630 CT scans were reported by radiology residents out of hours within one year period. There were 34 discrepancies giving the discrepancy rate of 5.4%. There were 3 major (0.5%),
14 significant (2.2%) and 17 minor (2.7%) discrepancies. Radiologist specific causes included 11 cognitive,
18 observational and 6 satisfaction of search errors. There were 3 false positive errors. No significant difference in discrepancy rate for various levels of training.
The three major discrepancies (Cases 1-3) and 3 of the 14 significant discrepancies (Cases 4-7) are demonstrated below.
Case 1
79 year old Female with a known history of Osteoporosis fell down 5 steps.
She complained of immediate neck pain.
Clinical examination revealed C2 tenderness.
The CT C-Spine was reported as normal by the radiology resident on call. Checking and verification of the scan by the Consultant revealed a fracture through the right C4/5 facet joint with widening (Fig.
1 and Fig.
2),
a fracture through the left C5 foramen transversarium and Clay Shoveler's fractures at C4 and C5 (Fig.
3).
Fig. 1: Axial CT image of fracture through the right C4/5 facet joint with widening.
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Fig. 2: Sagittal CT image of fracture through the right C4/5 facet joint.
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Fig. 3: Sagittal CT image of fracture through the left C5 foramen transversarium and Clay Shoveler's fractures at C4 and C5
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Case 2
81 year old female presented to the A&E Department with neck pain and multiple areas of bruising to the head after a fall whilst intoxicated.
He was tender at C5-C7.
The CT C-Spine was reported as normal by the radiology resident.
Checking of the scan by the Consultant Radiologist demonstrated a fracture through the right C5 foramen transversarium (Fig 4).
Fig. 4: Axial CT slice demonstrating a fracture through the right C5 foramen transversarium.
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Case 3
A 35 year old female was involved in a road traffic accident (RTA).
She had a whole body trauma CT scan.
The Radiology Resident reported the CT C-Spine as normal.
Checking by the Consultant Radiologist revealed an undisplaced fracture through the left occipital condyle (Fig.
5).
Fig. 5: Coronal CT image showing an undisplaced fracture through the left occipital condyle.
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Case 4
A 71 year old male presented after a fall with cervical spine pain.
On examination he was found to be tender at C1-C3.
The Radiology Resident reported the CT-Spine as abnormal with an acute
fracture of the right lateral mass of C1 vertebra (Fig 6).
On further checking by the Consultant,
the patient was found to have a flexion injury at C5/C6 level.
There was widening of the interspinous distance between C5 and C6 spinous processes (Fig 7.) and a 40% anterior wedge compression of C6 vertebral body (Fig.
8).
Fig. 6: Axial CT slice of an acute fracture of the right lateral mass of C1 vertebra.
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Fig. 7: Sagittal CT slice demonstrating widening of the interspinous distance between C5 and C6 spinous processes.
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Fig. 8: Sagittal image of 40% anterior wedge compression of C6 vertebral body.
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Case 5
An intoxicated 53 year old male presented post collapse.
He was complaining of general neck pain and a sensation of pins and needles in his fingers.
Examination revealed tenderness at C4-C5.
The CT C-Spine was reported as normal apart from degenerative changes by the Radiology Resident.
Further examination by the Consultant revealed a partially united fracture of the mandible at the symphysis menti (Fig.
9).
Fig. 9: Sagittal CT Slice demonstrating partially united fracture mandible at the symphysis menti.
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Case 6
A 26 year old female presented to the A&E Department after being involved in an RTA.
She was complaining of neck pain.
The Radiology Resident reported a minimally displaced fracture at the right facet of C5 on the ensuing CT C-Spine Report.
On further checking by the Consultant,
the patient was found to have an undisplaced fracture of the right lamina and right transverse process of C5 (Fig.
10).
There was mild widening at the right C5/C6 facet joint with minimal subluxation.
A further small undisplaced fracture of the inferior articular process of C3 on the right was demonstrated (Fig.
11).
Fig. 10: Sagittal CT slice of undisplaced fracture of the right transverse process of C5
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Fig. 11: Coronal CT of undisplaced fracture of the inferior articular process of C3 on the right.
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Case 7
A 19 year old patient presented with neck pain after being involved in an RTA.
A CT C-Spine performed for further assessment was reported as normal by the Radiology Resident.
Review by the Consultant demonstrated abnormal widening of the left C6/C7 facet joint with perching of the articular processes (Fig.
12 and Fig.
13).
Fig. 12: Coronal CT showing abnormal widening of the left C6/C7 facet joint with perching of the articular processes.
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Fig. 13: Sagittal CT image demonstrates abnormal widening of the left C6/C7 facet joint with perching of the articular processes.
References: Radiology,NHS Trust, university hospital Leicester-Leicester/UK
Learning Points
Please refer to Fig.
14
Fig. 14: How to assess a CT of the C-Spine
References: © Radiology,NHS Trust, university hospital Leicester-Leicester/UK