Sensitivity of prevertebral soft tissue measurement of C3 for detection of cervical spine fractures and dislocations.

A prevertebral soft tissue measurement exceeding 4 to 5 mm at C3 on a lateral spine radiograph is considered to be evidence of cervical spine injury. The objective of this study was to determine the sensitivity of the prevertebral soft tissue measurement at C3 in patients with proven cervical spine fractures or dislocations and to determine if this measurement correlates with the location or mechanism of injury. Consecutive patients 16 years of age or older who were admitted from July 1988 to June 1995 to a tertiary referral hospital with a discharge diagnosis of cervical spine fracture or dislocation were retrospectively studied. Patients were excluded if an interpretable lateral cervical radiograph taken within 24 hours of the injury was unavailable, medical records were unavailable or incomplete, the injury was caused by penetrating trauma or attempted hanging, or retropharyngeal air was present on the lateral radiograph. For each study patient, the earliest available lateral radiograph was obtained, and the prevertebral soft tissue measurement at the inferior aspect of C3 was recorded. All medical records and reports of imaging studies were reviewed. Two hundred thirty-two patients were identified and 21 were excluded, leaving 212 study patients. Injuries were classified as high (C1 to C2), low (C3 to C7), anterior, or posterior. For each patient the mechanism of injury was inferred from the fracture pattern according to established criteria. For all patients the sensitivity of a prevertebral soft tissue measurement at C3 of > 4 mm was 66% (95% confidence interval [CI] 59, 72). For C1 to C2 (n = 71) and C3 to C7 (n = 138) injuries, the sensitivities were 64% (95% CI 56, 78) and 64% (95% CI 56, 72), respectively. For anterior (n = 95) and posterior (n = 70) injuries the sensitivities were 64% (95% CI 54, 74) and 64% (95% CI 52, 75), respectively. There was no statistically significant difference in the prevertebral soft tissue measurement at C3 for high versus low injury, anterior versus posterior injury, or mechanism of injury. These results show that the prevertebral soft tissue measurement at C3 is an insensitive marker of cervical spine fracture or dislocation and does not correlate with the location or mechanism of injury.

Supralevator anorectal abscess presenting as acute low back pain and sciatica.

Anorectal abscess is a suppurative process that begins in the anal glands. Clinical presentation is variable and depends on the direction and tissue plane along which the infection tracks. All cases require urgent incision and drainage. We report an unusual case of a supralevator abscess in a man who presented to the emergency department on two occasions with acute low back pain and sciatica. The case demonstrates the importance and difficulty of identifying the exceptional case among the numerous routine cases of mechanical low back pain. Attentiveness to atypical features should direct the clinician to a more extensive evaluation for serious illness. The case also illustrates that sciatica is not a diagnostic end-point but rather a label for a pain syndrome that encompasses a long differential diagnosis.

The diagnosis of acute myocardial infarction in the emergency department; Part 2.

At present, routine use of cardiac enzymes in the emergency department (ED) cannot be justified, except possibly as a final screen prior to discharge. Computer-derived predictive instruments do not surpass the physician's diagnostic sensitivity for acute myocardial infarction (AMI), but do demonstrate significantly higher specificity. Limited data exist on the utility of echocardiography and thallium scanning in the ED. Methods of triaging patients on the basis of prognosis are well supported in the literature. The physician's high diagnostic sensitivity is maintained at the cost of significant numbers of admissions who subsequently rule out for AMI. No single clinical variable or combination of clinical variables can reliably confirm or exclude AMI in the ED. Ultimately, the physician's clinical assessment must remain the final determinant of the necessity for admission. However, judicious use of prediction rules and prognostic indicators should improve resource utilization.

The diagnosis of acute myocardial infarction in the emergency department; Part 1.

Despite major advances in treatment, the accurate diagnosis of acute myocardial infarction (AMI) in the emergency department (ED) remains a difficult clinical problem and is still mainly based on the history and interpretation of the electrocardiogram. Although the physician's clinical impression is a highly sensitive indicator for AMI, at least 4% of patients presenting to the ED with AMI may be mistakenly sent home. Although chest pain is the most common chief complaint, the clinical presentation can be extremely variable, particularly in the elderly. Complaints of sharp chest pain or chest wall tenderness should not be relied upon to exclude AMI. Radiation of chest pain is an important symptom. With careful analysis, the electrocardiogram may yield a higher diagnostic sensitivity than is commonly accepted.