The insanity never stops. It’s a good thing MRI is becoming increasingly available, because the more papers like this are published in major journals, the more we’re going to be stuck following every possible outcome to it’s bitterest end with the strongest microscope we have.
There a lots of problems with using this paper to change practice – of their 9152 patients undergoing CT for trauma, 741 had persistent midline tenderness leading towards MRI. Of those 741, only 174 were enrolled for a variety of reasons. And this study doesn’t tell us enough useful information to help distinguish the characteristics of the 78 patients in whom an injury was detected to help us differentiate them from the patients in whom no injury was detected.
But the fact remains, they identified serious injuries on MRI in patients who had negative CTs – and not just obtunded, intubated, polytrauma patients like in the other studies.
Just one more thing to worry about.
“Cervical Spine Magnetic Resonance Imaging in Alert, Neurologically Intact Trauma Patients With Persistent Midline Tenderness and Negative Computed Tomography Results”
http://www.ncbi.nlm.nih.gov/pubmed/21820209
Of note, only 5 patients had surgery.
The study doesn't address what would have happened to these patients had no MRI been done. None of them had progressive neurological findings so the decision to operate on 4 of them was based on MRI findings alone. Would they have had an adverse outcome without surgery? No one knows.
The 5th had delayed surgery based on abnormal flexion extension views at 6 weeks, rather than on the MRI findings.
The other 73 were treated with nothing, or with cervical collars, which are probably as effective as nothing.
Exactly – they don't have any sort of prospective look at patients with tenderness despite CT who had no other concerning indication for MRI. In essence, however, that control population would be the one we see every day and discharge from the ED with pain control and muscle relaxants – and my anecdotal experience is that essentially none have poor outcomes.
My chagrin is that articles like this will continue to tilt the "standard of care" towards more expensive testing that doesn't necessarily find any significant pathology. But, at least, they're not recommending any role for flex/ex….