Introduction of advanced trauma life support (ATLS) and how


Radiology to this
day has a high standard of development, which increases over the years with new
improved technology. The purpose of this review is to explore the research conducted
and to compare and contrast the positive aspects of computed tomography (CT) over
plain film imaging in relation to trauma of the cervical spine. Trauma within
the c-spine is highly known to occur from road traffic accidents, which are to
be the third leading cause of reduced health globally (Rissanen et al., 2017). Throughout
the review, I will discuss different aspects of themes, which relate to the
systemic research. Firstly, I will begin with the protocols from modern trauma
centres in relation to the assessment plan from NICE guidelines, which explains
what imaging modality is a high-quality preference.  Followed by this I will introduce the history
of advanced trauma life support (ATLS) and how it became a priority and more
demanding for improved patient centred care. Furthermore, I will continue to
discuss diagnostic errors within plain film radiography and explain the
importance in which this imaging modality is not beneficial for trauma to the
cervical spine. Lastly, I will then discuss and compare the overall importance
in why CT is more beneficial and should be the gold standard imaging modality
in trauma of the cervical spine.

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The methodology used
in this literature review consists of a systemic research of relevant articles
within the years of 1987 to 2016 and NICE guidelines (2017).  From this, I have gathered my information for
this literature review using resources such as Medline, Science Direct and
Google Scholar. Throughout my research in articles, the main keywords I used to
gather my information within the articles were “trauma in cervical spine”,
“imaging of trauma c-spine”, “protocols used in radiology for injury within the
cervical spine”, “diagnostic errors within imaging of cervical spine” and
“computed tomography over plain x-ray in spinal injuries”.  However, from these keywords, I have gathered
and managed to combine all my information together to compare why computed
tomography should be prioritised over plain film x-ray and to be the first
imaging modality in trauma patients with injury to their cervical spine.




Modern trauma
centres imaging protocols

Historically plain
film radiographs have been the gold standard for spinal injury in UK emergency
departments. The main aim of imaging the cervical spine in trauma is to prevent
neurological deterioration and to aid short and long-term management of spinal
injury. In a paper by Tins (2007), the incidence of missed injury on
radiographs versus CT as low as 0.5%, which is a high percentage, as missed
injuries should be accounted as 0%. From this, Tins (2007) also advises if CT
were gold standard in all modern trauma centres the percentage of missed
injuries would be as low as 0% as CT outlines the bony detail within the spine
in different views such as axial, sagittal and coronal.

Following from
this, Holmes (2005) states that in most modern trauma centres it can be
difficult to obtain high quality plain film radiographs in patients who are
immobilised.  Given it is time-consuming
with the examination lasting up to 30 minutes, and time is important whilst
dealing with trauma patients, reviewing this article, explains another example
in why CT should be the gold standard in imaging of the C-spine.  Current imaging protocols show that most
health care trusts no longer recommend the use of plain radiographs for
clearance of the cervical spine in trauma patients. According to NICE Guidelines
(2017) when assessing the cervical spine for diagnostic imaging when a head
injury is present, it states that all adults from the age of 16+ have to
undergo CT of the cervical spine within an hour of arrival.  Indication is given by the Canadian C-spine
rule, which identifies trauma patients clinically and physically, CT is also preferred
as the first imaging pathway for diagnosis of injury (Imaging Pathways, 2013);
within this protocol, Steill (2003) indicates that severe cervical spine trauma
can result in neurological disorders. For this reason, after CT, if there is a
neurological abnormality diagnosed which is in relation with the injury to the
spinal cord, magnetic resonance imaging (MRI) is the next preference.

Lastly, (Kelly
2012) advises us that only 67% of hospitals involved used a dedicated spinal
protocol, but more alarming was that 85% had access to CT during normal hours.
In comparison to modern trauma protocols within hospitals, it should be known
to all radiology departments within the healthcare environment that CT is a
gold standard imaging modality, and every trust should follow by the same
protocols within radiology to gain high quality images to benefit the patient.



NICE Guidelines

Furthermore, from
this, the management of the patient is suggested when a spinal assessment is
carried out. Adults who have sustained a head injury, it states that a CT of
the cervical spine should be examined alongside CT head according to NICE
guidelines (2017) and which is indicated by Canadian C-spine rule. In an
article by Steill (2003) he advises that if an initial assessment of a GCS is
shown less than 13 and if plain x-rays are technically inadequate or abnormal,
as a definitive cervical spine injury then a CT examination is needed urgently
as the patient may need to have surgery. From this CT should be the main
priority as patients who may need surgery, an action plan will be complete at a
higher speed as CT is less time-consuming.

Secondly, from
this it is also suggested depending on the patient’s movement, if the patient
is unable to rotate their neck 45 degrees, signs of motor or sensory deficits,
bony midline tenderness on palpation or percussion then the request for imaging
will follow and spinal immobilisation will take place. Reporting of a
provisional statement should be finalised within one hour after the examination
has been complete.

Thirdly, according
to NICE guidelines, if a patient has had a suspected injury, and can rotate
their neck 45 degrees which shows no indications for CT examination, then the
radiology department will have to perform three plain film x-rays of the
cervical spine with are anterior-posterior (AP) lateral and odontoid peg view.
Following from this on the NICE guidelines assessment path (See Appendix A) which
outlines the investigations of a cervical spine injury, if an injury is shown
then you return to the beginning of the assessment plan, which will then follow
by a CT scan and further investigations.

History of ATLS
and their first protocol in cervical spine imaging

Advanced trauma
life support (ATLS), was originally established after a plane crash in 1976
when an orthopaedic surgeon felt dissatisfied at the care his family had received
and his wife passing away. Following from this a group of surgeons worked
together with a university in Nebraska to present local courses to teach
advanced trauma life support skills, to increase the management of care levels
which has increased widely over the world, and patient centred care is at a
high priority now (Carmont, 2005). Evidently, Kool (2007) tells us that it all
had begun when cervical spine radiographs could not be requested for patients
who are neurologically normal and can flex and extend without pain. In all
other patients who were unable to move their neck and lateral, AP and
open-mouth odontoid views should be performed.  Although within the examination the lateral
projection may be complete, if not all cervical vertebrae are displayed, a
swimmers view projection had to be requested to ensure no injury had been

Secondly, using
another modality such as computed tomography (CT) had not been mentioned at the
start of ATLS protocol only an axial view with 3-mm intervals can be performed if
suspicious areas are not visualised within the examination. Coronal and
sagittal MPR’s also had not been mentioned within the ATLS protocol. Within the
ATLS protocol, it states that magnetic resonance imaging (MRI) is to be carried
out if a suspected neurological disorder is present. ATLS protocol states that
MRI should be highly recommended today for the detection of injury to the
ligaments within the cervical spine.

In discussion to
this, ATLS has been the main reason why trauma injuries and the health care received
today is at a high standard, and patient centred care is staffs first priority
in trauma incidents. As the years progress more generated technology is
available to ensure a good quality image is finalised, from this advanced
trauma care will grow. Lastly, in comparison to reading this article, it
therefore combines with other guidelines and articles that CT is much preferred
over x-ray when it comes to cervical spine injuries.


Diagnostic Errors
in Imaging of Cervical Spine in Plain Film X-ray

According to Thesleff
(2017) whilst researching for diagnostic errors in imaging of the cervical
spine it explains to us that diagnostic errors occur in every medical
speciality with an error rate estimated at 15%. Diagnostic errors in imaging
can continue to cause death in patients or long-term neurological disorders.
Following up in this study which encountered from 1987 to 2010, a number of
2,204 patients who had a cervical spine injury had died, 36.5% of these
patients had survived until the next day of injury. Within two days of the injury,
1,847 patients had died due to a cervical spine injury, which had no diagnosis
through plain film radiography. Following from this the use of CT over plain
x-ray is becoming widely available in health care trusts, as trauma to the
spine is classified as an emergency.

According to
another article Zaveri (2016) explains that Duane et al has reported limited that
sensitivity of clinical examination in diagnosing cervical spine fractures in
patients with blunt trauma so as many as 30% of the injuries are initially
missed and up to 29% can therefore continue to develop secondary neurological
deterioration. From this, death can also happen if the injury is yet not diagnosed
and long-term disorders can progress rapidly. As stated before Berlin (2003)
tells us that over 40% of cervical spine fractures are misdiagnosed then
revealed on CT, this also tells us that a high number of errors occur in plain
film radiography and therefore CT should be a gold standard for cervical spine
trauma in adults.

researching another article, Reid (1987) states there was 274 spinal injuries
over 3 years, from this there was a failure to take x-rays in 17 cases, and in
20 patients the fractures were missed despite adequate imaging, patients also
had a delay in diagnosis, which ranged from 1 day to 36 days. From this,
patients should get a diagnosis within the day, which can relate to ATLS and
patient centred care especially when cervical spine injuries are important. This
was all due to plain film imaging, which shows us another reason why CT should
be the gold standard and should be prioritised over plain film x-ray. From
these articles and results within diagnostic errors, it shows us a clear
example in why CT is much preferred for imaging of the cervical spine in trauma

In discussion to
this, diagnostic errors should not be happening and patients should not be
discharged from hospitals with an injury to the cervical spine until imaging is
complete and a 100% readable diagnostic image is available with nil fracture’s
or injuries present. As a result of the number of diagnostic errors over
different health trusts, this is another prime example why CT should be the
gold standard in most modern trauma centres.

Tomography Vs Plain Film X-ray

Reviewing articles
and comparing them on the differences between CT and plain x-ray for imaging of
the cervical spine in trauma patients, looking at both the pros and cons of
both imaging modalities it is clear that CT should be first priority despite
the risk of radiation. According to Holmes (2005), his article was based on 712
studies from 1995 to 2004 on what imaging modality was positive in patients
with cervical injuries. Reviewing this article the information, tells us that
CT has a sensitivity of 98%, as plain film x-ray only being 52%. From looking
at sensitivity, this is how well it can be positive amongst the diagnosis of
the injury. Specificity is how well it can distinguish those with an injury to
those without an injury. Therefore, from this, a higher percentage of
sensitivity shows that CT should be the main gold standard in imaging of the
cervical spine in trauma patients from comparing other articles.  Plain film x-ray has said to be sufficient in
patients who are alert and able to have their cervical spine clinically
assessed therefore the trauma is not a serious matter. CT does have drawbacks
for patients as it may limit its use for imaging. CT scanning involves a higher
dose of radiation in comparison to plain film x-ray, also to the thyroid gland,
which is the most sensitive organ to radiation exposure. In comparison to this,
it should not be a problem as risk v benefit for the patient is more important.

Secondly, CT
scanning is also more cost-effective than plain film radiography, but one study
according to Holmes (2015) tells us that cervical spine screening in CT is less
expensive which counts as a positive as the region of the body is not large. Thirdly,
he also explains to us that CT was time-consuming but with new generated CT,
scanners are much faster in image acquisition than doing multiple views on
plain film, as a CT scan of the c-spine is complete within a few minutes.
Finally, reviewing this article and comparing amongst others it is known that
CT outperforms plain x-ray imaging as a test for patients who are at a high
risk of cervical spine injury. Insufficient evidence also suggests that CT
should replace plain radiography as an initial screening test for the minor
injured patients who are at low risk of an injury.

CT imaging is best
suited for the assessment of bone injuries and alignment of the spine, if needed;
MRI can be requested to rule out soft tissue injury, as it can be difficult to diagnose
through CT imaging.  Berlin (2003) states
that in 1996, it was reported that 40% of cervical spine fractures had been
missed on plain film but are later then revealed on CT and from this, some
patients had deteriorated, given that this shows us another reason why CT
should be used over x-ray.

In discussion to
this and reviewing the articles, I have studied, clinically deciding that CT
should be the gold standard for cervical spinal imaging due to trauma. Spinal
injuries are also classed as an emergency as they are related to most brain
injuries therefore CT should be done in the first opportunity as it has an
effective examination time and high quality images to get a diagnosis from,
this is why most modern trauma centres should make CT first priority. From
reviewing and comparing other literature articles CT is now more common and is
the first imaging modality considered for trauma to the cervical spine.


Concluding this
systemic research, information relating to cervical spine injuries shows us
that computed tomography has a better sensitivity in ruling out cervical spinal
injuries in trauma patients over plain film radiography; this is due to better
image acquisition showing high quality fractures and alignment of the spine. Recommendations
from this study tell us that outlaying the risk v benefit is crucial. CT
requires a high radiation dose but includes a higher quality image with a
diagnosis of spinal injury, as plain film x-rays provide a lower dose of
radiation but can lead to a misdiagnosed image and this is when risk v benefit should
be taken into consideration to help with the diagnosis of injury. As patients
would prefer to risk the radiation dose to benefit that, their injury gets the
correct diagnosis and treatment.

involved for the future, with high gold standard imaging modalities, which will
get better with sensitivity and specificity and hopefully with new generated
technology, the radiation dose will start to decrease as the quality of imaging
increases. As CT has grown throughout the years as it has merged with other
medical imaging techniques such as PET-CT and SPECT-CT, it will only continue
to grow. With CT now being preferred over plain film radiography for most
regions of the body in trauma, plain film x-ray may be used for just
extremities in the future. Secondly, another prediction could be as more trauma
centres grow in patient self-centred care then CT will start to become a gold
standard in most health care trusts and will be the first option in spinal
assessment protocols for imaging the cervical spine when it comes to trauma.
This will ensure that patients get the correct diagnosis and treatment with the
use of CT.

Identification of
weaknesses throughout this literature review shows us that some initial
assessments on patients could have been taken more importantly to avoid the missed
diagnosis of cervical spinal injuries and risk v benefit should be considered for
the patients and the seriousness of their injuries. Another weakness that I
encountered is that all modern trauma centred hospitals should all follow by
the same protocols such as CT being that gold standard as this would decrease
the statistics in the number of diagnostic errors and missed injuries through
plain film imaging. Overall, the importance of spinal injuries being classed an
emergency especially within trauma a quicker diagnosis and treatment should be
provided. Evidently shown that CT being less time consuming with better
diagnosis results, it is clear that most modern trauma centres should be using
an up to date protocol which finalises that CT should be the gold standard
imaging modality when it comes to trauma within the cervical spine.