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Three Part Question

In [adults presenting to the emergency department following spinal trauma] is [CT better than plain film X-ray] at [diagnosing thoracolumbar fracture]

Clinical Scenario

A 45 year old male patient falls 12 ft from a ladder onto his back. He presents to the emergency department complaining of lower back pain. You wonder if CT is better than plain X-ray at diagnosing thoracolumbar fracture

Search Strategy

Cochrane Database of Systematic Reviews 2nd Quarter 2007. Medline 1950 to June week 2 using the Ovid interface. EMBASE 1996 to 2007 week 25.
({exp spinal fractures OR spinal trauma mp. OR exp thoracic vertebrae OR exp lumbar vertebrae} AND {exp tomography OR CT mp.} AND {exp X-rays OR X-ray$ mp. OR exp radiography OR lumbar adj radiograph$ mp. OR thoracolumbar adj radiograph$} AND {exp diagnosis}) LIMIT to english language. LIMIT to humans. LIMIT to all adult (19 years plus). LIMIT to "diagnosis (sensitivity)".

Search Outcome

1305 papers were found of which 7 were relevant to the clinical question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Berry GE. et al. 2005 USA	103 patients admitted to a level 1 trauma centre over a 2-month period who underwent CAP CT (chest-abdomen-pelvis) and plain film evaluation of the thoracolumbar spine	Retrospective case series	CT sensitivity and specificity for thoracolumbar fracture	100 % sensitive, 97 % specific	Only 26 of original 103 patients had TL fracture
			Plain radiograph sensitivity and specificity for thoracolumbar fracture	73 % sensitve, 100 % specific
			Negative predictive value for CT and Plain radiograph	100 % and 92 % respectively
			Area under the ROC curve for CT and Plain radiograph	0.98 and 0.86 (P < 0.02) respectively
Antevil JL, et al 2006 USA	573 patients evaluated for spinal trauma during two, three-month intervals. X-ray group (1999) 254 patients CT group (2002) 319 patients	Retrospective case series	Sensitivity in detecting spinal fracture	70 % specific (14 out of 20)	Only a small proportion of the intial number of patients had spinal fracture
			Sensitivity of CT in detecting spinal fracture	100 % specific (34 out of 34)
Rhee PM, et al 2002 USA	115 patients identified over a period of 6 years wtih diagnosed lumbar fracture 56 patients had AP-CT scans 110 pateints underwent two-view plain films (52 patients had both screening tests)	Retrospective study	Overall performance of screening methodology using AP-CT and two-view plain films	13/56 fractures were missed with AP-CT alone (missed fracture rate of 23.2 %), 14/110 fractures were missed by two-view plain films (missed fracture rate of 12.7 %, P = 0.08), a combination of both imaging modalities did not miss any fractures. The fractures that were missed by AP-CT and two-view plain film were not minor fractures, 46 % and 50 % respictively required surgery or brace
Sheridan R 2003 USA	78 trauma patients admitted over a period of 12 months in a level 1 trauma centre with one or more thoracic or lumbar spine fractures Thoracic fractures n = 35 Lumbar fractures n = 43	Retrospective case series	Diagnosis of thoracic spine fracture	Sensitivity of reformatted RHCT scanning was 97 %, sensitivity of conventional radiograph in diagnosis was 62 %.	small sample group
			Diagnosis of lumbar spine fracture	Sensitivity of RHCT scanning in diagnosis of lumbar spine fractures was 95 %, sensitivity of conventional radiograph in diagnosis of lumbar spine fracture was 86 %.
Inaba K, et al 2006 USA	All published studies comparing reformatted CT to traditional plain radiography for thoracolumbar spine clearance	Review article	Evaluation of sensitivity and specificity of reformatted CT and traditional plain radiography	Review articles highlighted superior sensitivity and interobserver variability for reformatted CT compared with plain radiographic screening. CT was also noted to be more accurate at localising , classifying, and delineating the age, bony intrusion, and soft-tissue damage associated with the fracture.
Wintermark M, et al 2003 Switzerland	26 patients with fractured vertebrae prospectively identified from 100 consecutive severe trauma patients	Comparitive study	Overall sensitivity of multi-detector row CT	78.1 % sensitive (97.2 % for unstable fractures)	Multi-detector row CT images were reviewed by the same three radiologists
			Overall intra-observer agreement for multi-detector row CT	kappa value = 0.787 (0.951 for unstable fractures)
			Overall sensitivity for conventional radiography	32 % sensitive (33.3 % for unstable fractures)
			Overall intraobserver agreement for conventional radiography	kappa value = 0.661 (0.368 for unstable fractures)
Gestring ML, et al 2002 USA	71 patients who sustained blunt injury and required computed lumbar spine radiographs (CLSRs) as well as abdominal and pelvic CT scans were propectively identified. 10 patients were found to have thoracolumbar fracture	Case series	Sensitivity and specificity of CT and scanograms	100 % sensitive and 100 % specific	Only 10 patients from the original study group of 71 were found to have thoracolumbar fracture

Comment(s)

Several papers were found relavant to the clinical question. Results highlight that CT was both more specific and more sensitive than plain film x-ray and also gave a higher intra-observer agreement value, therefore indicating that results from CT are more reproducible. Several papers also highlighted cost, radiation exposure and waiting time as important factors when considering the overall benefit of each imaging modality. Although plain film x-ray offers a reduce radiation level, repeat films make exposure levels comparable with CT. Time and cost also demonstrated results which favoured CT.

Clinical Bottom Line

CT scanning is a more sensitive and specific imaging technique than the gold standard of plain film X-ray in the diagnosis of thoracolumbar fracture.

References

1. Berry GE, et al Are plain radiographs of the spine necessary during evaluation after blunt trauma? Accuracy of screening torso computed tomography in thoracic/lumbar spine fracture diagnosis the journal of trauma injury, infection and critical care 2005;59:1410-1413
2. Antevil JL, et al Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care? The journal of trauma injury, infection and critical care 2006;61:382-387
3. Rhee PM Lumbar fractures in adult blunt trauma: Axial and single-slice helical abdominal and pelvic computed tomographic scans versus portable plain films The journal of trauma injury, infection and critical care 2002;53:663-667
4. Sheridan R Reformatted visceral protocol helical computed tomographic scanning allows conventional radiographs of the thoracic and lumbar spine to be eliminated in the evaluation of blunt trauma patients The journal of trauma injury, infection and critical care 2003;55:665-669
5. Inaba K Visceral torso computed tomography for clearence of the thoracolumbar spine in trauma: A review of the literature The journal of trauma injury, infection and critical care 2006;60:915-920
6. Wintermark M, et al Thoracolumbar spine fractures in patients who have sustained severe trauma: Depiction with multi-detector row CT Radiology 2003;227:681-689
7. Gestring ML, et al Evaluation of the lower spine after blunt trauma using abdominal computed tomographic scanning supplemented with lateral scanograms The journal of trauma injury, infection and critical care 2002;53:9-14