Purpose: To quantify the clinical value of cervical spine computed tomography (CT) in determining
the need for stabilizing treatment in cervical spine trauma.
Methods and Materials: A total of 227 CT scans from patients with acute traumatic cervical spine injuries
presenting to our level 1 trauma center in The Netherlands were assessed retrospectively
by three experienced neurosurgeons with different backgrounds. The neurosurgeons individually
determined whether the fracture(s) present on the scan was a fracture in need of stabilizing
therapy (FIST). Stabilizing therapy was defined as either a conservative (rigid cervical
collar or HALO traction) or surgical stabilization treatment. Subaxial cervical spine
injuries (C3–C7) were classified according to the AOSpine Subaxial Classification
System. Clinical information was not provided to optimize objective assessment of
the CT scan. Consensus was established on the scans on which the opinion of the neurosurgeons
initially differed. Outcomes of the FIST assignment by consensus of the neurosurgeons
were compared with the treatment actually provided. Diagnostic accuracy measures were
calculated to quantify the clinical value of cervical spine CT in determining the
need for stabilizing therapy.
Results: Overall, 152 of 227 cases (67.0%) were assigned as a FIST by the neurosurgeons.
In six patients, no information regarding the provided treatment was available. In
121 of 221 cases (54.8%), stabilizing treatment was initiated retrospectively. Agreement
between the assignment of (no) FIST by the neurosurgeons and the treatment provided
was found in 80.1%. The independent CT assessment without knowledge of clinical information
showed a sensitivity of 93.4% and a negative likelihood ratio of 0.1. Table 1 shows
other diagnostic accuracy measures.
The neurosurgeons identified all patients who received stabilizing therapy, except
for eight cases. Reassessing these cases, the neurosurgeons agreed on the retrospectively
provided treatment in five cases because of clinical (neurologic) symptoms and/or
the magnetic resonance imaging result, but in the remaining three cases, the neurosurgeons
agreed that no indication for stabilizing treatment existed.
A total of 36 cases were assigned as a FIST by consensus of the neurosurgeons but
not according to the retrospectively initiated treatment. In one case a soft cervical
collar was provided instead of stabilizing therapy because of the advanced age and
comorbidities of the patient. In all other cases, no indicators were found of insufficient
treatment in the electronic medical records. Therefore, the (most) correct treatment
could not be determined.
Conclusion: Even without clinical information, scrupulous assessment of a cervical spine CT
enables exclusion of patients in need of stabilizing treatment for traumatic cervical
spine injury.
Table 1
FIST injuries according to consensus by the three neurosurgeons and retrospective
provided treatment and related diagnostic accuracy measures
|
FIST consensus neurosurgeons, n (%)
|
149/221 (67.4)
|
|
FIST retrospective treatment, n (%)
|
121/221 (54.8)
|
|
Sensitivity (95% CI)
|
93.4 (87.4–97.1)
|
|
Specificity (95% CI)
|
64.0 (53.8–73.4)
|
|
Negative predictive value (95% CI)
|
88.9 (80.1–94.1)
|
|
Positive predictive value (95% CI)
|
75.8 (70.7–80.4)
|
|
Negative likelihood ratio (95% CI)
|
0.1 (0.05–0.2)
|
|
Positive likelihood ratio (95% CI)
|
2.6 (2.0–3.4)
|
Abbreviations: CI, confidence interval; FIST, fracture in need of stabilizing therapy.
