Quantifying Risk Factors for Slipped Capital Femoral Epiphysis and Postslip Osteonecrosis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a disorder of the proximal femoral physis occurring in late childhood and adolescence. Previously postulated risk factors include obesity and endocrinopathies. The purpose of this investigation was to identify risk factors for developing SCFE, as well as postslip osteonecrosis (ON), among the United States pediatric population. METHODS: A national database investigation was performed using PearlDiver Technologies, Inc., queried for SCFE and ON using International Classification of Disease codes (2010 to 2020). Regression analyses to determine the risk of developing a SCFE, and ON after a patient has already been diagnosed with a SCFE ("postslip"). Propensity matching between SCFE and control groups generated a pseudo-randomization model to compare the relative risk. RESULTS: There were 11,465 patients with SCFE available in the database, matched with 134,680 controls. After matching, vitamin D deficiency, obesity, hypothyroidism, and growth hormone use were risk factors for developing SCFE [relative risk ranges from 1.42 (95% CI: 1.21-1.39, vitamin D deficiency) to 3.45 (95% CI: 3.33-3.57, obesity)]. ON risk factors were vitamin D deficiency [1.65 (1.26-2.14)] and hypothyroidism [1.49 (1.10-2.07)]. CONCLUSIONS: This United States national database study quantified risk factors of developing an SCFE and postslip ON. Obesity is the most significant risk factor for the development of a slip, but not ON. Growth hormone use, hypothyroidism, and vitamin D deficiency are also risk factors for SCFE development, whereas only the latter two were associated with ON. These findings demonstrate the public health implications of obesity and comorbid conditions in pediatric hip pathology. LEVEL OF EVIDENCE: Level III.

Acetabular fracture pattern is altered by pre-injury sacroiliac joint autofusion.

PURPOSE: Acetabular fracture shape is determined by the direction of force applied. We perceive an anecdotally observed connection between pre-existing autofused sacroiliac joints (aSIJ) and high anterior column (HAC) injuries. The purpose of this study was to compare variations in acetabular fracture patterns sustained in patients with and without pre-injury sacroiliac (SI) joint autofusion. METHODS: All adult patients receiving unilateral acetabular fixation (level 1 academic trauma; 2008-2018) were reviewed. Injury radiographs and CT scans were reviewed for fracture patterns and pre-existing aSIJ. Fracture types were subgrouped presence of HAC injury (includes anterior column (AC), anterior column posterior hemitransverse (ACPHT), or associated both column (ABC)). ANALYSIS: Logistic regression determined the association between aSIJ and HAC. RESULTS: A total of 371 patients received unilateral acetabular fixation (2008-2018); 61 (16%) demonstrated CT evidence of idiopathic aSIJ. These patients were older (64.1 vs. 47.4, p < 0.01), more likely to be male (95% vs. 71%, p < 0.01), less likely to be smokers (19.0% vs. 44.8%, p < 0.01), and were injured from lower energy mechanisms (21.3% vs. 8.4%, p = 0.01). The most common patterns with autofusion were ACPHT (n = 13, 21%) and ABC (n = 25, 41%). Autofusion was associated with greater odds of patterns involving a high anterior column injury (ABC, ACPHT, or isolated anterior column; OR = 4.97, p < 0.01). After adjusting for age, mechanism, and body mass index, the connection between autofusion and high anterior column injuries remained significant (OR = 2.60, p = 0.01). CONCLUSIONS: SI joint autofusion appears to change mode of failure in acetabular injuries; a more rigid posterior ring may precipitate a high anterior column injury. LEVEL OF EVIDENCE: Prognostic level III.

Radiographic bladder shift is a harbinger of intraoperative blood loss in acetabular surgical fixation.

PURPOSE: The purpose of this study was to characterize the relationship between a novel radiographic measurement on initial AP pelvis radiograph (termed "bladder shift," BS) to intraoperative blood loss (IBL) during acetabular surgical fixation. METHODS: All adult patients receiving unilateral acetabular fixation (Level 1 academic trauma; 2008-18) were reviewed. AP pelvis radiographs were reviewed for visible bladder outlines and then measured to determine the percentage deformation toward the midline. Hemoglobin & hematocrit data were then used to calculate quantitative blood loss between pre- and post- operative blood counts for data analysis. RESULTS: 371 patients with unilateral traumatic acetabular fractures requiring fixation were reviewed; 99 of these had visible bladder outlines, complete blood count and transfusion data (2008-2018; 66% associated patterns). Median bladder shift (BS) was 13.3%. Every 10% of bladder shift was associated with 123 mL greater IBL. Patients with full bladder shift to midline sustained a median 1.5L IBL (interquartile range [IQR] 0.8 to 1.6). Associated patterns had a threefold greater median BS (associated: 16.5% [15.4 to 45.9] vs. elementary: 5.6% [1.1 to 15.4], p < 0.05) and received intraoperative pRBC twice as frequently (57% vs. 24%, p < 0.01). CONCLUSIONS: Radiographic bladder shift is an easily available visual marker, in patients sustaining acetabular fractures, that may predict intraoperative hemorrhage and need for transfusions.

Physical Examination Is Predictive of Cauda Equina Syndrome: MRI to Rule Out Diagnosis Is Unnecessary.

STUDY DESIGN: Cross-sectional cohort study. OBJECTIVES: Cauda equina syndrome (CES) is a neurologic emergency, and delay in diagnosis can result in irreversible impairment. Our purpose was to determine the value of physical examination in diagnosis of CES in patients complaining of bladder and/or bowel complications in the emergency department. METHODS: Adult patients at one tertiary academic medical center that endorsed bowel/bladder dysfunction, underwent a lumbar magnetic resonance imaging (MRI), and received an orthopedic spine surgery consultation from 2008 to 2017 were included. Patients consulted for trauma or tumor were excluded. A chart and imaging review was performed to collect demographic, physical examination, and treatment data. Sensitivity, specificity, and negative and positive predictive values were calculated, and fast-and-frugal decision trees (FFTs) were generated using R. RESULTS: Of 142 eligible patients, 10 were diagnosed with CES. The sensitivity and specificity of the exam findings were highest for bulbocavernosus reflex (BCR) (100% and 100%), followed by rectal tone (80% and 86%), postvoid residual bladder (80% and 59%), and perianal sensation (60% and 68%). The positive predictive value was high for BCR (100%), but low for other findings (13% to 31%). However, negative predictive values were consistently high for all examinations (96% to 100%). Two FFTs utilizing combinations of voluntary rectal tone, perianal sensation, and BCR resulted in no false negatives. CONCLUSIONS: A combination of physical examination findings of lower sacral function is an effective means of ruling out CES and, with further study, may eliminate the need for MRI in many patients reporting back pain and bowel or bladder dysfunction.

Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review.

OBJECTIVES: To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma. DATA SOURCES: A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010. STUDY SELECTION: English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion. DATA EXTRACTION: Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I. DATA SYNTHESIS: The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible. CONCLUSIONS: Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.

Methamphetamines and Acetabular Reoperation Rates: Poor Outcomes From the Front Lines.

OBJECTIVES: To compare acetabular fracture reoperation rates within 1 year of surgery in methamphetamine ("meth") abusers and abstainers. DESIGN: Retrospective database analysis. SETTING: Level 1 academic trauma facility, 2008-2018. PATIENTS/PARTICIPANTS: Three hundred seventy-one patients who underwent unilateral traumatic acetabular open reduction internal fixation during the study period, 36 of whom abused methamphetamines through self-report or toxicology. One hundred four were excluded for indeterminate abuse histories. INTERVENTION: Open reduction internal fixation. MAIN OUTCOME MEASUREMENTS: Reoperation resulting from major surgical complications, including hematoma, seroma, deep wound infection, failure of fixation, or arthrosis with conversion to arthroplasty. RESULTS: More than 10% of our cohort used meth, representing patients who were a mean 8 years younger and sustained a higher rate of high-energy mechanisms than sober peers. Meth abusers had a greater than 2-fold reoperation rate at 90 days and 1 year compared with abstainers (17% vs. 7% and 25% vs. 11%, respectively). The adjusted odds ratio of 1-year reoperation in meth users was 3.2 (confidence interval 1.2-8.5, P = 0.03). The adjusted 1-year survival of native hip after acetabular fractures in meth users approaches 55%. CONCLUSIONS: Methamphetamine use is a nonmodifiable factor associated with a 3-fold increase in adjusted odds for 1-year reoperation after surgical fixation of acetabular fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Adolescents with spondylolysis have lower SRS-22 scores than controls and peers with pre-operative idiopathic scoliosis.

PURPOSE: The Scoliosis Research Society Outcomes Questionnaire (SRS-22) is a health-related quality-of-life (HRQL) tool for scoliosis patients. Since no equivalent questionnaire exists for spondylolysis patients, we characterized patient-reported scores in pediatric spondylolysis patients using the SRS-22, and compared these scores to previously published values for age-matched controls and patients with pre-operative adolescent idiopathic scoliosis (AIS). METHODS: A single-institution cross-sectional observational study was performed using SRS-22 data from spondylolysis patients aged 12-18 years. Mean SRS-22 domain scores were compared to the existing literature values for adolescent control and AIS cohorts via unpaired Student t tests (α = 0.05) and against minimal clinically important differences (MCIDs). RESULTS: Thirty-five patients met inclusion criteria. Mean (± SD) spondylolysis patients' scores met the MCID across all domains except Mental Health (α= 0.05). Spondylolysis patient scores for Pain, Function, and Self-Image were significantly lower (p < 0.01) than AIS patients (Pain; 2.99 ± 0.66 vs 4.14 ± 0.79; Function; 3.81 ± 0.61 vs 4.09 ± 0.54; Self-Image; 3.45 ± 0.70 vs 3.80 ± 0.68). CONCLUSION: The adolescent spondylolysis population has clinically significantly lower SRS-22 scores compared to age-matched controls and AIS patients, suggesting that the SRS-22 questionnaire should be given to this population to assess patients' HRQL. Further research is needed to assess the utility of the SRS-22 in measuring treatment effects. LEVEL OF EVIDENCE: III.

A Systematic Review of the Utility of Postoperative Imaging in the Management of Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Recently published studies call into question the clinical utility of postoperative radiographs in the management of pediatric supracondylar humerus (SCH) fractures. This topic has been addressed as part of the American Academy of Orthopaedic Surgeons Appropriate Use Criteria, although recommendations regarding serial radiographs were not included as part of the discussion. The purpose of this systematic review is to summarize the recent literature regarding the utility of postoperative radiographs as part of the management of SCH fractures. METHODS: A systematic review of the literature published between January 1, 2000 and December 31, 2017 was conducted using PubMed/MEDLINE and SCOPUS databases to identify studies relevant to postoperative management of SCH. Eight studies met the inclusion criteria, from which data pooled estimates and an analysis of heterogeneity were calculated. RESULTS: The pooled estimate of changes in fracture management on the basis of postoperative radiographs was 1% (0.98±0.33). Significant interstudy heterogeneity was observed with an I test statistic of 76%. Changes in fracture management included prolonged immobilization following pin removal and return to the operating room. CONCLUSIONS: There is a paucity of articles focusing on the utility or appropriate use of postoperative radiographs in changing management of SCH fractures, one of the most common upper extremity fractures in children. There is a very low rate of change in management on the basis of imaging, and frequently authors commented that the management change could have been prompted without routine serial radiographs. The cumulate findings of these studies suggest routine postoperative radiographs after SCH fractures are infrequently associated with changes in management. Practitioners should consider postoperative protocols with the intention of identifying early postoperative alignment loss or when the complication is suspected to prevent excessive routine radiography in the management of pediatric SCH fractures. LEVEL OF EVIDENCE: Level III-systematic review of level III studies.

Utility of Follow-up Radiographs After Pin Removal in Supracondylar Humerus Fractures: A Retrospective Cohort Study.

INTRODUCTION: Displaced supracondylar humerus fractures (SCFs) are common pediatric injuries, typically treated by closed reduction and percutaneous pinning (CRPP). Radiographs are obtained at pin removal and subsequently to evaluate fracture healing. We evaluated the utility of radiographs obtained after pin removal in pediatric SCF management. METHODS: A retrospective cohort study of children aged 2 to 11 years with SCF requiring CRPP at a single institution from January 2007 to July 2017 was conducted. Radiographs were taken at pin removal and minimum 3 weeks later. Demographic and treatment data were collected via chart review. Radiographic measures were Baumann and lateral humeral-capitellar angles, anterior humeral line alignment, and number of cortices with callus. The McNemar-Bowker test analyzed anterior humeral line alignment and cortices with callus. The paired t-test analyzed Baumann and lateral humeral-capitellar angles. RESULTS: One hundred patients were included (47 males and 53 females, mean 5.7 years). The mean time to pin removal was 23.8 days, and the median clinical and radiographic follow-up periods were 109.0 and 52.2 days, respectively. Fracture patterns were extension type II (21%), III (73%), IV (1%), flexion (4%), and varus (1%). No patients' fracture management changed in the acute or long-term postoperative period because of findings on post-pin removal (PPR) radiographs. Fewer cortices with callus were seen at pin removal versus PPR (<0.001). At pin removal, no differences were found in the Baumann angle (75.8 ± 5.0 versus 74.6 ± 5.9; P = 0.053), lateral humeral-capitellar angles (30.7 ± 12.5 versus 31.6 ± 1.3; P = 0.165), or anterior humeral line alignment (P = 0.261). DISCUSSION: No patients' fracture management was modified because of findings evident on PPR radiographs. The number of cortices with callus was the only radiographic measure to differ over time, as is anticipated with routine healing. Elbow radiographic alignment measures did not differ in the interval between radiographs. Therefore, PPR radiographs may not provide clinical utility in the absence of other clinical findings. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Life Expectancy and Metastatic Spine Scoring Systems: An Academic Institutional Experience.

STUDY DESIGN: A retrospective data collection study with application of metastatic spine scoring systems. OBJECTIVES: To apply the Tomita and revised Tokuhashi scoring systems to a surgical cohort at a single academic institution and analyze spine-related surgical morbidity and mortality rates. SUMMARY OF BACKGROUND DATA: Surgical management of metastatic spine patients requires tools that can accurately predict patient survival, as well as knowledge of morbidity and mortality rates. METHODS: An Oregon Health & Science University (OHSU) Spine Center surgical database was queried (years 2002-2010) to identify patients with an ICD-9 code indicative of metastatic spine disease. Patients whose only surgical treatment was vertebral augmentation were not included. Scatter plots of survival versus the Tomita and revised Tokuhashi metastatic spine scoring systems were statistically analyzed. Spine-related morbidity and mortality rates were calculated. RESULTS: Sixty-eight patients were identified: 45 patients' (30 male patients, mean age 45 y) medical records included operative, morbidity, and mortality statistic data and 38 (26 male patients, mean age 54 y) contained complete metastatic spine scoring system data. Of the 38 deceased spine metastatic patients, 8 had renal cell, 7 lung, 4 breast, 2 chondrosarcoma, 2 prostate, 11 other, and 4 unknown primary cancers. Linear regression analysis revealed R values of 0.2570 and 0.2009 for the revised Tokuhashi and Tomita scoring systems, respectively. Overall transfusion, infection, morbidity, and mortality rates were 33% and 9%, and 42% and 9%, respectively. CONCLUSIONS: Application of metastatic prognostic scoring systems to a retrospective surgical cohort revealed an overall poor correlation with the Tomita and revised Tokuhashi predictive survival models. Morbidity and mortality rates concur with those in the medical literature. This study underscores the difficulty in utilizing metastatic spine scoring systems to predict patient survival. We believe a scoring system based on cancer type is needed to account for changes in treatment paradigms with improved patient survival over time.

A scoring system to predict postoperative medical complications in high-risk patients undergoing elective thoracic and lumbar arthrodesis.

BACKGROUND CONTEXT: Various surgical factors affect the incidence of postoperative medical complications following elective spinal arthrodesis. Because of the inter-relatedness of these factors, it is difficult for clinicians to accurately risk-stratify individual patients. PURPOSE: Our goal was to develop a scoring system that predicts the rate of major medical complications in patients with significant preoperative medical comorbidities, as a function of the four perioperative parameters that are most closely associated with the invasiveness of the surgical intervention. STUDY DESIGN/SETTING: This study used level 2, Prognostic Retrospective Study. PATIENT SAMPLE: The patient sample consisted of 281 patients with American Society of Anesthesiologists (ASA) scores of 3-4 who underwent elective thoracic, lumbar, or thoracolumbar fusion surgeries from 2007 to 2011. OUTCOME MEASURES: Physiologic risk factors, number of levels fused, complications, operative time, intraoperative fluids, and estimate blood loss were the outcome measures of this study. METHODS: Risk factors were recorded, and patients who suffered major medical complications within the 30-day postoperative period were identified. We used chi-square tests to identify factors that affect the medical complication rate. These factors were ranked and scored by quartiles. The quartile scores were combined to form a single composite score. We determined the major medical complication rate for each composite score, and divided the cohort into quartiles again based on score. A Pearson linear regression analysis was used to compare the incidence of complications to the score. RESULTS: The number of fused levels, operative time, volume of intraoperative fluids, and estimated blood loss influenced the complication rate of patients with ASA scores of 3-4. The quartile ranking of each of the four predictive factors was added, and the sum became the composite score. This score predicted the complication rate in a linear fashion ranging from 7.6% for the lowest risk group to 34.7% for the highest group (r=0.998, p<.001). CONCLUSIONS: Taken together, the four factors, though not independent of one another, proved to be strongly predictive of the major medical complication rate. This score can be used to guide medical management of thoracic and lumbar spinal arthrodesis patients with preexisting medical comorbidities.

Association between advanced degenerative changes of the atlanto-dens joint and presence of dens fracture.

BACKGROUND: Dens fractures in elderly patients are often related to issues associated with aging. We examined the association between degenerative changes of the atlanto-dens joint and the risk of dens fracture. METHODS: We conducted a retrospective study of trauma patients, fifty-five years of age or older, who had undergone a computed tomography scan of the cervical spine as part of their admission to a single level-I trauma center. There were 1794 patients who met the inclusion criteria; scans were evaluated for all fifty-six who presented with a dens fracture and for a random sample of 736 without a dens fracture. Intraosseous cyst formation, synovitis, and joint space narrowing were recorded from the scans. The prevalence of degenerative changes was compared between patients with and patients without a dens fracture. RESULTS: An intraosseous cyst in the dens was found in 16.4% of the patients without a dens fracture and in 64.3% of those with a fracture (p < 0.001). The dens fracture extended through the existing cyst in twenty-four (66.7%) of thirty-six patients with a cyst and a dens fracture. Retro-dens synovitis was present in 4.2% of the patients without a dens fracture and 25.0% of those with a fracture (p < 0.001). After adjustment for age and sex, both cysts (odds ratio [OR] = 7.7, 95% confidence interval [CI] = 4.2 to 14.1) and synovitis (OR = 4.6, 95% CI = 2.1 to 10.0) were significantly associated with dens fracture. CONCLUSIONS: Intraosseous dens cysts and retro-dens synovitis were associated with dens fracture; those with a dens fracture were nearly eightfold more likely to have an intraosseous cyst and nearly fivefold more likely to have synovitis compared with those without a dens fracture. Because the atlanto-dens joint is a synovial joint, its degeneration can lead to subchondral cyst formation and synovitis and predispose affected individuals to fracture.

Postoperative prevertebral soft tissue swelling does not affect the development of chronic dysphagia following anterior cervical spine surgery.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To characterize the relation between postoperative soft tissue swelling and the development of chronic dysphagia after anterior cervical spine surgery. Chronic dysphagia was defined as dysphagia that persists more than 1 year. SUMMARY OF BACKGROUND DATA: Dysphagia is commonly reported in the early postoperative period after anterior cervical spine surgery. Although prevertebral soft tissue swelling (STS) has been hypothesized as a potential risk factor for development of dysphagia, no studies have assessed STS' relation to dysphagia that persists more than 1 year. METHODS: Sixty-seven patients who underwent elective anterior cervical spine surgery from 2008 to 2011 and completed a dysphagia questionnaire were included in the study. Prevertebral STS was measured at the caudal endplates of C2 and C6 on plain lateral cervical radiographs preoperatively, immediately after, and 6 and 12 weeks postoperatively. The presence and severity of chronic dysphagia was assessed using the Bazaz-Yoo Dysphagia Score. The prevalence of dysphagia in relation to STS was evaluated using the Wilcoxon rank-sum test. RESULTS: By 6 weeks after surgery, 89% of STS at C2 and 97% of STS at C6 had resolved, as compared with preoperative values. The overall dysphagia prevalence in our cohort was 73%, with 48% reporting no or mild symptoms. Moderate symptoms were present in 39% and severe symptoms were present in 13% of the patients. There was no relation between STS measured at all time points compared with the development of chronic dysphagia. Dysphagia did trend toward significance with higher cervical fusions (C4 and above) and as the number of levels fused increased, but STS did not seem to influence this. CONCLUSION: Postoperative STS is a self-limiting process. The magnitude of STS during the postoperative period does not seem to influence the development of chronic dysphagia.

Incidence of second cervical vertebral fractures far surpassed the rate predicted by the changing age distribution and growth among elderly persons in the United States (2005-2008).

STUDY DESIGN: Nationwide epidemiological cohort study. OBJECTIVE: To characterize the incidence of second cervical vertebral (C2) fractures by age and geographical region among the elderly Medicare population and to elucidate if the rate changed in the years 2005 to 2008. SUMMARY OF BACKGROUND DATA: Recent publications hypothesized that the rate of cervical vertebral fractures may be increasing. To date, there are no published nationwide reports describing the incidence and demographics of these injuries in the elderly US population. METHODS: Incidence of C2 fracture in the years 2005 to 2008 was determined by querying PearlDiver Technologies, Inc. (Warsaw, IN), a commercially available database, using International Classification of Diseases code 805.02. Rates were calculated using the PearlDiver reported person-counts as the numerator and the Center for Medicare and Medicare Services midyear population file as the denominator, and reported per 10,000 person-years (10,000 p-y). The age and geographical distributions of fractures were examined. Variability in rates was analyzed using the mean, standard deviation, 95% confidence intervals, χ tests, and Pearson correlation coefficients. RESULTS: Although the elderly population increased by 6% between 2005 and 2008, the annual incidence of C2 fracture rose by 21%, from 1.58 to 1.91 per 10,000 p-y, trending upward in a straight-line function (r = 0.999, P = 0.0006). The incidence of fracture varied between age groups; however, an increase was observed in all age groups. Persons aged 65 to 74 years (the youngest age group) experienced the lowest incidence (0.63 in 2005 to 0.71 in 2008), and the rate of increase was the smallest among the age groups examined (13%). Persons aged 85 and older demonstrated the highest incidence (4.36-5.67) and the greatest increase (30%). CONCLUSION: From 2005 to 2008, the overall incidence of C2 fracture rose at a rate that was 3.5 times faster than the elderly population growth.

Traditional threshold for retropharyngeal soft-tissue swelling is poorly sensitive for the detection of cervical spine injury on computed tomography in adult trauma patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To examine the diagnostic value of prevertebral soft-tissue swelling in the setting of cervical spine trauma. SUMMARY OF BACKGROUND DATA: In adult patients with trauma, an increase in the thickness of the retropharyngeal soft tissues is commonly used as a potential indicator of occult injury, but no studies have examined this parameter using computed tomography (CT) as a screening modality. METHODS: A total of 541 patients with trauma with injuries at any level of the spine underwent CT. Patients with cervical injury were divided into those requiring noninvasive (observation or cervical collar, n = 142) management, and those requiring invasive (surgery or halo, n = 61) treatment. A control group of patients with isolated thoracic or lumbar injuries was used for comparison (n = 542). Retropharyngeal soft tissues were measured at the cranial and caudal endplates of all cervical levels on sagittal and axial CT. Sensitivity and specificity were calculated for +1, +2, and +3 standard deviations from mean values. RESULTS: Sensitivity for detection of injury was found to be universally poor for all measurement groups. This ranged from 14.4% to 21.2% at +1 SD to 5.3% to 8.7% at +2 SD. Positive and negative predictive values for injury were also universally poor, ranging from 38% to 75%. Soft-tissue swelling as a sentinel sign of cervical spine injury demonstrates consistently high specificity and low sensitivity, precisely the opposite of what would be desired in a screening test. This study shows at best a sensitivity of 21.6% when using this parameter for the detection of these injuries in adult patients with trauma. CONCLUSION: On the basis of the results of this study, we recommend against the routine use of measurement of the prevertebral soft tissues on CT as a screening tool for cervical spine injury in adult patients with trauma. LEVEL OF EVIDENCE: 3.