Correspondence
Clinical Criteria to Rule Out Cervical-Spine Injury
N Engl J Med 2000; 343:1338-1339November 2, 2000
- Article
To the Editor:
The report by Hoffman et al. (July 13 issue)1 is a validation of the clinical criteria that most emergency physicians currently use to exclude the possibility of traumatic injury to the cervical spine. In the study, a standard three-view set of radiographs was used unless the physician decided to use computed tomographic (CT) images or to order additional views, such as oblique or flexion–extension views. Many consider five views — cross-table lateral, anteroposterior, open-mouth, and right and left obliques — to be the standard.2,3 Because some of the standard views were omitted and the sensitivity of the radiologic evidence was thus decreased, subtle injuries may have been missed. Since there was no follow-up of the patients for post-traumatic problems, the exclusion of oblique views may have led to false reassurance that the criteria were completely validated. In institutions that routinely perform CT in all questionable cases, this may not be a substantial problem. The clinical criteria may be valid, but if radiography is going to be performed, five views are probably the standard unless CT is used.
3 ReferencesPaul Krochmal, M.D.
800 Village Walk, Guilford, CT 064371
Hoffman JR ,Mower WR ,Wolfson AB , et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-99
Full Text | Web of Science | Medline2
Freemyer B ,Knopp R ,Piche J ,Wales L ,Williams J . Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma. Ann Emerg Med 1989;18:818-821
CrossRef | Web of Science | Medline3
Turetsky DB ,Vines FS ,Clayman DA ,Northup HM . Technique and use of supine oblique views in acute cervical spine trauma. Ann Emerg Med 1993;22:685-689
CrossRef | Web of Science | Medline
To the Editor:
In the world in which we live, the guidelines tested by Hoffman et al. will most likely not be heeded by emergency room practitioners who are faced continuously with the threat of liability for missed diagnoses. On the basis of the two cases of true injury associated with negative screening (Table 2 of their article), it seems that the predictive instrument, even if followed carefully, would permit a few cases to escape detection. Even though these two cervical lesions had no important consequences during follow-up, such a “miss” might be very costly in the hands of an unscrupulous plaintiff's attorney.
Robert S. April, M.D.
Ronald Lanfranchi, D.C.
4 E. 88th St., New York, NY 10128Author/Editor Response
The authors reply:
To the Editor: Although some investigators recommend a five-view series for routine cervical-spine screening, we disagree with Krochmal's assertion that this approach is standard. Imaging decisions are often complex, as demonstrated by the inability of the American College of Radiology to reach a consensus on the benefits of routine oblique imaging.1
More important, as Krochmal states, we may have missed some injuries by failing to obtain exhaustive images (including oblique views, CT scans, and magnetic resonance images) for every patient. We acknowledged this potential for verification bias. Nevertheless, our comprehensive evaluation of all images obtained in the patients, combined with our review of neurosurgical and risk-management logs, makes it unlikely that we missed any clinically significant injuries.
April and Lanfranchi raise the ever-present specter of potential malpractice claims to suggest that clinicians will be hesitant to use our decision instrument because it was not 100 percent sensitive in our study population. Although we believe that legal concerns should never be a primary motivation for deciding on what is the best practice, we would make the following observations. No diagnostic approach to patients' problems can or should be expected to be perfect, and insisting on perfection is likely to cause more harm than benefit. The harmful effects of trying to attain 100 percent sensitivity include increased exposure to ionizing radiation, delays in other medical evaluations and care, and increased expenditure. Nevertheless, clinicians should feel free to override the decision instrument if they have particular cause for concern. Of the two patients at “low risk” whom we classified as having clinically significant injury, one almost certainly did not have an acute injury, and in the case of the other, there seems to have been an obvious misapplication, rather than a failure, of the decision instrument. Use of the decision instrument in our series of more than 34,000 patients would not have been associated with any harm to patients, which is the primary prerequisite for negligence claims.
Our results confirm the validity of the decision instrument in screening patients with blunt trauma for cervical-spine injury. Thus the results should provide strong legal support for any physician who applies the criteria appropriately, even in the extraordinary instance in which a patient at low risk ultimately proves to have a cervical-spine injury.
1 ReferencesJerome R. Hoffman, M.D.
William R. Mower, M.D., Ph.D.
University of California, Los Angeles, School of Medicine, Los Angeles, CA 90024- Citing Articles (2)
Citing Articles
1
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