Craniocervical junction computed tomography in major head injury patients

Abstract

Objectives: Evaluation of the cervical vertebra for injuries in patients who present to the emergency department with blunt head trauma is common practice. The aim of this study was to determine the utility of craniocervical junction CT for the assessment of the upper cervical region in unconscious or intubated patients with severe head injury by comparing injuries identified with this modality to those found by plain 3 view x-ray radiography of the cervical spine. The null hypothesis is: “Plain radiographies are not better than CT for the assessment of the upper cervical region”.
Materials and Methods: This was a prospective observational clinical study, performed during a three year study period at a University Hospital Emergency Department with an annual adult patient volume of more than 50.000. Patients of all ages who presented to the emergency department with blunt trauma and who had a Glasgow Coma Scale (GCS) score of less than nine were included in the study. Prior to CT examination, all patients had standard cervical X-Ray. During CT of the brain, 5 mm-long cross-sectional CT cuts of the upper cervical region were obtained. CT and plain radiographs were read by two different radiologists who were blinded to the study.
Results: 215 patients with multiple trauma and GCS of eight or lower presented to the emergency department during the study period. 128 of these patients were enrolled the study. There were imaging findings in 13,2% (n=17) of these patients at the craniocervical junction. 64,7% (n=11) of findings were only recognized by craniocervical CT, 23,5% (n=4) by both craniocervical CT and cervical X-Ray and 11,8% (n=2) by cervical X-Ray alone. When the craniocervical CT was taken as the gold standard, the sensitivity and specifity of the plain cervical radiography in demonstrating the craniocervical junction findings was 28% and 98%, respectively.
Conclusion: In patients with multiple trauma who present to the ED unconscious and with a GCS score of eight or less, CT is superior to conventional plain radiography in diagnosing upper cervical fractures. Conventional plain radiography could not detect 25% patients with cervical fractures. No additional neurological injury developed in any of these patients. Craniocervical junction CT should be routinely used for the patient population with a GCS score of 8 or less.