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Fix 2
Fix 2
Received:
25 November 2015
Accepted:
13 January 2016
http://dx.doi.org/10.1259/bjr.20150996
ULRICH LINSENMAIER, MD, PhD, 3ZSUSZSANNA DEAK, MD, 4AINA KRTAKOVSKA, MD, 5FRANCESCO RUSCHI, MD,
NORA KAMMER, MD, 2,3STEFAN WIRTH, MD, PhD, 3MAXIMILIAN REISER, MD, PhD and 2,3LUCAS GEYER, MD
3
1
INTRODUCTION
Approximately 23% of all trauma patients in emergency
departments suffer from cervical spine (C-spine) injury.1
The incidence of C-spine injuries in association with brain
injuries among adult trauma patients ranges from 1.7% to
8% and is actually ,1% among neurologically intact and
alert patients, leading to a large number of normal imaging
studies.13
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Linsenmaier et al
Table 1. Study group, patient demographics: age, gender and incidence of degenerative spine disease
Patient demographics
With CCI
Without CCI
34.0 6 1 (9.5)
33.6 6 4 (10.6)
F (32.4); M (34.3)
F (34.1); M (33.2)
30
34
42.9 (6.1)
43.5 (7.6)
Gender (n, %)
Gender/age correlation (years) (sex vs correlating mean age)
Signs of initial degenerative spine disease (%)
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Figure 1. Measurements of cervical spine alignment using absolute rotational angle of the posterior surface of C2 and C7 (ARA C27)
criteria for patients with cervical collar immobilization in place. ARAs were calculated as the angle of intersection of the posterior
tangents on the C2 and C7 vertebral bodies.
control group, the same exclusion criteria were applied, if applicable, as for the study group.
CT imaging
MDCT was performed on two 64-row scanners (VCT64 and
HD750; GE, Milwaukee, WI) using a standard scanning protocol for patients with a suspected C-spine trauma: 120 kV,
native helical scan with z-axis dose modulation (10250 mA) at
a noise index of 25 using the thinnest detector collimation
available (64 3 0.625 mm). Axial reconstructions were calculated with a slice thickness of 1.25 mm and a high-resolution
bone kernel, 2.5 mm and a soft-tissue kernel, and 0.65 mm for
multiplanar reconstructions, applying slice thickness of 2 mm
in the coronal and sagittal orientations.
Image evaluation
Two experienced, board-certied (7 and 12 years in radiology),
independent, blinded readers evaluated all 160 data sets and
performed all angle measurements on sagittal multiplanar reconstruction images. The SEM for the PTM Harrison (1 ,
SEM , 2) is lower than the reported values for the Cobb
method (3 , SEM , 10), and it is considered to be both
more reliable and reproducible.7,24 Therefore, in the present
study PTM Harrison was used to evaluate changes in the
C-spine curve.
Lordosis
35 (7)
Average
SD
Kyphosis
5 (1)
Straight
60 (12)
222.00
14
25.75
6.39
5.01
Min.
234
14
213
Max.
215
14
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Figure 2. Control group: distribution of cervical spine alignment types in a group of patients without head/neck trauma
and undergoing oncologic imaging.
Linsenmaier et al
RESULTS
Concerning interobserver variability, none of the recorded differences between angle values observed by the two independent
readers proved to be statistically signicant (p $ 0.05). Therefore
no consensus decisions were necessary.
Alignment
groups
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With CCI
Without CCI
%
Average
21
33
223.72
226.14
6.47
7.56
Min.
240
242
Max.
215
217
p . 0.05
Kyphosis
%
10
18
110.86
111.76
SD
4.02
5.16
Min.
Max.
20
21
Average
p , 0.05
Straight
%
Average
SD
p-value
p . 0.05
Lordosis
SD
Control group
The control group (n 5 20), i.e. patients without history of
trauma who underwent oncologic imaging studies, had a mean
age of 33 years (SD 6 6.53) and was analysed in accordance with
the criteria for the study group and evaluated against normal
values known from upright CR imaging (normal upright-CR
ARA C27) which had been obtained from literature data. Patient demographics, age and incidence of degenerative spine
disease did not differ from the study group.
69
49
24.25
22.95
5.54
5.00
Min.
213
212
Max.
Br J Radiol;89:20150996
33%, p 5 0.33) alignment, but these differences were not statistically signicant. In the group with CCI (CCI1), there was
a signicantly higher number of patients with a straight C-spine
alignment (69% vs 49%, p 5 0.05). The differences of distribution of C-spine alignment among supine patients with and
without CCI can be seen in Table 3.
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The ARA measurements for the patient groups with and without
CCI showed predominantly straight alignments (69%) (ARA
213 to 16) vs lordosis (21%) and kyphosis (10%). The RRA
measurements for the patient groups with CCI (CCI1) showed
segmental kyphosis in 17 (21%) individuals: 58% (n 5 10) of
them at the C5/6 level (mean 18.81, SD 3.22), 29% (n 5 5) of
them at the C4/5 level (mean 17.83, SD 2.93) and 12% (n 5 2)
of them at the C2C4 level (mean 16.00, SD 2.00) (Figure 4).
The RRA measurements for the patient group without CCI
(CCI2) revealed segmental kyphosis in 15 (19%) patients: 33%
(n 5 5) of them at the C5/6 level (mean 15.80, SD 1.3), 18%
(n 5 3) of them at the C4/5 level (mean 16.60, SD 1.52), 26%
(n 5 4) of them at the C3/4 level (mean 16.50, SD 1.91) and
13% (n 5 2) of them at the C2/3 level (mean 15.00, SD 1.00).
The resulting average ARA C27 values for both patient groups
are represented in Table 3.
From these results, it can be concluded that segmental kyphosis
in the group generally considered straight appeared mostly at
segment C46, however, without a statistically signicant difference between both patient groups. There is no difference in
the segmental kyphotic frequency between the two groups based
on RRA measurements.
DISCUSSION
There are no published scientic data to date based on supine
MDCT C-spine alignment measurements among trauma patients
with or without CCI. Therefore, the data drawn from this study
could not be compared with other authors using MDCT, and
a comparison with other studies based on upright CR imaging is
methodically difcult and limited in this context.
Figure 3. Control group, examples of the cervical spine (C-spine) alignment of the same patient in different examinations. The same
patient, with a 2-month interval between two multidetector CT examinations for oncologic reasons, no history of trauma. It is
evident that the C-spine alignment has slightly changed from straight (a: ARA C27, 4) to lordotic (b: ARA C27, 21) due to
a difference in the positioning of the head.
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Linsenmaier et al
Figure 5. Extreme angulations of C2/3 and C6/7 producing a pseudolordotic pattern. According to defined absolute rotational
angle values, these patients were classified as having a lordotic cervical spine curve, although upon subjective visual assessment,
they appear generally straight at C3C6.
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these patients was due to CCI impact, but the most proximal or
distal segments of the C-spine remained partially mobile,
probably because the cervical collar was not fastened tightly,
hence the angulation result in a generally straightened C-spine.
It can be concluded that non-lordotic, straightened or kyphotic C-spine alignment in supine adult single-trauma
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