title: CT for all or selective approach? Who really needs a cervical spine CT after blunt trauma.
abstract: BACKGROUND
  Computed tomography (CT) is the standard to screen blunt trauma patients for cervical spine (c-spine) fractures, yet there remains a reluctance to scan all trauma team activations because of radiation exposure and cost. The purpose of this study was to identify predictors of positive CT in an effort to decrease future CT use without compromising patient care.
  
  
  METHODS
  We performed a prospective study in which we documented 18 combined NEXUS and Canadian c-spine criteria on 5,182 patients before CT comparing those with and without fractures to identify predictors of injury. Clinical examination was considered positive if any of the 18 criteria were positive.
  
  
  RESULTS
  There were 324 patients with a fracture, for an incidence rate of 6.25%. Fracture patients were older (43.89 ± 18.83 years vs. 38.42 ± 17.45 years, p <; 0.0001), with a lower GCS (Glasgow Coma Scale) score (13.49 ± 3.49 vs. 14.32 ± 2.34, p < 0.0001), than nonfracture patients. Clinical examination had a 100% (324 of 324) sensitivity, 0.62% (30 of 4,858) specificity, 6.29% (324 of 5,152) positive predictive value, and 100% (30 of 30) negative predictive value. A total of 77.8% (14 of 18) criteria were significantly associated with fracture by univariate analysis, seven of which were independent predictors of fracture by logistic regression (midline tenderness, GCS score < 15, age ≥65 years, paresthesias, rollover motor vehicle collision, ejected, never in sitting position in emergency department). Evaluation of these seven factors demonstrated a sensitivity of 99.07% (321 of 324), positive predictive value of 6.95% (321 of 4,617), specificity of 11.57% (562 of 4,858), and negative predictive value of 99.47% (562 of 565).
  
  
  CONCLUSIONS
  Although sensitive, the standard clinical criteria used to determine patients who need radiographs lack specificity. Based on these results, more narrow criteria should be validated in an effort to limit the number of c-spine CTs while not compromising patient care.
  
  
  METHODS
  Prognostic study, level II; diagnostic study, level II.
authors.affiliation: Virginia Commonwealth University Medical Center, Richmond, VA, USA. tmduane@vcu.edu
authors.forename: Therèse M
authors.initials: TM
authors.lastname: Duane
authors.forename: Andrew
authors.initials: A
authors.lastname: Young
authors.forename: Julie
authors.initials: J
authors.lastname: Mayglothling
authors.forename: Sean P
authors.initials: SP
authors.lastname: Wilson
authors.forename: William F
authors.initials: WF
authors.lastname: Weber
authors.forename: Luke G
authors.initials: LG
authors.lastname: Wolfe
authors.forename: Rao R
authors.initials: RR
authors.lastname: Ivatury
mesh_terms: D000328:Adult; D002574:Cervical Vertebrae / Q000293:injuries*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010808:Physical Examination; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012680:Sensitivity and Specificity; D016103:Spinal Fractures / Q000000981:diagnostic imaging* / Q000453:epidemiology; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging*; D055815:Young Adult