Errors in Emergency and Trauma Radiology: C-Spine Imaging

  • Sadia R. QamarEmail author
  • Yuhao Wu
  • Luck Louis
  • Savvas Nicolaou


Errors and mistakes in interpretation of cervical spine imaging are multifactorial and can be attributed to technical, work environment, or radiologist-specific factors. To minimize these errors, radiologists should work in close collaboration with emergency physicians and other clinicians. They should obtain access to detailed clinical information and utilize a consistently accurate approach to interpret initial cervical spine CT imaging, as patients may have substantial and unstable ligamentous and/or vascular injuries despite subtle or no positive CT findings. Moreover, CT should be supplemented with CT angiography in suspected vascular injuries. MR imaging should be obtained in obtunded patients and those with potential ligamentous and/or spinal cord injuries.


Cervical spine Computed tomography (CT) Craniocervical junction Subaxial cervical spine Hyperflexion injuries Hyperextension injuries Imaging pitfalls 


  1. 1.
    Centers for Disease Control and Prevention. National Hospital ambulatory medical care survey. Atlanta, GA: Centers for Disease Control and Prevention; 2015.Google Scholar
  2. 2.
    Sheikh K, Belfi LM, Sharma R, et al. Evaluation of acute cervical spine imaging based on ACR Appropriateness Criteria®. Emerg Radiol. 2012;19(1):11–7.PubMedGoogle Scholar
  3. 3.
    Munera F, Rivas LA, Nunez DB, et al. Imaging evaluation of adult spinal injuries: emphasis on multidetector CT in cervical spine trauma. Radiology. 2012;263(3):645–60.PubMedGoogle Scholar
  4. 4.
    Berlin L. Radiologic errors and malpractice: a blurry distinction. Am J Roentgenol. 2007;189(3):517–22.Google Scholar
  5. 5.
    Pinto A, Reginelli A, Pinto F, et al. Errors in imaging patients in the emergency setting. Br J Radiol. 2016;89(1061):20150914.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Triantopoulou C, Tsalafoutas I, Maniatis P, et al. Analysis of radiological examination request forms in conjunction with justification of X-ray exposures. Eur J Radiol. 2005;53(2):306–11.PubMedGoogle Scholar
  7. 7.
    Kim YW, Mansfield LT. Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. Am J Roentgenol. 2014;202(3):465–70.Google Scholar
  8. 8.
    Krupinski EA, Berbaum KS, Caldwell RT, et al. Long radiology workdays reduce detection and accommodation accuracy. J Am Coll Radiol. 2010;7(9):698–704.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Renfrew DL, Franken EA, Berbaum KS, et al. Error in radiology: classification and lessons in 182 cases presented at a problem case conference. Radiology. 1992;183(1):145–50.PubMedGoogle Scholar
  10. 10.
    Bruno MA, Walker EA, Abujudeh HH. Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction. Radiographics. 2015;35(6):1668–76.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Hoffman JR, Mower WR, Wolfson AB, et al. 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. 2000;343(2):94–9.PubMedGoogle Scholar
  12. 12.
    Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841–8.PubMedGoogle Scholar
  13. 13.
    Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510–8.PubMedGoogle Scholar
  14. 14.
    Stiell IG, Clement CM, O’Connor A, et al. Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. CMAJ. 2010;182(11):1173–9.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Stiell IG, Clement CM, Grimshaw J, et al. Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. BMJ. 2009;339:b4146.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Paykin G, O’Reilly G, Ackland HM, et al. The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients. Injury. 2017;48(5):1020–4.PubMedGoogle Scholar
  17. 17.
    Daffner RH. Helical CT of the cervical spine for trauma patients: a time study. Am J Roentgenol. 2001;177(3):677–9.Google Scholar
  18. 18.
    Daffner RH, Weissman BN, Wippold FJ II, Angtuaco EJ, et al. Expert panels on musculoskeletal and neurologic imaging. ACR Appropriateness Criteria® suspected spine trauma. Reston, VA: American College of Radiology; 2012.Google Scholar
  19. 19.
    Becce F, Ben Salah Y, Verdun FR, et al. Computed tomography of the cervical spine: comparison of image quality between a standard-dose and a low dose protocol using filtered back-projection and iterative reconstruction. Skeletal Radiol. 2013;2(7):937–45.Google Scholar
  20. 20.
    Sliker CW. Blunt cerebrovascular injuries: imaging with multidetector CT angiography. Radiographics. 2008;28(6):1689–708. discussion 1709–1710.PubMedGoogle Scholar
  21. 21.
    Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg. 2012;72(2):330–5. discussion 336–337.PubMedGoogle Scholar
  22. 22.
    White AA, Panjabi MM. Clinical biomechanics of the spine. 2nd ed. Philadelphia, PA: Lippincott; 1990. Google Scholar
  23. 23.
    Schwartz ED, Flanders AE. Spinal trauma: imaging, diagnosis, and management. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. Google Scholar
  24. 24.
    Denis F. Spinal stability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop Relat Res. 1984;Oct(189):65–76.Google Scholar
  25. 25.
    Daffner RH, Deeb ZL, Rothfus WE. “Fingerprints” of vertebral trauma-a unifying concept based on mechanism. Skeletal Radiol. 1986;15(7):518–25.PubMedGoogle Scholar
  26. 26.
    Dvorak MF, Fisher CG, Fehlings MG, et al. The surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC classification system. Spine. 2007;32(23):2620–9.PubMedGoogle Scholar
  27. 27.
    Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma. 2005;58(5):902–5.PubMedGoogle Scholar
  28. 28.
    Berquist TH. Imaging of adult cervical spine trauma. Radiographics. 1988;8(4):667–94.PubMedGoogle Scholar
  29. 29.
    Banerjee A, Clayton-Jolly A, Mbamalu D. The radiological assessment of injuries to the atlanto-axial-occipital complex (C1 and C2 vertebrae). Trauma. 2008;10(4):231–8.Google Scholar
  30. 30.
    Rojas CA, Bertozzi JC, Martinex CR, et al. Reassessment of the craniocervical junction: normal values on CT. Am J Neuroradiol. 2007;28(9):1819–23.PubMedGoogle Scholar
  31. 31.
    Green JD, Harle TS, Harris JH Jr. Anterior subluxation of the cervical spine: hyperflexion sprain. Am J Neuroradiol. 1981;2(3):243–50.PubMedGoogle Scholar
  32. 32.
    Smoker WR. Craniovertebral junction: normal anatomy, craniotomy, and congenital anomalies. Radiographics. 1994;14(2):255–77.PubMedGoogle Scholar
  33. 33.
    Chang W, Alexander MT, Mirvis SE. Diagnostic determinants of craniocervical distraction injury in adults. Am J Roentgenol. 2009;192(1):52–8.Google Scholar
  34. 34.
    Hanson JA, Deliganis AV, Baxter AB, et al. Radiologic and clinical spectrum of occipital condyle fractures: retrospective review of 107 consecutive fractures in 95 patients. AJR Am J Roentgenol. 2002;178(5):1261–8.PubMedGoogle Scholar
  35. 35.
    Leone A, Cerase A, Colosimo C, Lauro L, Puca A, Marano P. Occipital condylar fractures: a review. Radiology. 2002;2016(3):635–44.Google Scholar
  36. 36.
    Anderson PA, Montesano PX. Morphology and treatment of occipital condyle fractures. Spine (Phila Pa 1976). 1988;13(7):731–6.Google Scholar
  37. 37.
    Gehweiler JA Jr, Duff DE, Martinex S, Miller MD, Clark WM. Fractures of the atlas vertebra. Skeletal Radiol. 1976;1(2):97–102.Google Scholar
  38. 38.
    Anderson LD, D’Alonxo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56(8):1663–74.PubMedGoogle Scholar
  39. 39.
    Junewick JJ. Pediatric craniocervical junction injuries. Am J Roentgenol. 2011;196(5):1003–10.Google Scholar
  40. 40.
    Dreizin D, Michael L, Sliker CW, Chokshi FH, Bodanapally U, Mirvis S, et al. Multidetector CT of blunt cervical spine trauma in adults. Radiographics. 2014;34(7):1842–65.PubMedGoogle Scholar
  41. 41.
    Levine AM, Edwards CC. Fractures of the atlas. J Bone Joint Surg Am. 1991;73(5):680–91.PubMedGoogle Scholar
  42. 42.
    Hagedorn JC II, Emery SE, France JC, et al. Does CT angiography matter for patients with cervical spine injuries? J Bone Joint Surg Am. 2014;96(11):951–5.PubMedGoogle Scholar
  43. 43.
    Rankine JJ. Spinal trauma. In: Adam A, editor. Grainger & Allison’s diagnostic radiology. 6th ed. London: Churchill Livingstone Elsevier; 2015. p. 1374–89.Google Scholar
  44. 44.
    Raniga SB, Menon V, Al Muzahmi KS, et al. MDCT of acute subaxial cervical spine trauma: a mechanism-based approach. Insights Imaging. 2014;5(3):321–38.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Kim KS, Chen HH, Russell EJ, et al. Flexion teardrop fracture of the cervical spine: radiographic characteristics. Am J Roentgenol. 1989;152(2):319–26.Google Scholar
  46. 46.
    Posthuma de Boer J, van Wulfften Palthe AF, Stadhouder A, et al. The clay shoveler’s fracture: a case report and review of the literature. J Emerg Med. 2016;51(3):292–7.PubMedGoogle Scholar
  47. 47.
    Lin JT, Lee JL, Lee ST. Evaluation of occult cervical spine fractures on radiographs and CT. Emerg Radiol. 2003;10(3):128–34.PubMedGoogle Scholar
  48. 48.
    Han SR, Sohn MJ. Twelve contiguous spinous process fracture of cervicothoracic spine. Korean J Spine. 2014;11(3):212–3.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Regenbogen VS, Rogers LF, Atlas SW, et al. Cervical spine cord injuries in patients with cervical lordosis. Am J Roentgenol. 1986;146(2):277–84.Google Scholar
  50. 50.
    Scher AT. Hyperextension trauma in the elderly: an easily overlooked spinal injury. J Trauma. 1983;23(12):1066–8.PubMedGoogle Scholar
  51. 51.
    Edeiken-Monroe B, Wagner LK, Harris JHJ. Hyperextension dislocation of the cervical spine. Am J Roentgenol. 1986;146(4):803–8.Google Scholar
  52. 52.
    Daffner RH, Daffner SD. Vertebral injuries: detection and implications. Eur J Radiol. 2002;42(2):100–16.PubMedGoogle Scholar
  53. 53.
    Kumar Y, Hayashi D. Role of magnetic resonance imaging in acute spinal trauma: a pictorial review. BMC Musculoskelet Disord. 2016;17:310–41.PubMedPubMedCentralGoogle Scholar
  54. 54.
    Selden NR, Quint DJ, Patel N, et al. Emergency magnetic resonance imaging of cervical spinal cord injuries: clinical correlation and prognosis. Neurosurgery. 1999;44(4):785–92. discussion 792–783.PubMedGoogle Scholar
  55. 55.
    Chandra J, Sheerin F, Lopez de Heredia L, et al. MRI in acute and subacute post-traumatic spinal cord injury: pictorial review. Spinal Cord. 2012;50(1):2–7.PubMedGoogle Scholar
  56. 56.
    Song J, Mizuno J, Inoue T, et al. Clinical evaluation of traumatic central cord syndrome: emphasis on clinical significance of prevertebral hyperintensity, cord compression, and intramedullary high-signal intensity on magnetic resonance imaging. Surg Neurol. 2006;65(2):117–23.PubMedGoogle Scholar
  57. 57.
    Wu SK, Kuo LC, Lan HC, et al. The quantitative measurements of the intervertebral angulation and translation during cervical flexion and extension. Eur Spine J. 2007;16(9):1435–44.PubMedPubMedCentralGoogle Scholar
  58. 58.
    Molliqaj G, Payer M, Schaller K, et al. Acute traumatic central cord syndrome: a comprehensive review. Neurochirurgie. 2014;60(1-2):5–11.PubMedGoogle Scholar
  59. 59.
    Harada K, Chiko Y, Toyokawa T. Anterior spinal cord syndrome-“owl’s eye sign”. J Gen Fam Med. 2018;19(2):63–4.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Matsubayashi J, Tsuchiya K, Shimizu S, et al. Posterior spinal artery syndrome showing marked swelling of the spinal cord: a clinico-pathological study. J Spinal Cord Med. 2013;36(1):31–5.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Pratt ES, Green DA, Spengler DM. Herniated intervertebral discs associated with unstable spinal injuries. Spine (Phila Pa 1976). 1990;15(7):662–6.Google Scholar
  62. 62.
    Harrington JF, Likavec MJ, Smith AS. Disc herniation in cervical fracture subluxation. Neurosurgery. 1991;29(3):374–9.PubMedGoogle Scholar
  63. 63.
    Hadley MN, Walters BC, Grabb BC, et al. Initial closed reduction of cervical spine fracture-dislocation injuries. Neurosurgery. 2002;50(3 Suppl):S44–50.PubMedGoogle Scholar
  64. 64.
    Andreas C, Johannes H, Christoph O, Christian W, Stefan U, Lukas E. CT dose and image quality in the last three scanner generations. World J Radiol. 2013;5(11):421–9.Google Scholar
  65. 65.
    Piazzolla A, Solarino G, Lamartina C, et al. Vertebral bone marrow edema (VBME) in conservatively treated acute vertebral compression fractures (VCFs): evolution and clinical correlations. Spine. 2015;40(14):E842–8.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Sadia R. Qamar
    • 1
    Email author
  • Yuhao Wu
    • 1
  • Luck Louis
    • 1
  • Savvas Nicolaou
    • 2
  1. 1.Vancouver General HospitalUniversity of British ColumbiaVancouverCanada
  2. 2.Department of Radiology, Jim Pattison Pavilion SouthVancouver General HospitalVancouverCanada

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