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Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT

  • Magnetic Resonance
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Purpose

To determine the utility of cervical spine MRI in blunt trauma evaluation for instability after a negative non-contrast cervical spine CT.

Methods

A review of medical records identified all adult patients with blunt trauma who underwent CT cervical spine followed by MRI within 48 h over a 33-month period. Utility of subsequent MRI was assessed in terms of findings and impact on outcome.

Results

A total of 1,271 patients with blunt cervical spine trauma underwent both cervical spine CT and MRI within 48 h; 1,080 patients were included in the study analysis. Sixty-six percent of patients with a CT cervical spine study had a negative study. Of these, the subsequent cervical spine MRI had positive findings in 20.9%; 92.6% had stable ligamentous or osseous injuries, 6.0% had unstable injuries and 1.3% had potentially unstable injuries. For unstable injury, the NPV for CT was 98.5%. In all 712 patients undergoing both CT and MRI, only 1.5% had unstable injuries, and only 0.42% had significant change in management.

Conclusions

MRI for blunt trauma evaluation remains not infrequent at our institution. MRI may have utility only in certain patients with persistent abnormal neurological examination.

Key Points

• MRI has limited utility after negative cervical CT in blunt trauma.

• MRI is frequently positive for non-specific soft-tissue injury.

• Unstable injury missed on CT is infrequent.

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Abbreviations

ALL:

Anterior Longitudinal Ligament

CSI:

Cervical spine injury

CT:

Computed tomography

ED:

Emergency department

GCS:

Glasgow Coma Scale

IRB:

Institutional Review Board

MRI:

Magnetic resonance imaging

MVA:

Motor vehicle accident

NEXUS:

National Emergency XRadiography Utilization Study

NPV:

Negative predictive value

PLC:

Posterior ligamentous complex

PLL:

Posterior longitudnal ligament

References

  1. Young AJ, Wolfe L, Tinkoff G, Duane TM (2015) Assessing incidence and risk factors of cervical spine injury in blunt trauma patients using the National Trauma Data Bank. Am Surg 81:879–883

    PubMed  Google Scholar 

  2. Badhiwala JH, Lai CK, Alhazzani W et al (2015) Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review. Ann Intern Med 162:429–437

    Article  PubMed  Google Scholar 

  3. Harris MB, Kronlage SC, Carboni PA et al (2000) Evaluation of the cervical spine in the polytrauma patient. Spine (Phila Pa 1976) 25:2884–2891 discussion 2892

    Article  CAS  Google Scholar 

  4. Levi AD, Hurlbert RJ, Anderson P et al (2006) Neurologic deterioration secondary to unrecognized spinal instability following trauma--a multicenter study. Spine (Phila Pa 1976) 31:451–458

    Article  Google Scholar 

  5. Reid DC, Henderson R, Saboe L, Miller JD (1987) Etiology and clinical course of missed spine fractures. J Trauma 27:980–986

    Article  PubMed  CAS  Google Scholar 

  6. Poonnoose PM, Ravichandran G, McClelland MR (2002) Missed and mismanaged injuries of the spinal cord. J Trauma 53:314–320

    Article  PubMed  Google Scholar 

  7. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI (2000) Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 343:94–99

    Article  PubMed  CAS  Google Scholar 

  8. Stiell IG, Wells GA, Vandemheen KL et al (2001) The Canadian C-spine rule for radiography in alert and stable trauma patients. Jama 286:1841–1848

    Article  PubMed  CAS  Google Scholar 

  9. Holmes JF, Akkinepalli R (2005) Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma 58:902–905

    Article  PubMed  Google Scholar 

  10. Hennessy D, Widder S, Zygun D, Hurlbert RJ, Burrowes P, Kortbeek JB (2010) Cervical spine clearance in obtunded blunt trauma patients: a prospective study. J Trauma 68:576–582

    Article  PubMed  Google Scholar 

  11. Malhotra A, Wu X, Kalra VB et al (2017) Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis. Eur Radiol 27:1148–1160

    Article  PubMed  Google Scholar 

  12. Muchow RD, Resnick DK, Abdel MP, Munoz A, Anderson PA (2008) Magnetic resonance imaging (MRI) in the clearance of the cervical spine in blunt trauma: a meta-analysis. J Trauma 64:179–189

    Article  PubMed  Google Scholar 

  13. Stelfox HT, Velmahos GC, Gettings E, Bigatello LM, Schmidt U (2007) Computed tomography for early and safe discontinuation of cervical spine immobilization in obtunded multiply injured patients. J Trauma 63:630–636

    Article  PubMed  Google Scholar 

  14. Tomycz ND, Chew BG, Chang YF et al (2008) MRI is unnecessary to clear the cervical spine in obtunded/comatose trauma patients: the four-year experience of a level I trauma center. J Trauma 64:1258–1263

    Article  PubMed  Google Scholar 

  15. Sanchez B, Waxman K, Jones T, Conner S, Chung R, Becerra S (2005) Cervical spine clearance in blunt trauma: evaluation of a computed tomography-based protocol. J Trauma 59:179–183

    Article  PubMed  Google Scholar 

  16. Harris TJ, Blackmore CC, Mirza SK, Jurkovich GJ (2008) Clearing the cervical spine in obtunded patients. Spine (Phila Pa 1976) 33:1547–1553

    Article  Google Scholar 

  17. Gargas J, Yaszay B, Kruk P, Bastrom T, Shellington D, Khanna S (2013) An analysis of cervical spine magnetic resonance imaging findings after normal computed tomographic imaging findings in pediatric trauma patients: ten-year experience of a level I pediatric trauma center. J Trauma Acute Care Surg 74:1102–1107

    Article  PubMed  Google Scholar 

  18. Vanguri P, Young AJ, Weber WF et al (2014) Computed tomographic scan: it's not just about the fracture. J Trauma Acute Care Surg 77:604–607

    Article  PubMed  Google Scholar 

  19. Diaz JJ Jr, Aulino JM, Collier B et al (2005) The early work-up for isolated ligamentous injury of the cervical spine: does computed tomography scan have a role? J Trauma 59:897–903 discussion 903-894

    Article  PubMed  Google Scholar 

  20. Kaiser ML, Whealon MD, Barrios C, Kong AP, Lekawa ME, Dolich MO (2012) The current role of magnetic resonance imaging for diagnosing cervical spine injury in blunt trauma patients with negative computed tomography scan. Am Surg 78:1156–1160

    PubMed  Google Scholar 

  21. Benzel EC, Hart BL, Ball PA, Baldwin NG, Orrison WW, Espinosa MC (1996) Magnetic resonance imaging for the evaluation of patients with occult cervical spine injury. J Neurosurg 85:824–829

    Article  PubMed  CAS  Google Scholar 

  22. Patel MB, Humble SS, Cullinane DC et al (2015) Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 78:430–441

    Article  PubMed  PubMed Central  Google Scholar 

  23. Denis F (1983) The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976) 8:817–831

    Article  CAS  Google Scholar 

  24. Cybulski GR, Douglas RA, Meyer PR Jr, Rovin RA (1992) Complications in three-column cervical spine injuries requiring anterior-posterior stabilization. Spine (Phila Pa 1976) 17:253–256

    Article  CAS  Google Scholar 

  25. Morrison J, Jeanmonod R (2014) Imaging in the NEXUS-negative patient: when we break the rule. Am J Emerg Med 32:67–70

    Article  PubMed  Google Scholar 

  26. Ackland HM, Cameron PA, Varma DK et al (2011) Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. Ann Emerg Med 58:521–530

    Article  PubMed  Google Scholar 

  27. Inaba K, Byerly S, Bush LD et al (2016) Cervical spinal clearance: a prospective Western Trauma Association Multi-institutional Trial. J Trauma Acute Care Surg 81:1122–1130

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  28. James IAO, Moukalled A, Yu E et al (2014) A systematic review of the need for MRI for the clearance of cervical spine injury in obtunded blunt trauma patients after normal cervical spine CT. J Emerg Trauma Shock 7:251–255

    Article  PubMed  PubMed Central  Google Scholar 

  29. Russin JJ, Attenello FJ, Amar AP, Liu CY, Apuzzo ML, Hsieh PC (2013) Computed tomography for clearance of cervical spine injury in the unevaluable patient. World Neurosurg 80:405–413

    Article  PubMed  Google Scholar 

  30. Schoenfeld AJ, Bono CM, McGuire KJ, Warholic N, Harris MB (2010) Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma 68:109–113 discussion 113-104

    Article  PubMed  Google Scholar 

  31. Panczykowski DM, Tomycz ND, Okonkwo DO (2011) Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma. J Neurosurg 115:541–549

    Article  PubMed  Google Scholar 

  32. Raza M, Elkhodair S, Zaheer A, Yousaf S (2013) Safe cervical spine clearance in adult obtunded blunt trauma patients on the basis of a normal multidetector CT scan--a meta-analysis and cohort study. Injury 44:1589–1595

    Article  PubMed  Google Scholar 

  33. Malhotra A, Wu X, Kalra VB, Schindler J, Matouk CC, Forman HP (2016) Evaluation for blunt cerebrovascular injury: review of the literature and a cost-effectiveness analysis. AJNR Am J Neuroradiol 37:330–335

    Article  PubMed  CAS  Google Scholar 

  34. Hogan GJ, Mirvis SE, Shanmuganathan K, Scalea TM (2005) Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi-detector row CT findings are normal? Radiology 237:106–113

    Article  PubMed  Google Scholar 

  35. Wu X, Malhotra A, Geng B et al (2017) Cost-effectiveness of magnetic resonance imaging in cervical spine clearance of neurologically intact patients with blunt trauma. Ann Emerg Med. https://doi.org/10.1016/j.annemergmed.2017.07.006

  36. Fisher BM, Cowles S, Matulich JR, Evanson BG, Vega D, Dissanaike S (2013) Is magnetic resonance imaging in addition to a computed tomographic scan necessary to identify clinically significant cervical spine injuries in obtunded blunt trauma patients? Am J Surg 206:987–993 discussion 993-984

    Article  PubMed  Google Scholar 

  37. Sarani B, Waring S, Sonnad S, Schwab CW (2007) Magnetic resonance imaging is a useful adjunct in the evaluation of the cervical spine of injured patients. J Trauma 63:637–640

    Article  PubMed  Google Scholar 

  38. Schoenfeld AJ, Tobert DG, Le HV et al (2017) The utility of adding magnetic resonance imaging to computed tomography alone in the evaluation of cervical spine injury: a propensity matched analysis. Spine (Phila Pa 1976). https://doi.org/10.1097/brs.0000000000002285

  39. Resnick S, Inaba K, Karamanos E et al (2014) Clinical relevance of magnetic resonance imaging in cervical spine clearance: a prospective study. JAMA Surg 149:934–939

    Article  PubMed  Google Scholar 

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Funding

The authors state that this work has not received any funding.

Author information

Authors and Affiliations

  1. Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT, 06520-8042, USA

    Ajay Malhotra & David Durand

  2. Yale School of Medicine, New Haven, CT, USA

    Xiao Wu & Bertie Geng

  3. Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA

    Khalid Abbed

  4. Division Chief of Neuroradiology, Director Emergency Radiology, Brigham and Women’s and Hospital, Harvard Medical School, Boston, MA, USA

    Diego B. Nunez

  5. Department of Radiology Northwell Health, New York, NY, USA

    Pina Sanelli

Authors
  1. Ajay Malhotra
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  2. David Durand
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  3. Xiao Wu
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  4. Bertie Geng
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  5. Khalid Abbed
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  6. Diego B. Nunez
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  7. Pina Sanelli
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Corresponding author

Correspondence to Ajay Malhotra.

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Guarantor

The scientific guarantor of this publication is Ajay Malhotra.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Ethical approval

Institutional Review Board of Yale University approval was obtained for this study.

Informed consent

Written informed consent was waived by Institutional Review Board.

Methodology

• retrospective

• case-control study

• performed at one institution

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Malhotra, A., Durand, D., Wu, X. et al. Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT . Eur Radiol 28, 2823–2829 (2018). https://doi.org/10.1007/s00330-017-5285-y

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  • DOI: https://doi.org/10.1007/s00330-017-5285-y

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