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Evaluating Cervical Spine Fractures

February 5, 2010
Written by: , Filed in: Emergency Radiology, Neuroradiology
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Multidetector CT has resulted in improved image quality and ability to obtain thinner images and high-quality reformatted images. Yet despite the advances, every radiology department must grapple with which thickness images should be interpreted, and weigh factors such as sensitivity and specificity, interpretation time, and storage costs.

The objective of a recent study was to determine whether 1-mm images result in increased detection of cervical spine fractures compared with 3-mm images.

In this study, 1-mm CT images offered no benefit over 3-mm images in detecting clinically significant fractures, but did detect a significant number of fractures deemed as clinically insignificant.

Participants
25 consecutive patients with cervical spine fractures, and 25 patients without fractures from the same time period.

Methods
CT was obtained with 16-section multislice CT 0.75-mm acquisition thickness. One- and 3-mm axial images were reconstructed, and 2- to 3-mm sagittal and coronal images were produced.

Four radiologists interpreted the 1- and 3-mm images 2 to 4 months apart. Half the time, axial images were interpreted before the sagittal and coronals, and half the time the opposite.

Results
There were 39 fractures in 26 patients. Twenty-nine fractures were deemed clinically significant and 10 insignificant, based on previously published criteria.

Clinically nonsignificant fractures included 8 transverse process fractures, 1 spinous process fracture, and a minimal fracture of the inferolateral vertebral body.

The only statistically significant difference between 1- and 3-mm images was that clinically nonsignificant fractures were detected better by 1-mm than 3-mm images (85% vs 58%; P =0.0064). That is, readers missed 1 of 10 insignificant fractures 6 times with 1-mm images and 17 times on 3-mm images (out of 40 readings for each thickness).

Fracture detection overall was higher with 1-mm images than with 3-mm images (92.0% vs 86.5%), but this was not statistically significant.

For clinically significant fractures, 3-mm images performed better than 1-mm images (sensitivity of 96.5 vs 94.8), but again this was not significant.

Three readers detected more fractures with 1-mm images, and 1 reader detected more with 3-mm images.

Emergency Radiology The University of Washington School of Medicine, Harborview Medical Center, Department of Radiology * Features case-based presentations with extensive explanations – 15 hours of video * What, when, and how of imaging in relation to specific topics in emergency medicine * Stresses the interaction and communication required to be an effective part of the emergency medicine team * Provides guidance in diagnosis of polytrauma, commonly missed diagnoses, and when to change existing protocols Click here to read more or order: Emergency Radiology

Conclusions
When read with multiplanar coronal and sagittal reformations, there is no significant difference between 1- and 3-mm axial images in detection of clinically significant fractures.

Reviewer’s Comments
This was a well-designed study with relevant useful information. The authors’ discussion was also useful and interesting, and they discuss some of their findings regarding the impact of reformatted images depending on whether they were interpreted first or second.

This provides some data for those who would prefer to use 3-mm images, but with the knowledge that they may lose sensitivity in detecting those fractures classified as insignificant in this study.

As the authors point out, this may include transverse process fractures that extend to the vertebral foramina, although presumably nondisplaced.

Also, legal implications of missing a so-called clinically insignificant fracture are unclear.

Author: Yaron Lebovitz, MD

Reference:
Phal PM, Riccelli LP, et al. Fracture Detection in the Cervical Spine With Multidetector CT: 1-mm Versus 3-mm Axial Images. AJNR; 2008;29 (September): 1446-1449

Emergency Radiology The University of Washington School of Medicine, Harborview Medical Center, Department of Radiology * Features case-based presentations with extensive explanations – 15 hours of video * What, when, and how of imaging in relation to specific topics in emergency medicine * Stresses the interaction and communication required to be an effective part of the emergency medicine team * Provides guidance in diagnosis of polytrauma, commonly missed diagnoses, and when to change existing protocols Click here to read more or order: Emergency Radiology
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