Prospective comparison of admission computed tomographic scan and plain films of the upper cervical spine in trauma patients with altered mental status

Objective. The accurate evaluation of patients with multiple injuries is lo gistically complex and time sensitive, and must be cost-effective. We hypot hesize that computed tomographic (CT) scan of the upper cervical spine (occ iput to C3 [Co-C3]) would add little to the initial evaluation of patients with multiple injuries who have altered mental status. Methods. The study consisted of a prospective, unblinded, consecutive serie s. Patients met entry criteria if they had sustained a blunt mechanism of i njury and had an altered mental status requiring CT scan of two or more bod y systems. All patients received CT scan of Co-C3 with 2-mm cuts and subseq uent reconstructions as well as five-view cervical spine plain films. Cervi cal spine injury was defined as any radiographically identified fracture or subluxation that required treatment. Patients were excluded if they died o r were cleared clinically before plain film series were obtained. CT scan o f Co-C3 and cervical spine films were reviewed by two different attending r adiologists. Results. Of the 2,690 consecutive admissions between December 1998 and Nove mber 1999, 1,356 patients met entry criteria. Seventy patients (5.2%) had a total of 95 injuries to the upper cervical spine. CT scan of Co-C3 identif ied 67 of 70 patients and plain films identified 38 of 70 patients with inj uries to the upper cervical spine. Twelve patients (17%) had neurologic def icits attributable to Co-C3 injuries. Three patients had false-negative CT scans of Co-C3, and one patient was quadriplegic. There were 32 patients wi th false-negative plain films, including four patients with motor deficits (one with quadriplegia). Use of the guidelines developed by the Eastern Ass ociation for the Surgery of Trauma identified all patients with upper cervi cal spine injuries; to date, no patient in the study group was readmitted o r has initiated a lawsuit for missed injury of the upper cervical spine. Conclusion: CT scan of Co-C3 was superior to plain films in the early ident ification of upper cervical spine injury. Plain films failed to identify 45 % of upper cervical spine injuries; four of these missed injuries resulted in motor deficits. Our study supports the practice guidelines developed by the Eastern Association for the Surgery of Trauma for clearance of the uppe r cervical spine in patients with altered mental status, as all patients wi th injuries were identified using these guidelines.