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Clinical Decisionmaking

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Using a simple set of clinical criteria can reduce unnecessary cervical spine x-rays in patients with blunt trauma

Doctors x-ray the cervical spine of nearly all patients with blunt trauma because they want to rule out hidden cervical spine injuries. However, a new study suggests that when doctors use a simple set of clinical criteria they can identify patients who have a very low probability of spinal injury and consequently do not need spinal x-rays. Using these criteria can reduce unnecessary cervical spine x-rays of blunt trauma victims, concludes William R. Mower, M.D., Ph.D., of the University of California, Los Angeles.

In a study supported by the Agency for Healthcare Research and Quality (HS08239), Dr. Mower and colleagues examined the ability of five clinical criteria—no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no painful, distracting injury—to predict which blunt trauma patients would be unlikely to have cervical spine injury. They examined the performance of these criteria (decision instrument) in 34,069 patients who underwent x-rays of the cervical spine after blunt trauma at 21 centers across the United States.

This approach identified all but 8 of the 818 patients who had cervical spine injury (99 percent sensitivity). Only two of the patients classified as unlikely to have an injury according to these criteria were considered to have a clinically significant injury. Also, only one of these two patients had to undergo surgery to repair the injury. According to these results, x-rays could have been avoided in the cases of 4,309 (12.6 percent) of the 34,069 evaluated patients.

More details are in "Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma," by Jerome R. Hoffman, M.D., Dr. Mower, Allan B. Wolfson, M.D., and others, in the July 13, 2000 New England Journal of Medicine 343(2), pp. 94-99.

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