THE WESTERN Journal of Medicine Refer to: Jergens ME, Morgan MT, McElroy CE: Selective use of radiography of the skull and cervical spine. West J Med 127:1-4, Jul 1977
Selective Use of Radiography of the Skull and Cervical Spine MARK E. JERGENS, MD; MARSHALL T. MORGAN, MD, and CHARLES E. McELROY, MD Los Angeles
Based on the findings of a five-month study, the authors suggest that physicians should be more discriminating in using radiography of the skull, especially when dealing with patients who are minimally injured. The low incidence of fractures disclosed by radiography in patients with insignificant head injuries is a primary factor in arriving at this recommendation. A lack of correlation between skull fractures, and cerebral injury, and subsequent therapy is another factor. Finally, the prohibitive cost of medical care generally (and radiographs in particular) makes greater selectiveness imperative. Although the number of cervical spine fractures in this study was small, the findings indicate that based on history and physical examination there can and should be increasing selectivity in ordering routine cervical spine series, without increasing the risk of missed fractures.
THE RELATIVELY LOW YIELD of clinically relevant data derived from skull radiographs in emergency situations was reported by Bell and Loop' in 1971 and later corroborated by other authors.2 Despite this, the skull and cervical spine series continue to be integral to an evaluation of traumatized patients with suspected head or neck injuries regardless of physical findings. In view of the implied inefficiency of this and other radiographic examinations,3 we undertook a prospective study spanning five months of experience at the UniFrom the Departments of Surgery and Medicine, Emergency Medicine Center, UCLA Hospital, Los Angeles. Submitted October 20, 1976. Reprint requests to: Mrs. Seba Kolb, Editor, Department of Surgery, UCLA Center for the Health Sciences, Los Angeles, CA 90024.
versity of California at Los Angeles (UCLA) Emergency Medicine Center. From October through December 1975 and from March through April 1976, an investigative effort was made to determine the resident house staff's capability to predict fractures based on physical findings and to evaluate the effects of clinically unsuspected but radiographically shown fractures on patients' clinical course, as well as to establish the clinical indication for ordering skull or cervical spine radiographic series, or both. Criteria for selective ordering of radiographs would obviously reduce the cost of health care yet avoid the risk of litigation resulting from insufficient data having been acquired. THE WESTERN JOURNAL OF MEDICINE
1
RADIOGRAPHY OF THE SKULL AND SPINE
Material and Methods The UCLA Emergency Medicine Center serves population of about 500,000 people, and is located in a relatively high socioeconomic residential, business and light industrial area. Although flanked by two major freeway systems znd serving as a base station for eight paramedic units, there is a preponderance of patients having nontraumatic and minor injuries. The monthly census seen by the surgical house staff averages 2,500 patients. Residents on duty in the Emergency Medicine Center were asked to complete a questionnaire whenever radiographs of the skull or spine were ordered. This required designating the type of examination, the primary indication for the procedure, the character of any physical findings and the physician's estimate of the probability of fracture being present. Moreover, the radiology resident completed a similar questionnaire dealing with his findings. An attempt was made to exclude data derived from patients with fractures resulting from previous injury. Although some questionnaires were completed retrospectively, missing or incomplete forms were rectified within 24 hours of the event, at the time of daily staff radiographic review. Most such evaluations concerned severely traumatized patients whose clinical condition precluded prospective clerical completeness. a
TABLE 1.-Distribution of Radiographs and Fractures in Each Clinical Category Clinical Category
Total
Skull
90%
...... ......
......
761 71 15
755 65 6
6 6 9
0.8 8.5 60
847
826
21
2.4
510 55 8
508 52 6
2 3 2
0.4 5.5 25.
573
566
7
1.2
Cervical Spine
90%
.
...
Number With- Number of Percent of out Fracture Fractures Fractures
..
......
......
All of the patients with fractures were followed up after a three-month interval by telephone contact either with the patient or his physician, and information about the long-term effects of the fracture on the patient's health was requested. Results During the five-month investigation, there were 21 skull fractures in 847 skull examinations (2.4 percent), and seven cervical spine fractures in 573 examinations (1.2 percent). Table 1 compares the clinical prediction of the likelihood of fracture with the percentage of actual fractures in each group. In cases where the clinician believed the probability of fracture to be low, 0.8
TABLE 2.-Disposition of Patients With Fractures Number of Fractures
Category
Skuill 90% ......
...
9
90% ......
...
2
Cervical Spine
2
Follow-up
All placed under observation and then discharged. All have returned to normal lives. Three patients placed under observation and then discharged. All have returned to normal lives. Two patients with concomitant cervical spine fractures were admitted for treatment of those fractures. One patient with cerebrospinal fluid otorrhea was treated for that and has suffered no sequelae. Two patients without neurologic deficits were placed under observation and then discharged. Both have returned to normal lives. Four patients with concomitant cerebral contusions were admitted to hospital and treated for those contusions. All have returned to normal lives. Two patients died after evacuation of subdural hematomas. One patient with cervical spine fractures and massive head, chest and abdominal injuries died secondary to those injuries. One patient admitted to hospital and did well with cervical traction. One patient with stable fracture was treated as an outpatient with a brace. Two patients admitted to hospital and did well with cervical traction. One patient with stable fracture was treated as outpatient with a cervical brace. One patient died while evacuation of subdural hematoma was being done. One patient with concomitant massive head, chest and abdominal injuries died secondary to those injuries.
JULY 1977 * 127 * 1
RADIOGRAPHY OF THE SKULL AND SPINE TABLE 3.-Reasons for Ordering Radiographs in Patients with Less Than 10 Percent Likelihood of Fracture Number
Skuill Series Strictly medicolegal .............. Patient or family request ........ . Physical findings ................ Cervical Spine Series Strictly medicolegal .............. Patient or family request ........ Physical findings ................
Number of Fractures
146 33 582
1 0 5
132 26 352
0 0 2
percent of the skull examinations taken actually showed a fracture, and 0.4 percent of all cervical spine examinations in the same category showed a fracture. Table 2 shows that all patients with less likelihood of fracture (less than 10 percent) were observed for potential neurologic sequelae. In six of the eight patients who had greater likelihood (greater than 90 percent) of skull fracture, significant concomitant cerebral injury was shown. (These percentages are approximations.) As Table 3 shows, 19 percent of all skull examinations and 26 percent of all cervical spine radiographs were ordered primarily for medicolegal considerations even though in most of the patients concerned there were no suspicious findings at the time of examination. A number of examinations were ordered at patients' request or insistence. In our total of 847 skull radiographic examinations, 761 were not expected clinically to show fracture, and in fact less than 1 percent of this group did. These six fractures were all linear in nature, and no abnormal neurologic findings were noted at examination of the patients. Each case was handled conservatively with overnight observation of neurologic function followed by subsequent release. In two patients with skull fractures among the 71 patients in the "50-50" clinical category, hemotympanum was present and basilar skull fractures were noted. Three patients in whom only soft tissue swelling and significant tenderness were present over the area of fracture were confirmed as being neurologically stable. In two patients significant cerebral injury was present and they were admitted for treatment. These groups comprised 832 patients or 98 percent of our entire study group; the cost of radiography was $44,000. In all patients, including those with subdural hematomas and those with
cerebral contusions, treatment was based on results of neurologic examination rather than on radiographically demonstrated fracture. Every case in which obvious hemotympanum, or cerebrospinal fluid rhinorrhea or otorrhea was present (and hence predictable basilar skull fracture) was similarly managed by following the clinical course and not on the basis of skull film results.
Comments We believe that the findings of this study substantiate the concept that attention should be directed first to a patient's mental status and neurologic examination rather than to the presence or absence of skull fractures when predicting immediate or long-term neurologic outcome. Our study also shows that 20 percent of these skull films, though lacking in clinical indication, were taken for "insurance" against potential litigation problems rather than strictly for clinical reasons. These data also indicate that a clinician in training usually can accurately predict a skull fracture without radiographs. Indeed, our statistics show a less than 1 percent incidence of unsuspected fracture for 761 patients. Whenever a resident physician believed there was a significant likelihood of injury, he was proven correct 50 percent of the time, therefore allowing a safe margin for error. On the other hand, the study of cervical spine radiographs is somewhat less conclusive. Although the overall incidence of fractures is low at 1.2 percent, definitive inpatient management was required in three of seven patients because of radiographically shown fractures, while neck braces were fitted in two as outpatients. One patient died while evacuation of bilateral subdural hematomas was being done and the seventh patient seen died after a cerebral injury and massive trauma. Moreover, one of the patients, who had a clinically unsuspected cervical spine fracture, had no significant head injury but was found to have a ruptured spleen as a result of involvement in a motor vehicle accident; this points out the need for cervical spine radiographs when there is a history of significant decelerative accident. The fact that there was a significant concomitant occurrence of cervical spine and head injuries explains why many cervical spine examinations are done in conjunction with radiographs of the skull to determine if head injuries are present despite the absence of cervical spine pathology on physical examination. THE WESTERN JOURNAL OF MEDICINE
3
RADIOGRAPHY OF THE SKULL AND SPINE
The study by Bell and Loop' reported findings similar to ours in that the relatively low yield of skull fractures in all patients in whom radiographs of the skull were done was less than 6 percent. They further established that showing the presence of fracture radiographically was not helpful in predicting either short-term or long-term sequelae when compared with physical examinations. Similarly, Piazza and Christi2 concluded that plain skull radiography itself was insufficient to predict the need for angiography or craniotomy in closed-head injuries. In their review of 100 such cases, the only consistent reliable radiographic sign (significant pineal shift) appeared 20 times; however, in 18 of these patients there also were findings on physical examination that pointed to the side of injury. Nevertheless, the specter of litigation under which emergency physicians labor is immense, as recent reports4 show. The standard of practice seems to be to carry out x-ray studies in any and every case of head injury in order to denote fractures, regardless of a patient's neurologic status and whether or not it will alter the patient's therapy. Although it is beyond the scope of this paper to list all of the indications for skull and cervical spine radiography in emergency situations, we believe that substantial percentages of skull and cervical spine radiographs in this study could have been safely eliminated when there was neither a history of decelerative force, loss of consciousness or other neurologic deficit, nor a finding of notable palpable tenderness on exami-
4
JULY 1977 * 127 * 1
nation of the skull. In patients with serious neurologic trauma, full radiographic workup can be done after stabilization, with neurologic status serving as the barometer of injury. The question must certainly be raised as to whether the $44,000 allocated in an urban Los Angeles emergency room during the brief time of this study represented a prudent health care expenditure. Would this money be better spent for observation in a greater number of patients for a period of 12 to 24 hours? Should radiographs continue to be taken to show fractures over the course of the middle meningeal artery, so that a patient can be placed under observation to rule out an acute epidural hematoma? Our data showing 556 radiographic examinations without a fracture across the course of the middle meningeal artery and the proven predictability of fracture in this area by physical examination make us think not. In view of the increasing demands for costeffective medicine and peer review, we believe that our data raise important health care questions and suggest that improved screening of patients would reduce the number of radiographs required to provide good patient care while at the same time keeping fear of litigation to a minimum. REFERENCES 1. Bell RS, Loop JW: The utility and futility of radiographic skull examinations for trauma. N EngI J Med 284:236-239, 1971 2. Piazza G, Cristi G: The role of radiographic skull examination in the emergency evaluation of intracranial expanding lesions
following closed head injuries. Neuro Radiology 6:101-103, 1973 3. Brewer RJ, Golden GT, Hitch DC, et al: Abdominal pain. Am J Surg 131:219-223, 1976 4. Professional Liability Newsletter 7, No. 9, Jan 1976
Selective Use of Radiography of the Skull and Cervical Spine MARK E. JERGENS, MD; MARSHALL T. MORGAN, MD, and CHARLES E. McELROY, MD Los Angeles
Based on the findings of a five-month study, the authors suggest that physicians should be more discriminating in using radiography of the skull, especially when dealing with patients who are minimally injured. The low incidence of fractures disclosed by radiography in patients with insignificant head injuries is a primary factor in arriving at this recommendation. A lack of correlation between skull fractures, and cerebral injury, and subsequent therapy is another factor. Finally, the prohibitive cost of medical care generally (and radiographs in particular) makes greater selectiveness imperative. Although the number of cervical spine fractures in this study was small, the findings indicate that based on history and physical examination there can and should be increasing selectivity in ordering routine cervical spine series, without increasing the risk of missed fractures.
THE RELATIVELY LOW YIELD of clinically relevant data derived from skull radiographs in emergency situations was reported by Bell and Loop' in 1971 and later corroborated by other authors.2 Despite this, the skull and cervical spine series continue to be integral to an evaluation of traumatized patients with suspected head or neck injuries regardless of physical findings. In view of the implied inefficiency of this and other radiographic examinations,3 we undertook a prospective study spanning five months of experience at the UniFrom the Departments of Surgery and Medicine, Emergency Medicine Center, UCLA Hospital, Los Angeles. Submitted October 20, 1976. Reprint requests to: Mrs. Seba Kolb, Editor, Department of Surgery, UCLA Center for the Health Sciences, Los Angeles, CA 90024.
versity of California at Los Angeles (UCLA) Emergency Medicine Center. From October through December 1975 and from March through April 1976, an investigative effort was made to determine the resident house staff's capability to predict fractures based on physical findings and to evaluate the effects of clinically unsuspected but radiographically shown fractures on patients' clinical course, as well as to establish the clinical indication for ordering skull or cervical spine radiographic series, or both. Criteria for selective ordering of radiographs would obviously reduce the cost of health care yet avoid the risk of litigation resulting from insufficient data having been acquired. THE WESTERN JOURNAL OF MEDICINE
1
RADIOGRAPHY OF THE SKULL AND SPINE
Material and Methods The UCLA Emergency Medicine Center serves population of about 500,000 people, and is located in a relatively high socioeconomic residential, business and light industrial area. Although flanked by two major freeway systems znd serving as a base station for eight paramedic units, there is a preponderance of patients having nontraumatic and minor injuries. The monthly census seen by the surgical house staff averages 2,500 patients. Residents on duty in the Emergency Medicine Center were asked to complete a questionnaire whenever radiographs of the skull or spine were ordered. This required designating the type of examination, the primary indication for the procedure, the character of any physical findings and the physician's estimate of the probability of fracture being present. Moreover, the radiology resident completed a similar questionnaire dealing with his findings. An attempt was made to exclude data derived from patients with fractures resulting from previous injury. Although some questionnaires were completed retrospectively, missing or incomplete forms were rectified within 24 hours of the event, at the time of daily staff radiographic review. Most such evaluations concerned severely traumatized patients whose clinical condition precluded prospective clerical completeness. a
TABLE 1.-Distribution of Radiographs and Fractures in Each Clinical Category Clinical Category
Total
Skull
90%
...... ......
......
761 71 15
755 65 6
6 6 9
0.8 8.5 60
847
826
21
2.4
510 55 8
508 52 6
2 3 2
0.4 5.5 25.
573
566
7
1.2
Cervical Spine
90%
.
...
Number With- Number of Percent of out Fracture Fractures Fractures
..
......
......
All of the patients with fractures were followed up after a three-month interval by telephone contact either with the patient or his physician, and information about the long-term effects of the fracture on the patient's health was requested. Results During the five-month investigation, there were 21 skull fractures in 847 skull examinations (2.4 percent), and seven cervical spine fractures in 573 examinations (1.2 percent). Table 1 compares the clinical prediction of the likelihood of fracture with the percentage of actual fractures in each group. In cases where the clinician believed the probability of fracture to be low, 0.8
TABLE 2.-Disposition of Patients With Fractures Number of Fractures
Category
Skuill 90% ......
...
9
90% ......
...
2
Cervical Spine
2
Follow-up
All placed under observation and then discharged. All have returned to normal lives. Three patients placed under observation and then discharged. All have returned to normal lives. Two patients with concomitant cervical spine fractures were admitted for treatment of those fractures. One patient with cerebrospinal fluid otorrhea was treated for that and has suffered no sequelae. Two patients without neurologic deficits were placed under observation and then discharged. Both have returned to normal lives. Four patients with concomitant cerebral contusions were admitted to hospital and treated for those contusions. All have returned to normal lives. Two patients died after evacuation of subdural hematomas. One patient with cervical spine fractures and massive head, chest and abdominal injuries died secondary to those injuries. One patient admitted to hospital and did well with cervical traction. One patient with stable fracture was treated as an outpatient with a brace. Two patients admitted to hospital and did well with cervical traction. One patient with stable fracture was treated as outpatient with a cervical brace. One patient died while evacuation of subdural hematoma was being done. One patient with concomitant massive head, chest and abdominal injuries died secondary to those injuries.
JULY 1977 * 127 * 1
RADIOGRAPHY OF THE SKULL AND SPINE TABLE 3.-Reasons for Ordering Radiographs in Patients with Less Than 10 Percent Likelihood of Fracture Number
Skuill Series Strictly medicolegal .............. Patient or family request ........ . Physical findings ................ Cervical Spine Series Strictly medicolegal .............. Patient or family request ........ Physical findings ................
Number of Fractures
146 33 582
1 0 5
132 26 352
0 0 2
percent of the skull examinations taken actually showed a fracture, and 0.4 percent of all cervical spine examinations in the same category showed a fracture. Table 2 shows that all patients with less likelihood of fracture (less than 10 percent) were observed for potential neurologic sequelae. In six of the eight patients who had greater likelihood (greater than 90 percent) of skull fracture, significant concomitant cerebral injury was shown. (These percentages are approximations.) As Table 3 shows, 19 percent of all skull examinations and 26 percent of all cervical spine radiographs were ordered primarily for medicolegal considerations even though in most of the patients concerned there were no suspicious findings at the time of examination. A number of examinations were ordered at patients' request or insistence. In our total of 847 skull radiographic examinations, 761 were not expected clinically to show fracture, and in fact less than 1 percent of this group did. These six fractures were all linear in nature, and no abnormal neurologic findings were noted at examination of the patients. Each case was handled conservatively with overnight observation of neurologic function followed by subsequent release. In two patients with skull fractures among the 71 patients in the "50-50" clinical category, hemotympanum was present and basilar skull fractures were noted. Three patients in whom only soft tissue swelling and significant tenderness were present over the area of fracture were confirmed as being neurologically stable. In two patients significant cerebral injury was present and they were admitted for treatment. These groups comprised 832 patients or 98 percent of our entire study group; the cost of radiography was $44,000. In all patients, including those with subdural hematomas and those with
cerebral contusions, treatment was based on results of neurologic examination rather than on radiographically demonstrated fracture. Every case in which obvious hemotympanum, or cerebrospinal fluid rhinorrhea or otorrhea was present (and hence predictable basilar skull fracture) was similarly managed by following the clinical course and not on the basis of skull film results.
Comments We believe that the findings of this study substantiate the concept that attention should be directed first to a patient's mental status and neurologic examination rather than to the presence or absence of skull fractures when predicting immediate or long-term neurologic outcome. Our study also shows that 20 percent of these skull films, though lacking in clinical indication, were taken for "insurance" against potential litigation problems rather than strictly for clinical reasons. These data also indicate that a clinician in training usually can accurately predict a skull fracture without radiographs. Indeed, our statistics show a less than 1 percent incidence of unsuspected fracture for 761 patients. Whenever a resident physician believed there was a significant likelihood of injury, he was proven correct 50 percent of the time, therefore allowing a safe margin for error. On the other hand, the study of cervical spine radiographs is somewhat less conclusive. Although the overall incidence of fractures is low at 1.2 percent, definitive inpatient management was required in three of seven patients because of radiographically shown fractures, while neck braces were fitted in two as outpatients. One patient died while evacuation of bilateral subdural hematomas was being done and the seventh patient seen died after a cerebral injury and massive trauma. Moreover, one of the patients, who had a clinically unsuspected cervical spine fracture, had no significant head injury but was found to have a ruptured spleen as a result of involvement in a motor vehicle accident; this points out the need for cervical spine radiographs when there is a history of significant decelerative accident. The fact that there was a significant concomitant occurrence of cervical spine and head injuries explains why many cervical spine examinations are done in conjunction with radiographs of the skull to determine if head injuries are present despite the absence of cervical spine pathology on physical examination. THE WESTERN JOURNAL OF MEDICINE
3
RADIOGRAPHY OF THE SKULL AND SPINE
The study by Bell and Loop' reported findings similar to ours in that the relatively low yield of skull fractures in all patients in whom radiographs of the skull were done was less than 6 percent. They further established that showing the presence of fracture radiographically was not helpful in predicting either short-term or long-term sequelae when compared with physical examinations. Similarly, Piazza and Christi2 concluded that plain skull radiography itself was insufficient to predict the need for angiography or craniotomy in closed-head injuries. In their review of 100 such cases, the only consistent reliable radiographic sign (significant pineal shift) appeared 20 times; however, in 18 of these patients there also were findings on physical examination that pointed to the side of injury. Nevertheless, the specter of litigation under which emergency physicians labor is immense, as recent reports4 show. The standard of practice seems to be to carry out x-ray studies in any and every case of head injury in order to denote fractures, regardless of a patient's neurologic status and whether or not it will alter the patient's therapy. Although it is beyond the scope of this paper to list all of the indications for skull and cervical spine radiography in emergency situations, we believe that substantial percentages of skull and cervical spine radiographs in this study could have been safely eliminated when there was neither a history of decelerative force, loss of consciousness or other neurologic deficit, nor a finding of notable palpable tenderness on exami-
4
JULY 1977 * 127 * 1
nation of the skull. In patients with serious neurologic trauma, full radiographic workup can be done after stabilization, with neurologic status serving as the barometer of injury. The question must certainly be raised as to whether the $44,000 allocated in an urban Los Angeles emergency room during the brief time of this study represented a prudent health care expenditure. Would this money be better spent for observation in a greater number of patients for a period of 12 to 24 hours? Should radiographs continue to be taken to show fractures over the course of the middle meningeal artery, so that a patient can be placed under observation to rule out an acute epidural hematoma? Our data showing 556 radiographic examinations without a fracture across the course of the middle meningeal artery and the proven predictability of fracture in this area by physical examination make us think not. In view of the increasing demands for costeffective medicine and peer review, we believe that our data raise important health care questions and suggest that improved screening of patients would reduce the number of radiographs required to provide good patient care while at the same time keeping fear of litigation to a minimum. REFERENCES 1. Bell RS, Loop JW: The utility and futility of radiographic skull examinations for trauma. N EngI J Med 284:236-239, 1971 2. Piazza G, Cristi G: The role of radiographic skull examination in the emergency evaluation of intracranial expanding lesions
following closed head injuries. Neuro Radiology 6:101-103, 1973 3. Brewer RJ, Golden GT, Hitch DC, et al: Abdominal pain. Am J Surg 131:219-223, 1976 4. Professional Liability Newsletter 7, No. 9, Jan 1976
