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C. Blackmore, S. Ramsey, F. Mann, R. Deyo (1999)
Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis.Radiology, 212 1
D. Reid, R. Henderson, L. Saboe, J. Miller (1987)
Etiology and clinical course of missed spine fractures.The Journal of trauma, 27 9
J. Raphael, R. Chotai (1994)
Effects of the cervical collar on cerebrospinal fluid pressureAnaesthesia, 49
J Raphael, R Chotai (1994)
Effects of the cervical collar of cerebrospinal fluid pressureAnaesthesia, 49
Brian Gerrelts, Elizabeth Petersen, John Mabry, S. Petersen (1991)
Delayed diagnosis of cervical spine injuries.The Journal of trauma, 31 12
E. Benzel, B. Hart, P. Ball, N. Baldwin, W. Orrison, M. Espinosa (1996)
Magnetic resonance imaging for the evaluation of patients with occult cervical spine injury.Journal of neurosurgery, 85 5
Reshma Mathen, K. Inaba, F. Munera, P. Teixeira, L. Rivas, M. Mckenney, P. Lopez, C. Ledezma (2007)
Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients.The Journal of trauma, 62 6
CH Rabb, JL Johnson, D VanSickle, K Beauchamp, G Bolles, EE Moore
Are upright lateral cervical radiographs in the obtunded trauma patient useful? A retrospective studyWorld J Emerg Surg, 2
Louise Jelly, D. Evans, Marina Easty, Timothy Coats, Otto Chan (2000)
Radiography versus spiral CT in the evaluation of cervicothoracic junction injuries in polytrauma patients who have undergone intubation.Radiographics : a review publication of the Radiological Society of North America, Inc, 20 Spec No
James Davis, D. Phreaner, D. Hoyt, R. Mackersie (1993)
The etiology of missed cervical spine injuries.The Journal of trauma, 34 3
C. Rabb, Jeffrey Johnson, D. Vansickle, Kathryn Beauchamp, G. Bolles, E. Moore, Jeffrey Org, Org, Vansickle-David David, Kathryn Edu, Beauchamp-Kathryn, Gene Org, Bolles-Gene, Ernest Org
World Journal of Emergency Surgery Open Access Are Upright Lateral Cervical Radiographs in the Obtunded Trauma Patient Useful? a Retrospective Study
A. Ireland, I. Britton, Alastair Forrester (1998)
Do supine oblique views provide better imaging of the cervicothoracic junction than swimmer's views?Journal of Accident & Emergency Medicine, 15
M. Jenkins, P. Curran, L. Rocke (1999)
Where do we go after the three standard cervical spine views in the conscious trauma patient? A survey.European journal of emergency medicine : official journal of the European Society for Emergency Medicine, 6 3
John Adams, M. Cockburn, L. Difazio, F. Garcia, B. Siegel, J. Bilaniuk (2006)
Spinal Clearance in the Difficult Trauma Patient: A Role for Screening MRI of the SpineThe American Surgeon, 72
J. Berne, G. Velmahos, Qalid El-Tawil, D. Demetriades, J. Asensio, J. Murray, E. Cornwell, H. Belzberg, T. Berne (1999)
Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study.The Journal of trauma, 47 5
S. Liew, David Hill (1994)
Complication of hard cervical collars in multi-trauma patients.The Australian and New Zealand journal of surgery, 64 2
Macdonald Rl, Schwartz Ml, D. Mirich, Sharkey Pw, N. Wr (1990)
Diagnosis of cervical spine injury in motor vehicle crash victims: how many X-rays are enough?The Journal of trauma, 30 4
K. Brohi, M. Healy, T. Fotheringham, O. Chan, C. Aylwin, S. Whitley, M. Walsh (2005)
Helical computed tomographic scanning for the evaluation of the cervical spine in the unconscious, intubated trauma patient.The Journal of trauma, 58 5
M. D'Alise, E. Benzel, B. Hart (1999)
Magnetic resonance imaging evaluation of the cervical spine in the comatose or obtunded trauma patient.Journal of neurosurgery, 91 1 Suppl
F. Dodd, E. Simon, D. Mckeown, M. Patrick (1995)
The effect of a cervical collar on the tidal volume of anaesthetised adult patientsAnaesthesia, 50
P. Platzer, M. Jaindl, G. Thalhammer, S. Dittrich, T. Wieland, V. Vécsei, C. Gaebler (2006)
Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosisEuropean Spine Journal, 15
A. Ajani, D. Cooper, C. Scheinkestel, J. Laidlaw, D. Tuxen (1998)
Optimal Assessment of Cervical Spine Trauma in Critically Ill Patients: A Prospective EvaluationAnaesthesia and Intensive Care, 26
Background: One of the basic principles in the primary survey of a trauma patient is immobilisation of the cervical spine till cleared of any injury. Lateral cervical spine radiograph is one of the important initial radiographic assessments. More than often additional radiographs like the Swimmer's view are necessary for adequate visualisation of the cervical spine. How good is the Swimmer's view in visualisation of the cervical spine after an inadequate lateral cervical spine radiograph? Methods: 100 Swimmer's view radiographs randomly selected over a 2 year period in trauma patients were included for the study. All the patients had inadequate lateral cervical spine radiographs. The radiographs were assessed with regards to their adequacy by a single observer. The criteria for adequacy were adequate visualisation of the C7 body, C7/T1 junction and the soft tissue shadow. Results: Only 55% of the radiographs were adequate. None of the inadequate radiographs provided adequate visualisation of the C7 body and the C7/T1 junction. In 42.2% radiographs the soft tissue shadow was unclear. Poor exposure accounted for 53% of the inadequacies while overlapping bones accounted for the rest. Conclusion: Clearing the cervical spine prior to removing triple immobilisation is essential in a trauma patient. This needs adequate visualisation from C1 to C7/T1 junction. In our study Swimmer's views did not satisfactorily provide adequate visualisation of the cervical spine in trauma patients. We recommend screening the cervical spine by a CT scan when the cervical spine lateral radiographs and Swimmer's views are inadequate. T1 junction in a patient with suspected cervical spine Background Lateral cervical spine radiograph is one of the important injury cannot be understated. Visualising the cervical initial radiographic assessments among the three view spine from C1 to C7/T1 junction is of utmost importance series in the trauma patient. An adequate lateral cervical to avoid neurological deficit due to missed cervical spine spine radiograph is a valuable projection in detecting cer- injuries. Missing a subluxation or dislocation at this junc- vical spine injuries. The importance of visualizing the C7- tion can have dire consequences for the patient. Tradition- Page 1 of 4 (page number not for citation purposes) BMC Medical Imaging 2008, 8:2 http://www.biomedcentral.com/1471-2342/8/2 ally the Swimmer's view is used for visualizing the C7-T1 junction. It is used as an adjunct to lateral cervical spine radiographs. The Swimmer's view is the preferred additional view when the lateral cervical spine radiograph is inadequate (the C7- T1 junction is not clearly visualised). In trauma situations getting an adequate lateral cervical spine is a difficult proposition especially when the cervical spine is triply immobilized. Thus the use of Swimmer's view has increased. Does the Swimmer's view adequately reveal the C7-T1 junction? The aim of our study was to assess this. Methods This was a retrospective study conducted in a district hos- pital. Over a two year period 100 Swimmer's views from the radiology archiving system were selected for the study. Swimmer's views taken following inadequate lateral cervi- cal spine radiographs in trauma patients were included in the study. Radiographs taken in non trauma patients were excluded from the study. The radiographs were assessed on the digital imaging software Synapse. The selected Swimmer's views were assessed for adequacy. The criteria for adequacy were: ▪ Visualization of the C7 – T1 junction ▪ Visualization of the C7 & T1 vertebral body Excellent Swim Figure 1 mer's view Excellent Swimmer's view. Adequate visualisation of C7T1 ▪ Visualization of the soft tissues anterior to the C7 & T1 junction, C7 & T1 bodies, soft tissues. vertebral bodies. Data was collected from the archiving system (Synapse). This software allowed better visualization of radiographs by allowing change to the image quality for assessment of junction and the bodies of C7 and T1 vertebrae were not the soft tissues, bones and by adjusting the contrast of the clearly visualized in all radiographs and the soft tissues image. The radiographs were assessed according to the cri- were not clear in 19/45 (42.2%) radiographs. The reason teria of adequacy mentioned above. Radiographs were for inadequacy were poor exposure in 24/45 (53.3%) deemed inadequate if there was improper visualization of radiographs and overlapping bone (humerus & clavicle) any of the three structures: the C7 – T1 junction, the C7 & in 21/45 (46.6%) radiographs (Table 1). No radiologi- T1 vertebral body and the soft tissues anterior to the C7 & cally significant cervical spine injuries were detected from T1 vertebral bodies. Image settings were adjusted using any of the radiographs assessed or CT scans done follow- the software (Synapse) for better visualization. After ing inadequate plain radiographs. assessment of adequacy, the reasons for inadequacy were documented along with a count up of the inadequate Discussion radiographs among the Swimmer's views. One of the basic principles in the primary survey of a trauma patient is immobilisation of the cervical spine till cleared of any injury. The lateral cervical spine radiograph Results 100 Swimmer's views were included in the study. 62 is part of the initial radiological survey for trauma patients patients had concomitant injuries (femoral, tibial, ankle according to the Advanced Trauma Life Support (ATLS) and upper limb fractures) while the remaining patients teachings. The lateral cervical spine radiograph is one of were suspected to have cervical spine injuries. 55/100 the important initial radiographic assessments for the cer- (55%) radiographs were found to be adequate (Figure 1). vical spine in trauma. Studies have mentioned varied neg- 45/100 (45%) radiographs were classified as inadequate ative predictive values of three view cervical spine series (Figure 2). Among the inadequate radiographs, the C7-T1 (cervical spine anteroposterior, lateral & odontoid peg Page 2 of 4 (page number not for citation purposes) BMC Medical Imaging 2008, 8:2 http://www.biomedcentral.com/1471-2342/8/2 the cervical spine, the occiput to C2 and at the C7-T1 lev- els [7-9]. Visualising the C7-T1 junction is therefore extremely important. In order to improve the visualiza- tion of this region, various additional imaging modalities have been recommended with the Swimmer's view being the commonest [10-13]. There has been no study in the literature that assesses the adequacy of the Swimmer's view on its own. Our study aims to do this. There are studies comparing the supine oblique views and the Swimmer's view but the results are varied [14,15]. Our study showed that 45% of the Swimmer's view radio- graphs were inadequate. Although this study has its limi- tations (retrospective study, small sample), in light of our findings we strongly believe that the Swimmer's view should not be used as the imaging modality of choice to visualize the C7-T1 junction prior to clearing the cervical spine for removal of immobilization. In order to increase the sensitivity of the radiographic assessment of the cervi- cal spine in trauma patients, we recommend a CT or MR evaluation of the cervical spine. The utility of these imag- ing modalities for this purpose is well documented in the literature [10-13]. If there is a high level of clinical suspi- cion the sensitivity and specificity of a CT or an MRI scan will be increased. The efficacy of a multislice CT or an MR Inadequate swimmer's view Figure 2 Inadequate swimmer's view. C7 and T1 bodies not visualised. for screening of the cervical spine in obtunded patients is C7/T1junction not seen. Soft tissues not clear. Poor expo- well documented [16,17]. These modalities have been sure. found to be superior to dynamic radiography and plain radiography [18,19]. MR imaging detects ligamentous injuries in the cervical spine which can be missed on CT view) in trauma patients (93% – 98%) although the sen- scans [19,20]. sitivity has been lower (62.5% – 84%) [1-3]. In light of these facts and the findings from our study, The most significant consequence of premature discontin- should we be performing the Swimmer's view at all? Is it uation of cervical spine immobilization is neurological better to perform a CT evaluation of the cervical spine injury. Prolonged immobilization, however, is associated prior to clearing the cervical spine? with morbidity as well. Decubitus ulcers, increased cere- brospinal fluid pressure, pain and pulmonary complica- Conclusion tions have all been described with prolonged The Swimmer's view is generally considered as the com- immobilization of the cervical spine [4-6]. The single monest additional view to supplement an inadequate lat- most common cause of missed cervical spine injury eral cervical spine radiograph to visualize the cervical appears to be failure to adequately visualize the region of spine [15]. Adequate visualization of the entire cervical injury. This can be caused by failure to obtain radio- spine is essential in a trauma patient to prevent neurolog- graphs, or by making judgments on technically subopti- ical injury due to hasty removal of immobilization in a mal films. This occurs most commonly at the extremes of missed cervical spine injury. We found the Swimmer's Table 1: Swimmer's radiographs – inadequacies and reasons for inadequacy Swimmer's view n = 100 Adequate – 55/100 (55%) Inadequate – 45/100 (45%) Inadequate Swimmer's n = 45 C7/T1 junction & body not clear – 45/45 (100%) Soft tissues not clear – 19/45 (42.2%) Reason for inadequacy Poor exposure 24/45 (53.3%) Overlapping bones – 21/45 (46.6%) Page 3 of 4 (page number not for citation purposes) BMC Medical Imaging 2008, 8:2 http://www.biomedcentral.com/1471-2342/8/2 14. Ireland AJ, Britton I, Forrester AW: Do supine oblique views pro- view to be unreliable for this purpose and recommend vide better imaging of the cervicothoracic junction than using other imaging modalities like CT or MR scans. swimmer's views? J Accid Emerg Med 1998, 15(3):151-4. 15. Jenkins MG, Curran P, Rocke LG: Where do we go after thethree standard cervical spine views in the conscious trauma List of abbreviations patient? A survey. Eur J Emerg Med 1999, 6(3):215-7. CT – Computed Tomography 16. Mathen R, Inaba K, Munera F, Teixeira PG, Rivas L, McKenney M, Lopez P, Ledezma CJ: Prospective evaluation of multislice com- puted tomography versus plain radiographic cervical spine MR – Magnetic Resonance clearance in trauma patients. J Trauma 2007, 62(6):1427-31. 17. Brohi K, Healy M, Fotheringham T, Chan O, Aylwin C, Whitley S, Walsh M: Helical computed tomographic scanning for the Competing interests evaluation of the cervical spine in the unconscious, intubated The author(s) declare that they have no competing inter- trauma patient. J Trauma 2005, 58(5):897-901. ests. 18. Rabb CH, Johnson JL, VanSickle D, Beauchamp K, Bolles G, Moore EE: Are upright lateral cervical radiographs in the obtunded trauma patient useful? A retrospective study. World J Emerg Authors' contributions Surg 2:4. 2007 Feb 8 19. Platzer P, Jaindl M, Thalhammer G, Dittrich S, Wieland T, Vecsei V, UR, the main author was responsible for conducting the Gaebler C: Clearing the cervical spine in critically injured study, acquisition, analysis and interpretation of the data patients: a comprehensive C-spine protocol to avoid unnec- and preparing the manuscript. essary delays in diagnosis. Eur Spine J 2006, 15(12):1801-10. 20. Adams JM, Cockburn MI, Difazio LT, Garcia FA, Siegel BK, Bilaniuk JW: Spinal clearance in the difficult trauma patient: a role for RSUY, the co-author was responsible for literature review, screening MRI of the spine. Am Surg 2006, 72(1):101-5. data acquisition and has approved the final draft. Pre-publication history SSB, the senior author was responsible for supervising the The pre-publication history for this paper can be accessed study, proof reading of the manuscript and has approved here: the final draft of the manuscript. http://www.biomedcentral.com/1471-2342/8/2/prepub References 1. Ajani A, Cooper D, Scheinkestel C, Laidlaw J, Tuxen D: Optimal assessment of cervical spine trauma in critically ill patients: a prospective evaluation. Anaesthesia and Intensive Care 1998, 26:487-491. 2. Berne J, Velmahos G, El-Tawil Q, Demetriades D, Asensio J, Murray J, Cornwell E, Belzberg H, Berne T: Value of complete cervical helical computed tomographic scanning in identifying cervi- cal spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study. Journal of Trauma 1999, 47:896-903. 3. Macdonald RL, Schwartz ML, Mirich D, Sharkey PW, Nelson WR: Diagnosis of cervical spine injury in motor vehicle crash vic- tims: how many x-rays are enough. J Trauma 1990, 30:392-7. 4. Dodd F, Simon E, McKeown D, Patrick M: The effect of a cervical collar on the tidal volume of anesthatised adult patients. Anaesthesia 1995, 50:961-63. 5. Liew S, Hill D: Complications of hard cervical collars in multi- trauma patients. Australian and New Zealand Journal of Surgery 1994, 64:139-140. 6. Raphael J, Chotai R: Effects of the cervical collar of cerebrospi- nal fluid pressure. Anaesthesia 1994, 49:437-439. 7. Davis J, Phreaner D, Hoyt D, Mackersie R: The etiology of missed cervical spine injuries. J Trauma 1993, 34:342-346. 8. Reid D, Henderson R, Saboe L, Miller J: Etiology and clinical course of missed spine fractures. J Trauma 1987, 27:980-986. 9. Gerrelts B, Peterson E, Mabry J, Peterson S: Delayed diagnosis of Publish with Bio Med Central and every cervical spine injuries. J Trauma 1991, 31:1622-1626. 10. Benzel E, Hart B, Ball P, Baldwin N, Orrison W, Espinosa M: Mag- scientist can read your work free of charge netic resonance imaging for the evaluation of patients with "BioMed Central will be the most significant development for occult cervical spine injury. Journal of Neurosurgery 1996, disseminating the results of biomedical researc h in our lifetime." 85:824-829. 11. D'Alise M, Benzel E, Hart B: Magnetic resonance imaging evalu- Sir Paul Nurse, Cancer Research UK ation of the cervical spine in the comatose or obtunded Your research papers will be: trauma patient. Journal of Neurosurgery Spine 1999, 91:54-59. 12. Blackmore CC, Ramsey SD, Mann FA, Deyo RA: Cervical spine available free of charge to the entire biomedical community screening with CT in trauma patients: a cost-effectiveness peer reviewed and published immediately upon acceptance analysis. Radiology 1999, 212(1):117-25. 13. Jelly LM, Evans DR, Easty MJ, Coats TJ, Chan O: Radiography ver- cited in PubMed and archived on PubMed Central sus spiral CT in the evaluation of cervicothoracic junction yours — you keep the copyright injuries in polytrauma patients who have undergone intuba- tion. Radiographics 2000, 20:S251-9. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 4 of 4 (page number not for citation purposes)
BMC Medical Imaging – Springer Journals
Published: Jan 15, 2008
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