What is the role of plain radiography in the workup of spinal cord injury (SCI)?

Updated: Nov 01, 2018
  • Author: Lawrence S Chin, MD, FACS, FAANS; Chief Editor: Brian H Kopell, MD  more...
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In many emergency departments (EDs), radiology support is limited. If unsure of a finding, request a formal interpretation or immobilize the patient appropriately, pending formal review of the studies.

In addition, note that the failure to adequately immobilize the spine when the mechanism of injury is consistent with the diagnosis is a pitfall.

Agitated, intoxicated patients are often the most difficult to manage properly. Pharmacologic restraint may be required to allow proper assessment. Haldol and intravenous (IV) droperidol have been used successfully, even in large doses, without hemodynamic or respiratory compromise. Occasionally, rapid-sequence intubation and pharmacologic paralysis is required to manage these patients.

Physical examination and radiographic studies could be delayed until the patient is more cooperative, if his or her overall condition permits.

Radiographic views

Radiographs are only as good as the first and last vertebrae seen, therefore, radiographs must adequately depict all vertebrae. A common cause of missed injury is the failure to obtain adequate images (eg, cervical spine radiograph that incompletely depicts the C7-T1 junction). However, be aware that radiography is insensitive to small fractures of the vertebra.

Published clinical criteria have established guidelines for cervical spine radiography in symptomatic trauma patients with neck pain. The NEXUS (National Emergency X-Radiography Utilization Study) criteria and the Canadian C-spine rules were validated in large clinical trials. [38, 39, 40] These algorithms may be used to guide physicians to determine whether or not imaging of the cervical spine is required. [38, 39, 40]

The standard 3 views of the cervical spine are recommended in patients with suspected spinal cord injury (SCI): anteroposterior (AP), lateral, and odontoid.

The cervical spine radiographs must include the C7-T1 junction to be considered adequate. Subtle findings (eg, increased prevertebral soft tissue swelling or widening of the C1-C2 preodontoid space) indicate potentially unstable cervical spine injuries that could have serious consequences if they are not detected.

Dynamic flexion/extension views are safe and effective for detecting occult ligamentous injury of the cervical spine in the absence of fracture. The negative predictive value of a normal 3-view cervical spine series and flexion/extension views exceeds 99%. The incidence of occult injury in the setting of normal findings on cervical spine radiography and CT scanning is low, so clinical judgment and the mechanism of injury should be used to guide the decision to order flexion/extension views.

Anteroposterior and lateral views of the thoracic and lumbar spine are recommended for suspected injuries to the thoracolumbar spine.

Adequate spinal radiography supplemented by computed tomography (CT) scanning through areas that are difficult to visualize or are suspicious detects the vast majority of fractures with a reported negative predictive value between 99% and 100%. [34]

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