Computed tomographic scanning of cervical spine fractures: Does it influence treatment?

Objective: To determine whether the superior sensitivity of computed tomogr aphy (CT) results in changes in treatment plans for cervical spine fracture s that have been diagnosed on plain films alone. Design: Retrospective review of radiographic studies for cervical spine tra uma. Setting/Participants: An orthopaedic spine surgeon (SS),an orthopaedic trau matologist (OT), an orthopaedic spine fellow (SF), and an orthopaedic chief resident (CR) were independently presented thirty-nine cases of cervical s pine trauma imaged with adequate plain radiographs and with CT. Main Outcome Measures: Agreement was measured by calculation of kappa coeff icients. Results: The detection rare of total fractures on plain radiographs alone r anged from 47 percent to 71 percent, and the diagnosis changed an average 5 3 percent of cases. Change in treatment plans ranged from 10 percent (SS) t o 46 percent (CR) of cases. Of these changes, undertreatment occurred as fo llows: SS =3 percent, OT =8 percent, SF =36 percent,and CR = 46 percent. Th e; mean kappa coefficient for intraobserver agreement of treatment plans wa s 0.69. The experienced observers demonstrated "excellent" agreement with a n average kappa coefficient of 0.85, whereas the mean coefficient for inexp erienced observers was 0.54 or "moderate" agreement. Complete diagnostic ag reement occurred between the experienced observers after review of both the plain films and CT scans. The interobserver agreement of treatment plans f or the experienced observers increased from 0.79 to 0.88. Conclusions: CT scanning afforded additional information for all observers. Experienced observers can reliably determine treatment plans for cervical spine trauma diagnosed on plain films alone, whereas inexperienced observer s are less realiable. For the experienced observers, interobserver agreemen t on treatment plans increased after the addition of CT.