Systematic review of the benefits and harms of whole-body computed tomography in the early management of multitrauma patients: are we getting the whole picture?

BACKGROUND: There is considerable interest in whether routine whole-body computed tomography (WBCT) imaging produces different patient outcomes in blunt trauma patients when compared with selective imaging. This article aimed to systematically review the literature for all outcomes measured in comparing WBCT with selective imaging in trauma patients and to evaluate the comprehensiveness of relevant dimensions for this comparison. METHODS: We performed a systematic review of studies comparing WBCT and selective imaging approaches during the initial assessment of multitrauma patients. Peer-reviewed studies including cohort studies, randomized controlled trials, meta-analyses, and systematic reviews were identified through large database searches and filtered through methodologic inclusion criteria. Data on study characteristics, hypotheses and conclusions made, outcomes assessed, and references to potential benefits and harms were extracted. RESULTS: Eight retrospective cohort studies and two systematic reviews were identified. Six primary studies evaluated mortality as an outcome, and four studies found a significant difference in results favoring WBCT imaging over selective imaging. All five articles assessing various time intervals in hospital following imaging after injury found significantly reduced times with WBCT. Radiation exposure was found to be increased after WBCT imaging compared with selective imaging in the only study in which it was evaluated. The two systematic reviews analyzed the same three articles with regard to mortality but concluded differently about overall benefits. CONCLUSION: WBCT imaging seems to be associated with reduced times to events in hospital following traumatic injury and seems to be associated with decreased mortality. Whether this is a true effect mediated through an as yet unsubstantiated change in management or the result of hospital- or individual-level confounders is unclear. When evaluating these outcomes, it seems that the authors of both primary studies and systematic reviews have often been selective in their choice of short-term outcomes, painting an incomplete picture of the issue. LEVEL OF EVIDENCE: Systematic review, level III.

Outcomes at 12 months after early magnetic resonance imaging in acute trauma patients with persistent midline cervical tenderness and negative computed tomography.

STUDY DESIGN: A prospective observational cohort study of alert, neurologically intact trauma patients presenting to the emergency department with midline cervical tenderness. Screening cervical magnetic resonance imaging (MRI) had been conducted after negative computed tomography (CT) when tenderness was persistent. OBJECTIVE: To determine the association of acute findings and demographic characteristics with any long-term neck disability, and with time to return to work in such patients. SUMMARY OF BACKGROUND DATA: The relationship between acute findings and outcomes in these patients is unknown, and we hypothesized that outcomes at 12 months would correlate with acute clinical signs and symptoms, MRI findings, and mechanisms of injury. METHODS: Patients at a Level 1 trauma center with persistent midline cervical tenderness in the absence of evidence of intoxication, painful distracting injury, persistently abnormal neurology, or acute CT findings, who underwent early cervical MRI under the institutional protocol, were reviewed in the outpatient spine clinic after discharge. In addition, the factors associated with neck disability and time to return to work were examined at follow-up at 12 months after presentation. RESULTS: There were 162 of 178 patients available for follow-up at 12 months (91%). Of these, 46% had MRI-identified cervical spine injury at their initial examination, and 22% had required clinical management, including 2.5% with operative stabilization. Neck disability was present in 43% of patients and was associated with depressive symptoms, workers' compensation, and low annual income. Delay in return to work was associated with the presence of minor limb/other fractures and depressive symptoms, whereas patients on high annual incomes were found to return to work more quickly. CONCLUSION: Surprisingly in these acute trauma patients, MRI-detected injury, clinical factors, and injury mechanism were not found to be associated with long-term patient outcomes. As a result, a trial of a more targeted, individual return to work plan, including strategies aimed at improving physical and psychological function, may now be justified to optimize long-term recovery, reduce health resource costs, and maximize economic productivity through early return to work.

Health resource utilisation costs in acute patients with persistent midline cervical tenderness following road trauma.

INTRODUCTION: The costs associated with patients discharged with isolated clinician-elicited persistent midline tenderness and negative computed tomography (CT) findings have not been reported. Our aim was to determine the association of acute and post-acute patient and injury characteristics with health resource costs in such patients following road trauma. METHODS: In a prospective cohort study, road trauma patients presenting with isolated persistent midline cervical tenderness and negative CT, who underwent additional acute imaging with MRI, were recruited. Patients were reviewed in the outpatient spine clinic following discharge, and were followed up at 6 and 12 months post-trauma. Multivariate linear regression was used to assess the association of injury mechanism, clinical assessment, socioeconomic factors and outcome findings with health resource costs generated in the acute hospital and post-acute periods. RESULTS: There were 64 patients recruited, of whom 24 (38%) had cervical spine injury detected on MRI. Of these, 2 patients were managed operatively, 6 were treated in cervical collars and 16 had the cervical spine cleared and were discharged. At 12 months, there were 25 patients (44%) with residual neck pain, and 22 (39%) with neck-related disability. The mean total cost was AUD $10,153 (SD=10,791) and the median was $4015 (IQR: 3044-6709). Transient neurologic deficit, which fully resolved early in the emergency department, was independently associated with higher marginal mean acute costs (represented in the analysis by the ß coefficient) by $3521 (95% CI: 50-6880). Low education standard (ß coefficient: $5988, 95% CI: 822-13,317), neck pain at 6 months (ß coefficient: $4017, 95% CI: 426-9254) and history of transient neurologic deficit (ß coefficient: $8471, 95% CI: 1766-18,334) were associated with increased post-acute costs. CONCLUSION: In a homogeneous group of road trauma patients with non fracture-related persistent midline cervical tenderness, health resource costs varied considerably. As long term morbidity is common in this population, a history of resolved neurologic deficit may require greater intervention to mitigate costs. Additionally, adequate communication between acute and community care providers is essential in order to expedite the recovery process through early return to normal daily activities.

Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results.

STUDY OBJECTIVE: We aim to determine the prevalence and factors associated with cervical discoligamentous injuries detected on magnetic resonance imaging (MRI) in acute, alert, neurologically intact trauma patients with computed tomography (CT) imaging negative for acute injury and persistent midline cervical spine tenderness. We present the cross-sectional analysis of baseline information collected as a component of a prospective observational study. METHODS: Alert, neurologically intact trauma patients presenting to a Level I trauma center with CT negative for acute injury, who underwent MRI for investigation of persistent midline cervical tenderness, were prospectively recruited. Deidentified images were assessed, and injuries were identified and graded. Outcome measures included the presence and extent of MRI-detected injury of the cervical ligaments, intervertebral discs, spinal cord and associated soft tissues. RESULTS: There were 178 patients recruited during a 2-year period to January 2009. Of these, 78 patients (44%) had acute cervical injury detected on MRI. There were 48 single-column injuries, 15 two-column injuries, and 5 three-column injuries. Of the remaining 10 patients, 6 had isolated posterior muscle edema, 2 had alar ligamentous edema, 1 had epidural hematoma, and 1 had atlanto-occipital edema. The injuries to 38 patients (21%) were managed clinically; 33 patients were treated in cervical collars for 2 to 12 weeks, and 5 patients (2.8%) underwent operative management, 1 of whom had delayed instability. Ordinal logistic regression revealed that factors associated with a higher number of spinal columns injured included advanced CT-detected cervical spondylosis (odds ratio [OR] 11.6; 95% confidence interval [CI] 3.9 to 34.3), minor isolated thoracolumbar fractures (OR 5.4; 95% CI 1.5 to 19.7), and multidirectional cervical spine forces (OR 2.5; 95% CI 1.2 to 5.2). CONCLUSION: In patients with cervical midline tenderness and negative acute CT findings, we found that a subset of patients had MRI-detected cervical discoligamentous injuries and that advanced cervical spine degeneration evident on CT, minor thoracolumbar fracture, and multidirectional cervical spine forces were associated with increased injury extent. However, a larger study is required to validate which variables may reliably predict clinically important injury in such patients, thereby indicating the need for further radiographic assessment.

Traumatic cervical discoligamentous injuries: correlation of magnetic resonance imaging and operative findings.

STUDY DESIGN: Retrospective review using prospectively collected data. OBJECTIVE: The purpose of the study was to investigate the diagnostic properties of cervical magnetic resonance imaging (MRI) in detecting surgically verified disruptions of the anterior longitudinal ligament (ALL), intervertebral disc, and posterior longitudinal ligament (PLL). SUMMARY OF BACKGROUND DATA: Cervical MRI findings commonly provide the basis for the decision to stabilize cervical injury operatively. The correlation of cervical MRI findings with direct visualization of the cervical discoligamentous structures during operative management is a subject of debate. METHODS: The cervical spine MRI scans of patients who subsequently underwent anterior surgical stabilization after traumatic discoligamentous injury of the cervical spine were reviewed. The level and severity of ALL, disc and PLL disruption was compared with surgical findings. The sensitivity, specificity, positive and negative predictive values of MRI in the detection of surgically verified injuries were calculated. RESULTS: The MRI and surgical findings were compared on 31 consecutive patients, with the kappa values for ALL, intervertebral disc, and PLL disruption measuring 0.22, 0.25, and 0.31, respectively. MRI scans provided reasonable sensitivity to disc disruption (0.81) but poor sensitivity to ALL (0.48) and PLL (0.50) injury. Specificity for ALL and PLL disruption was 1.00 and 0.87, respectively, but 0.00 for disc disruption. The positive predictive value of MRI for ALL and intervertebral disc injury was 1.00 and 0.96, respectively, but 0.63 for PLL disruption. The false-negative rates for disruption of the ALL, disc and PLL were 0.52, 0.19, and 0.50, respectively. CONCLUSION: The ability of cervical MRI to detect surgically verified disruptions of the ALL, intervertebral disc, and PLL varied depending on the structure examined. MRI was sensitive but not specific for disc injury, and specific but not sensitive to ALL and PLL disruption. In this series, the comparison of cervical MRI and operative findings indicated that MRI was reliable only when positive for ALL and disc injury, and a reasonably reliable indicator of PLL status only when negative for PLL injury. Additionally, the high false-negative rates for ALL and PLL injury are concerning.

Occipital condyle fractures: incidence and clinical follow-up at a level 1 trauma centre.

The purpose of the study was to investigate the incidence, management, and outcomes of occipital condyle fractures at a level 1 trauma center. Blunt trauma patients with occipital condyle fracture admitted to a level 1 trauma center over a 3-year period were identified. Prospective clinical and functional follow-up was undertaken, including further radiographic imaging. The incidence of occipital condyle fracture in patients presenting to our level 1 trauma center was 1.7/1,000 per year. Twenty-four patients were followed up at a mean of 27 months post-injury. There was one case of isolated occipital condyle fracture; all other patients had sustained additional orthopedic, cervical spine, and/or head injury. Seven (29%) patients sustained unilateral Type III avulsion fractures, none of which were isolated injuries. Traumatic brain injury was detected in 46% of study patients, and 42% had cervical spine injury. External halothoracic immobilization was used in 33% of cases. Fracture union with anatomical alignment occurred in 21 patients (88%). No patient had cranial nerve deficit at admission or follow-up. Three patients (12.5%) had moderate to severe neck pain/disability at follow-up, all of whom had sustained multiple injuries. Occipital condyle fractures most frequently occur in conjunction with additional injuries, particularly head and cervical spine injuries. Most cases can be managed successfully nonoperatively. Functional outcome is generally determined by pain and disability related to other injuries, rather than occipital fracture configuration.

Nonoperative management of type II odontoid fractures in the elderly.

STUDY DESIGN: Retrospective case series of elderly patients with Type II odontoid fractures, with prospective functional follow-up. OBJECTIVE: We aimed to investigate the functional outcomes after nonoperative management of Type II odontoid fractures in elderly patients at a Level 1 trauma center. SUMMARY OF BACKGROUND DATA: Controversy exists regarding the most appropriate method of treatment of Type II odontoid fractures in the elderly population. The primary aim of management has generally been considered to be the achievement of osseous fusion. METHODS: Patients >or=65 years of age presenting to a Level 1 trauma center with Type II odontoid fractures were identified retrospectively from a prospective neurosurgery database. Those initially treated operatively, or who died before follow-up were excluded. Long-term pain and functional outcomes were assessed. RESULTS: Forty-two patients were followed up at a median of 24 months post injury. Ten patients (24%) were treated in cervical collars alone and 32 patients (76%) were managed in halothoracic braces. Radiographically demonstrated osseous fusion occurred in 50% of patients treated in collars and in 37.5% of patients managed in halothoracic bracing. However, fracture stability was achieved in 90% and 100% of cases respectively. In patients treated in collars, 1 patient had severe residual neck pain, severe disability, and poor functional outcome. There were no cases of severe pain or disability, or poor functional outcome in patients managed in halothoracic orthoses. There was no difference in outcome in those achieving osseous union compared with stable fibrous union. CONCLUSION: The nonoperative management of Type II odontoid fractures in elderly patients results in fracture stability, by either osseous union or fibrous union in almost all patients. Long-term clinical and functional outcomes seem to be more favorable when fractures have been treated with halothoracic bracing in preference to cervical collars. Stable fibrous union may be an adequate aim of management in elderly patients.