Jr. Hoffman et al., Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma., N ENG J MED, 343(2), 2000, pp. 94-99
Citations number
43
Categorie Soggetti
General & Internal Medicine","Medical Research General Topics
Background: Because clinicians fear missing occult cervical-spine injuries,
they obtain cervical radiographs for nearly all patients who present with
blunt trauma. Previous research suggests that a set of clinical criteria (d
ecision instrument) can identify patients who have an extremely low probabi
lity of injury and who consequently have no need for imaging studies.
Methods: We conducted a prospective, observational study of such a decision
instrument at 21 centers across the United States. The decision instrument
required patients to meet five criteria in order to be classified as havin
g a low probability of injury: no midline cervical tenderness, no focal neu
rologic deficit, normal alertness, no intoxication, and no painful, distrac
ting injury. We examined the performance of the decision instrument in 34,0
69 patients who underwent radiography of the cervical spine after blunt tra
uma.
Results: The decision instrument identified all but 8 of the 818 patients w
ho had cervical-spine injury (sensitivity, 99.0 percent [95 percent confide
nce interval, 98.0 to 99.6 percent]). The negative predictive value was 99.
8 percent (95 percent confidence interval, 99.6 to 100 percent), the specif
icity was 12.9 percent, and the positive predictive value was 2.7 percent.
Only two of the patients classified as unlikely to have an injury according
to the decision instrument met the preset definition of a clinically signi
ficant injury (sensitivity, 99.6 percent [95 percent confidence interval, 9
8.6 to 100 percent]; negative predictive value, 99.9 percent [95 percent co
nfidence interval, 99.8 to 100 percent]; specificity, 12.9 percent; positiv
e predictive value, 1.9 percent), and only one of these two patients receiv
ed surgical treatment. According to the results of assessment with the deci
sion instrument, radiographic imaging could have been avoided in the cases
of 4309 (12.6 percent) of the 34,069 evaluated patients.
Conclusions: A simple decision instrument based on clinical criteria can he
lp physicians to identify reliably the patients who need radiography of the
cervical spine after blunt trauma. Application of this instrument could re
duce the use of imaging in such patients. (N Engl J Med 2000;343:94-9.) (C)
2000, Massachusetts Medical Society.