New work from The University of Pittsburgh Medical Center weighs the risks and benefits of utilizing computed tomography angiography (CTA) in cervical spine patients using a novel 2-step algorithm which may well result in better patient selection.
Novel 2-step Algorithm Improves CT Angiography Patient Selection
1 min read Premium comments
Secondary#cervicalfractures#bluntcerebrovascularinjuries#computedtomographyangiography
The study, “Cervical Spine Fractures: Who Really Needs CT Angiography?” appears in the December 1, 2019 edition of Spine.
William F. Donaldson, III, M.D., Executive Vice Chairman for Clinical Services and the Professor and Chief of Spine Service in the Department of Orthopaedic Surgery at the University of Pittsburgh Medical Center, described the genesis of this study to OTW, “We were noting that most patients with a cervical spine injury were getting a CTA. The concern of complications and reactions to the test had to be weighed against the benefits of stroke prevention.”
As Dr. Donaldson explained, computed tomography angiography enables rapid detection of blunt cerebrovascular injuries and, not coincidentally, patient screening criteria for using computed tomography angiography has broadened. However, added Donaldson, “more recent work warns of the potential for the overdiagnosis of blunt cerebrovascular injuries, which must be considered with the adoption of broad criteria.”
So, Donaldson and his research team collected data from 721 patients with cervical fractures—of whom 417 underwent computed tomography angiography.
They employed a novel two-step metric for screening patients for computed tomography and compared it with the American College of Surgeons guidelines and the expanded Denver Criteria. They then assessed the ability of each metric to identify blunt cerebrovascular injuries and posterior circulation strokes.
Dr. Donaldson described his findings to OTW, “The novel two step algorithm helps identify the patients with cervical spine injuries that may require treatment. The algorithm also helps identify those patients that should not be tested and therefore not subject them to the risks of a CT angiogram. Further prospective studies will help refine the criteria for those patients that should have a CTA to mitigate risk of stroke from vertebral artery injury during cervical trauma.”
React:
Discussion
This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
Join the conversation
Orthopedic professionals are discussing this. Sign in and upgrade to read every comment and add your voice.