzed. Radiology readings (LCSX and CSCT) of the selected patients were reviewed and comparisons were made to determine the number of patients for which the LCSX was inconclusive or unsatisfactory. It was also determined whether, in selected cases, there were injuries or abnormal findings that were detected in one imaging modality but were not detected in the other.

RESULTS: A total of 895 trauma admissions were reviewed; 177 had both LCSX and CSCT. The radiological results of the 177 patients were analyzed. Fifty-one (28%) patients were determined to have inadequate LCSX in which further scans were required for diagnosis or clearance of the cervical spine. Thirty-six (20%) patients had fractures that were undetected by LCSX.

CONCLUSIONS: Our research supports previous studies demonstrating the greater accuracy of CT in evaluating the cervical spine in acute trauma patients. Moreover, with spiral CT scanning, the length of time required to obtain images has been eliminated as an issue. We conclude that LCSX should be eliminated from trauma protocols and that CSCT should be the sole imaging modality used in the initial evaluation of the cervical spine after trauma.