Predictors of Cervical Spine Fractures and Fracture Risk

Flow diagram (originally published by Blackmore CC, et al, Radiology 1999) demonstrating a prediction rule for determination of risk of cervical spine fracture in blunt trauma patients. Percentages indicate the risk of fracture for each group with 95% CIs. Area under the ROC curve = 0.87

Facts:

• Three common options exist to "clear" cervical spine in trauma patients: clinical evaluation, radiography or CT
• Canadian C-spine Rule (CCR) or NEXUS criteria are generally used by emergency physicians and trauma surgeons to determine which patients require imaging clearance
• Among patients who, based on CCR or NEXUS, need imaging clearance: an issue exists whether to choose x-ray vs. CT
• In general, CT is preferred for patients with moderate or high likelihood of having C-spine injury given its higher accuracy, cost-effectiveness and ease of performance. However, C-spine CT has not been tested as cost-effective among patients with low likelihood of C-spine injury - practice has been different from one place to another

According to Blackmore CC, et al

• We can stratify patients into groups of different fracture probabilities by using 4 predictors: severe head injury, high-energy cause, age and focal neurologic deficit
• Definition of severe head injury = intracranial hematoma, brain contusion, skull fracture or unconsciousness
• Definition of high-energy cause = high-speed MVC (greater than 30 mph), pedestrian struck by car
• Definition of moderate-energy cause = low-speed MVC, MVC at unknown speed, bicycle accident, motorcycle accident or fall
• Definition of focal deficit = those that could be in a spinal cord or spinal nerve distribution

Reference:

Blackmore CC, Emerson SS, Mann FA, Koepsell TD. Cervical spine imaging in patients with trauma: determination of fracture risk to optimize use. Radiology 1999; 211:759-765.