Letters to the Editor  |   August 2008
Author Affiliations
  • Barry J. Sheridan, DO
    Department of Emergency Medicine Carl R. Darnall Army Medical Center Fort Hood, Tex
    Brooke Army Medical Center Fort Sam Houston, Tex
Article Information
Emergency Medicine / Imaging / Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment
Letters to the Editor   |   August 2008
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 471-472. doi:
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 471-472. doi:
We thank Dr Fletcher for his letter in response to our article in JAOA—The Journal of the American Osteopathic Association1 regarding the use of osteopathic manipulative treatment (OMT) in the emergency department (ED) setting. 
We hope the JAOA`s readers were not left with the misimpression that OMT is broadly applicable in the ED setting—particularly with respect to patients who were in motor vehicle accidents (MVAs), as was Dr Fletcher's concern. 
We used an extensive list of exclusion criteria in our study.1 For trauma patients (including patients in MVAs), we excluded those with individuals who had substantial trauma, distracting injuries, neurologic deficits, alcohol intoxication, or other factors that precluded a reliable physical examination. Average “fender-bender” MVAs were not considered “substantial trauma” in our study.2 Cervical radiographs were obtained if there was a history of trauma and the patient could not be cleared clinically. 
Although not specifically stated in the discussion of methods used in our study,1 we used the criteria of the National Emergency X-Radiography Utilization Study (NEXUS)3,4 to clinically clear the cervical spine. These criteria are: absence of tenderness at the posterior midline of the cervical spine; absence of a focal neurologic deficit; a normal level of alertness; no evidence of intoxication; and absence of a distracting injury.3,4 
In NEXUS,3,4 34,000 blunt trauma patients were evaluated by cervical spine imagining in 21 EDs nationwide. Of these patients, 818 (2.4%) had cervical spine injuries. The study's criteria were 99.0% sensitive for identifying all cervical spine injuries and 99.6% sensitive for identifying clinically significant cervical spine injuries.4 
It is with such low-risk patients that we believe OMT can be provided safely without the need of cervical computed tomography (CT). We do not consider our study results to be “broadly applicable,” but rather applicable to only a carefully selected population of patients in the ED. 
We acknowledge that plain film radiography does not allow visualization of every cervical spine injury sustained as a result of blunt trauma. The risk of neurologic disability and potential litigation from missing an occult unstable cervical spine fracture exists—regardless of whether OMT, medication, or no treatment is provided to the patient. A prospective observational study by Mower et al5 found that occult unstable injuries (ie, injuries that were not identified on plain radiographs) were missed infrequently with the use of plain film radiography. These missed injuries represented only 0.4% of all injuries and occurred in only 0.015% of all blunt trauma presentations (ie, fewer than 1 in every 6500 screening evaluations) in that study.5 
Patients in EDs who are at high risk (eg, with altered mental status, multi-system injuries, neurologic deficits, or intoxication) should be evaluated by CT. Computed tomography should also be used if a patient's plain film radiographs are deemed to be inadequate, suspicious, or definitely abnormal—or if clinical suspicion of injury continues despite a normal radiograph result. 
In cases where ligamentous injuries are suspected, we agree with Dr Fletcher that the use of magnetic resonance imaging (MRI) and/or flexion-extension films should be considered. Unfortunately, routinely obtaining an MRI in the ED is not currently feasible at most institutions. As MRI becomes faster and more readily available, however, its use may become commonplace in the ED setting. 
Because of high direct medical costs and potential risks to patients of radiation-induced malignant thyroid cancer, a CT scan should be used only when it can be fully justified after appropriate clinical stratification with decision rules. The thyroid gland is exposed to approximately 14 times more radiation during cervical CT scanning (26 mGy) than during plain film radiography (1.8 mGy).6 
It is important to keep in mind, however, that decision rules are only guidelines, not absolute requirements. If necessary, physicians—drawing on their own clinical acumen and experience—should make exceptions to such guidelines for individual patients. No decision-making tool should replace the clinical judgment of a physician in the care of individual patients. 
We are unaware of any studies suggesting—as Dr Fletcher implies—that physicians who practice in ED teaching hospitals have higher levels of awareness of legal consequences than do physicians who practice in other ED settings. All physicians should realize that safety is of paramount importance for all patients—regardless of the clinical setting in which that care is provided. 
We believe that the use of OMT in the ED provides physicians with another powerful therapeutic tool that can and should be used in the correct clinical setting. Patients in EDs with acute neck pain should be given (or not given) OMT based on clinical criteria and evidence-based medicine—not on physicians' fears of litigation. 
McReynolds TM, Sheridan BJ. Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: a randomized clinical trial. J Am Osteopath Assoc. 2005;105:57-68. Available at: Accessed July 31, 2008.
Shekelle PG, Coulter I. Cervical spine manipulation: summary report of a systematic of the literature and a multidisciplinary expert panel. J Spinal Disord. 1997;10:223-228.
Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998;32:461-469.
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group [published correction appears in N Engl J Med. 2001;344:464]. N Engl J Med. 2000;343:94-99. Available at: Accessed July 31, 2008.
Mower WR, Oh JY, Zucker MI, Hoffman JR; for the NEXUS Group. Occult and secondary injuries missed by plain radiography of the cervical spine in blunt trauma patients. Emerg Radiol. 2001;8:200-206.
Rybicki F, Nawfel RD, Judy PF, Ledbetter S, Dyson RL, Halt PS, et al. Skin and thyroid dosimetry in cervical spine screening: two methods for evaluation and a comparison between a helical CT and radiographic trauma series. AJR Am J Roentgenol. 2002;179:933-937. Available at: Accessed July 31, 2008. ♦