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Ruling out C-Spine Injury Without Radiography

Each year in the U.S., about 800,000 cervical spine radiographs are performed. Of these, 97.6 percent are negative for fracture. Previous studies have suggested that 5 clinical criteria can predict the absence of fracture, but these studies lacked sufficient numbers of patients to yield statistically significant results. These authors sought to establish that the criteria are sufficiently sensitive to virtually eliminate the possibility of clinically significant injury, thereby identifying patients who do not require cervical spine radiography.

In a multicenter study, the 5 clinical criteria were applied to 34,069 patients who underwent cervical spine radiography after blunt trauma. The criteria were: no tenderness at the posterior midline of the cervical spine; no focal neurologic deficit; a normal level of alertness; no evidence of intoxication; and no other painful injury that might distract the patient from the pain of a cervical spine injury. The criteria are intended to be general because too much detail would make them unusable.

Of the 34,069 patients, 818 (2.4 percent) had radiographically documented cervical spine injuries. The instrument failed to detect only 8 of these patients; according to predefined criteria, injuries in 6 of these 8 were not clinically significant (i.e., did not require treatment and were not likely to result in harm). One of the remaining 2 patients had a presumably old injury, and in the other the rule likely was misapplied; these 2 patients are the subject of a long annotation by the authors. For all patients, the instrument had a sensitivity of 99.0 percent and a negative predictive value of 99.8 percent; for patients with clinically significant injuries, the sensitivity was 99.6 percent and the negative predictive value was 99.9 percent. Application of the instrument could reduce imaging by 12.6 percent, or about 100,000 films per year in the U.S.. The authors conclude that patients meeting all 5 criteria have such a low probability of injury on clinical grounds that radiography need not be performed (negative predictive value, 99.8 percent).

Comment: This is a landmark study addressing a very common and important issue in emergency medicine. The study is recognized as such in an accompanying editorial, which notes that use of the clinical rule will save far more than money: Patient inconvenience and length of stay, as well as use of hospital resources and personnel, also will decrease. Furthermore, the rule will provide a performance standard that has the potential to improve patient outcomes and reduce medicolegal disputes.

— JS Bohan

Published in Journal Watch Emergency Medicine August 22, 2000

Citation(s):

Hoffman JR et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000 Jul 13 343 94-99.

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• Medline abstract (Free)

Marx JA and Biros MH. Who is at low risk after head or neck trauma? N Engl J Med 2000 Jul 13 343 138-139.

• Original article (Subscription may be required)
• Medline abstract (Free)

From time to time, a study is published that is of such importance to physicians that it warrants special attention and should lead to an immediate reappraisal of a current practice or to the adoption of a new approach. When such articles are identified by the editorial boards of the Journal Watch publications, they will receive the designation "Landmark Article." We encourage our readers to obtain the full text of these articles and review them carefully.