Injuries missed by limited computed tomographic imaging of patients with cervical spine injuries

Study objective: It has been prominently suggested that computed tomographic (CT) imaging is unnecessary in evaluating patients who have one of a number of specific index cervical spine injuries identified on plain radiographs. We seek to evaluate this recommendation by examining how frequently patients with these index cervical spine injuries have additional secondary injuries that are missed on plain radiography. Methods: We identified all patients in the National Emergency X-Radiography Utilization Study (NEXUS) cervical spine data set who had an index cervical spine injury identified by plain radiography. We reviewed all radiographic studies done on each of these patients, including CT, to determine whether any patient sustained additional cervical spine injuries not visualized on plain radiographs. Results: Of 818 patients with cervical spine injuries in NEXUS, 224 had one of these index cervical spine injuries diagnosed on plain film radiography. Eighty-one of these 224 patients (36.2%; 95% confidence interval [CI] 29.9% to 42.8%) had at least 1 secondary injury that was not identified on plain radiography. A noncontiguous spinal injury was found in 22 of these 81 patients (27.2%; 95% Cl 17.9% to 38.2%) with multiple cervical spine injuries. Conclusion: More than a third of patients who had one of the index cervical spine injuries sustained a secondary injury that was not diagnosed by plain radiography, and approximately one fourth of the patients with multiple cervical spine injuries have a noncontiguous spinal injury. Guidelines about the necessity for CT scanning in such patients should be reconsidered.