title: Frequent computed tomography scanning due to incomplete three-view X-ray imaging of the cervical spine.
abstract: BACKGROUND
  Conventional C-spine imaging (3-view series) is still widely used in trauma patients, although the utilization of computed tomography (CT) scanning is increasing. The aim of this study was to analyze the value of conventional radiography and the frequency of subsequent CT scanning due to incompleteness of three-view series of the C-spine in adult blunt trauma patients.
  
  
  METHODS
  We analyzed the data of a prospectively collected database including all patients between November 2005 and November 2007 treated in the trauma resuscitating room. We assessed the reasons for subsequent CT scanning after the three-view series according to the following classification: inevaluability, incompletion, evaluation of findings on three-view series or evaluation of unexplained, and persistent clinical symptoms. Furthermore, we evaluated possible predictors for incompleteness.
  
  
  RESULTS
  Of 1,283 blunt trauma patients, 88 C-spine injuries were diagnosed with an overall incidence of 6.9%. One hundred fifty-nine patients (12%) had their C-spine cleared based on the NEXUS criteria and 12 died before C-spine imaging could be performed. A total of 717 patients were primarily evaluated with three-view series and 395 patients primarily with CT scanning. Within the population with primarily three-view series, 249 (35%) were repeatedly incomplete and 16 (2%) were inevaluable. In the majority of the incomplete three-view series, no apparent reason could be determined. However, the presence of clavicular fractures (resulting in incomplete radiographs in 68% vs. 34% without a fracture; p < 0.001) and rib fractures (56% vs. 34%; p = 0.008) were associated with incomplete three-view series.
  
  
  CONCLUSIONS
  In more than one third of the patients primarily assessed with three-view X-ray series of the C-spine, the results are incomplete or inevaluable necessitating CT scanning. Although the majority of the incomplete series remain unexplained, we advise CT scanning in patients having clavicular and rib fractures because this increases the likelihood of obtaining incomplete three-view series.
authors.affiliation: Trauma Unit Department of Surgery, Neurosurgical Center Amsterdam, Amsterdam, The Netherlands. t.p.saltzherr@amc.uva.nl
authors.forename: Teun Peter
authors.initials: TP
authors.lastname: Saltzherr
authors.forename: Ludo F M
authors.initials: LF
authors.lastname: Beenen
authors.forename: Johannes B
authors.initials: JB
authors.lastname: Reitsma
authors.forename: Jan S K
authors.initials: JS
authors.lastname: Luitse
authors.forename: W Peter
authors.initials: WP
authors.lastname: Vandertop
authors.forename: J Carel
authors.initials: JC
authors.lastname: Goslings
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D016477:Artifacts; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries; D002968:Clavicle / Q000293:injuries; D002985:Clinical Protocols; D003951:Diagnostic Errors / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000000981:diagnostic imaging; D009426:Netherlands / Q000453:epidemiology; D018579:Patient Selection; D011187:Posture; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D012253:Rib Fractures / Q000000981:diagnostic imaging; D016103:Spinal Fractures / Q000000981:diagnostic imaging; D013124:Spinal Injuries / Q000000981:diagnostic imaging / Q000453:epidemiology; D014057:Tomography, X-Ray Computed / Q000379:methods* / Q000706:statistics & numerical data; D014193:Trauma Centers; D019564:Unnecessary Procedures / Q000706:statistics & numerical data; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging