ABSTRACT
This research work was aimed at assessing the challenges that are associated with spinal trauma cases in radiography using UNTH, NOHE and ESUTH as case study.
It is a non experimental, questionnaire based research. A total of 48 questionnaires were filled and returned and the respondents were radiographers including interns and youth corpers.
This result of the research showed various challenges that radiographers encounter while examining patients with spinal trauma. Some of the challenges include lifting and transferring of patients to couch, non cooperation of patients among others.
The research also showed some of the methods that radiographers employ to overcome these challenges.
 
LIST OF TABLES
Table: 1 Age and Sex distribution of practicing radiographers
Table:2 Educational level of the radiographers
Table: 3 Spinal trauma patients come on trolley
Table: 4 Spinal trauma patients aided by nurses/ward attendant into the department
Table: 5 Spinal trauma patients cooperate with instructions
Table: 6 Response on equipment consistency
Table: 7 Response on processor consistency
Table: 8 The most challenging region in x-ray imaging of spinal trauma patients
Table: 9 The most challenging category in x-ray imaging of spinal trauma patients
Table: 10 Attitude of radiographers towards spinal trauma patients

TABLE OF CONTENTS
Title page     
Acknowledgement    
Abstract  
List of tables 
Table of contents  
CHAPTER ONE
1.0    Introduction
1.1Background of study 
1.2 Statement of problems 
1.3 Objectives of the study
1.4 Significance of the study
1.5 Scope of the study  
1.6 Review of the related literature 
CHAPTER TWO
2.0    Theoritical background
2.1Role of radiography in trauma care   
2.2 Equipment used in trauma radiography 
2.2.1 Dedicated equipment 
2.2.2 Features of trauma equipment
2.4 Anatomy of the spine
2.4.1 The vertebrae
2.4.2 Spinal cord 
CHAPTER THREE
3.0    Research methodology 
3.1Design of study
3.2 Population of study 
3.3 Instrument used for data collection 
3.4 Procedure for the data collection  
3.5 Method of data analysis 
CHAPTER FOUR
4.0    Data presentation, Discussion and Summary
4.1Data presentation 
4.2 Discussion of data 
4.3 Summary of findings

CHAPTER FIVE
5.0    Recommendations, Areas for further study, Limitations and Conclusion 
5.1Recommendations from the study 
5.2 Areas for further study
5.3 Limitations of study 
5.4 Conclusion 
REFERENCES
APPENDIX                           

CHAPTER ONE
INTRODUCTION
1.1    BACKGROUND OF STUDY
The practice of radiography entails sound scientific knowledge and technical skills founded upon theoretical concepts, utilizing of equipment and accessories consistent with the purpose for which they have been designed, employing procedures and techniques appropriately, with effective patient interaction to provide quality care and useful diagnostic information.
    One of the ethical requirements of radiographers is to provide quality patient care and services unrestricted by the concern of personal attributes or nature of disease.1 This, he achieves most times through the adequate co-operation of the patient. However, at some other times, patient co-operation becomes difficult and compromised as observed with most fractured patients, accident and emergency cases, unconscious patients and generally in trauma cases. It is still expected of radiographers to produce images of reasonable diagnostic quality in the above cases. This, most times, poses serious challenges to radiographers during radiological procedures especially the young radiographers and student radiographers who are less versed in clinical practice.
 Spinal cord trauma can be caused by any number of injuries to the spine. They can result from motor vehicle accidents, falls, sports injuries (particularly diving into shallow water), industrial accidents, gunshot wounds, assault, and other causes2.
For all health care professionals, mental preparation and communication are key factors when dealing with trauma situations. Usually trauma patients and the health care team are anxious and don't know what to expect. Effective communication by radiographers is essential so the imaging process is effective and as stress-free as possible. Any problem with communication, major or minor, will affect the outcome of the case. Many aspects of dealing with a trauma situation are taught in the radiography curriculum: anatomy, image production, positioning and patient care. However, effective communication in stressful trauma situations is seldom taught. Unfortunately, it is usually learned by hard experience. It is expected that images be produced without causing further harm to patient3.
Besides mental preparation and effective communication, there are also necessary modifications we adopt when confronted with cases of trauma. These range from equipment selection and orientation, factor selection, patient positioning and the use of positioning accessories/aids. Also of utmost importance is the maintenance of a sterile environment as trauma can be exposed and thus, have increased chance of contamination. However, the positioning principles for trauma cases are similar to those applied for routine general radiography. The primary difference can be summarized with the word adaptation. Each trauma case and situation is unique and the radiographer must evaluate the patient and adapt4. The challenges associated with imaging in spinal trauma cases by radiographers have not been assessed in the institutions under study and this has prompted me to embark on this research.




1.2    STATEMENT OF PROBLEMS
Injury to the spinal cord is a serious and life-threatening one. Paralysis and loss of sensation of part of the body are common. This includes total paralysis or numbness and varying degrees of movement or sensation loss. Death is possible, particularly if there is paralysis of the breathing muscles.2
In addition to the above, the researcher, during his clinical posting observed increased repeat examinations with spinal trauma cases.
1.3    OBJECTIVES OF THE STUDY
    To assess the difficulties frequently encountered by radiographers during examination of spinal trauma cases.
    To assess the attitude of radiographers towards spinal trauma patients.
    To assess how the radiographers cope with spinal trauma cases despite challenges.  
1.4    SIGNIFICANCE OF THE STUDY
    With the knowledge of the common challenges associated with examination of spinal trauma patients and some idea of how to cope, radiographers will be better guided in their handling of such cases.
    The research will reveal how radiographers cope with the challenges and avoid much repeat. This would ensure reduced dose to patients and staff, wastage of resources and further injury to patients.
1.5        SCOPE OF THE STUDY
The study will be restricted to radiographers at UNTH, ESUTH and NOHE.

1.6            REVIEW OF RELATED LITERATURE
Radiography is an essential tool in the diagnosis and management of spinal trauma cases. However, this could be very challenging to the radiographer, the radiologist as well as other health care professionals.
Miller et al in their work CT in the evaluation of spine trauma wrote that One of the most challenging and vexing problems in emergency medicine is cervical spine trauma. Not only do patients with such trauma often have multisystem injuries-in which abdominal and thoracic injuries may have the highest treatment priority-but they also may have an altered mental status from associated head injury or concomitant use of alcohol or drugs. Interpreting preliminary radiographs is often difficult because of the complex anatomy of the area and the technically suboptimal studies that sometimes result from portable technique, poor patient cooperation and reluctance to move a patient for proper positioning.5
    Shaffer et al opined that although the traditional radiographic examination for suspected cervical spine trauma has been a cross-table lateral view, some injuries like Jefferson and odontoid fractures, as well as rotary injuries of C1-2, may not be apparent on the cross-table lateral view, and injuries involving C-7 may be difficult to interpret because of overlapping soft tissues and bony structures of the shoulder. Occasionally, even mid cervical injuries may be missed on a single cross-table lateral view because of the subtlety of the injury or poor technical quality of the initial radiographs.They conclude that a standard anteroposterior and open-mouth or modified odontoid view should be done routinely before mobilizing a patient's head or neck in all cases of suspected cervical spine injury and likewise, vertebral arch views (pillar views) should be done if there is evidence of a hyperextension injury.6
    Bohlman wrote that the diagnosis of an unstable spinal injury and its subsequent management can be difficult, and a missed spine injury can have devastating long-term consequences, therefore, spinal column injury must therefore be presumed until it is excluded.7
Some studies of spinal trauma have recorded a missed injury rate as high as 33%. Delayed or missed diagnosis is usually attributed to failure to suspect an injury to the cervical spine, or to inadequate cervical spine radiology and incorrect interpretation of radiographs.8
Writing on the immobilization and patient handling during the management of the multiply injured patient, Callenoff et al asserted that the ideal position is with the whole spine immobilised in a neutral position on a firm surface. This may be achieved manually or with a combination of semi-rigid cervical collar, side head supports and strapping. Strapping should be applied to the shoulders and pelvis as well as the head to prevent the neck becoming the centre of rotation of the body.9
Children have a disproportionately larger head size than adults, and when supine on a firm surface will be in a position of slight flexion. This slight degree of flexion is rarely a problem, though it can give rise to difficulties in X-ray interpretation. This can be corrected by placing a folded towel or sheet under the patient's shoulders to bring the cervical spine into the neutral position.10
Mortality as a result of cervical spine injuries is predominantly associated with respiratory complications. Besides atelectasis, pneumonia, or respiratory failure, possible complications also include damage to anatomical structures of the respiratory tract. A case report of a 44-year-old man who suffered a cervical spine injury with associated tracheal laceration after a fall from a height of about 2 meters was presented by Sobietal etal. The vertebrae C3, C4, C5 were damaged with anterior dislocation at the C3/C4 level. Because of the development of respiratory failure, the patient was intubated and mechanical ventilation was commenced. In view of a complete and irreversible spinal cord injury, the patient was not qualified for an emergency stabilization of the vertebral fractures. Surgery was further delayed because of increasing signs of a respiratory infection. On the 12th intensive care unit day, a perforation of the anterior tracheal wall was identified during an elective tracheotomy. Due to the presence of pus at the tracheostomy site and air leakage around the tracheostomy tube cuff, the patient was intubated with a double-lumen endotracheal tube. On the 23rd intensive care unit day, acute problems with mechanical ventilation developed due to persisting air leakage around the tube cuff accompanied by signs suggestive of a tracheo-oesophageal fistula. Replacement of the double-lumen tube with a single-lumen one and a bronchoscopy was followed by cardiac arrest. Resuscitation led to the return of circulation over four hours, followed by death of the patient in the setting of increasing shock.11
The following situations place special demands on radiologic technologists when they perform a complete radiography study for patients with cervical spine trauma:
Unconscious or uncooperative patients.These patients may not be able to communicate about their pain or remain still for various positions.
Intubated patients.The odontoid projection may be compromised in these patients.
Cervical collar problems.Not all collars are radiolucent.
Congenital changes.Congenital deformities of the spine are caused by anomalous vertebral development in the embryo. These changes in the spine
shape and size may make it difficult to accurately assess vertebral damage. The 3 major patterns of congenital spinal deformity are hyperlordosis (exaggerated lumbar curve), kyphosis (a progressive spinal disorder that may cause a deformity
described as humpback or hunchback) and scoliosis(abnormal curvature of the spine).
Adequate evaluation of the C7-T1 junction.The C7-T1 junction is a unique area that deserves much attention. It is a common site of developmental anomalies; it is a major site of arterial, lymphatic and neurologic traffic; and it is the juncture of the highly mobile cervical spine and the very limited thoracic spine. The features of the  C7-T1 junction highlight the area’s importance and contribute to the difficulty of adequately visualizing this region. Radiographs of this region are technically difficult to obtain.
Swimmer’s lateral projection.If a patient’s arms are in traction, a swimmer’s lateral may have limited value.
Flexion-extension radiographs. A recent study noted that up to one third of all flexion/extension studies are inadequate due to limited range of motion.12
Krell opined that it is necessary to employ the appropriate lifting technique while handling a wheel chair patient and patient in stretcher. This is to avoid inflicting more pains to such categories of patient He emphasized that radiographers should be involved in lifting patient to the couch or x-ray table and care should be taken while lifting them.13
    The care of patients with multiple injuries is challenging but early optimal management is essential after trauma, since many life-threatening situations can occur. Any delay in diagnosis and treatment will continue to long term complications such as sepsis and organ failure and will increase late mortality.14
     Trunkey also supported the above view of prompt care of traumatized patients in his work “ The Principles of the Management of Multiple Trauma ”. He noted that early and simultaneous assessment and resuscitation followed by a complete physical examination and diagnostic studies to establish the priorities for life saving surgery are the fundamental principles of the management of multiple trauma.15
     Writing on the challenges facing geriatric trauma care, Isaac et al wrote that management and care of the injured geriatric victims is challenging. National vital statistics reports of America show that geriatric trauma victims, 75-85 years old and older, have the highest death rates7. Studies have shown that compared to younger trauma victims, geriatric trauma victims not only have greater morbidity and mortality, but also have longer hospital stays and consume more hospital resources at the same injury severity scores.16,17
Bachulis B. et al wrote on the need of immobilization of patients after trauma in their book entitled “ Clinical Indications for Cervical Spine Radiography in Traumatized Patient”  noted that immobilization of an injury victim’s cervical spine following trauma is now standard care in the vast majority of Emergency Medical Services (EMS) systems. Immobilization of the cervical spine is maintained until spinal cord or spinal cord injury is ruled out by clinical assessment and/or radiographic survey.18
     On the various complications which can pose challenges to radiographers during care of trauma patients, Kushner wrote that for patients with physical trauma to the brain, there could be effects on consciousness which could be stupor, coma, minimally conscious state, locked-in syndrome which is a condition in which a patient is aware and awake, but cannot move or communicate due to complete paralysis of the body. Voluntary control of eye movements or blinking may be spared, permitting the detection of conscious awareness and enabling the establishment of functional communication. Brain death which is the irreversible loss of measurable brain function, with loss of any integrated activity among distinct areas of the brain can also ensue depending on severity.19
On cognitive deficits, most patients with severe traumatic brain injury who recover consciousness suffer from cognitive disabilities, including the loss of many higher-level mental skills. Cognitive deficits that can follow this injury include impaired attention; disrupted insight, judgement, and thought; reduced processing speed; distractibility; and deficits in executive functions such as abstract reasoning, planning, problem-solving, and multitasking. Memory loss, the most common cognitive impairment among head-injured people, occurs in 20–79% of people with closed head trauma, depending on severity. Post-traumatic amnesia (PTA), a confusional state with impaired memory is characterized by loss of specific memories or the partial inability to form or store new ones.20
     Patients with moderate to severe traumatic brain injury have more problems with cognitive deficits than do those with mild traumatic brain injury, but several mild traumatic brain injuries may have an additive effect. About one in five career boxers is affected by chronic traumatic brain injury, which causes cognitive, behavioral, and physical impairments.20
     On communication problems, some patients with traumatic brain injury may experience aphasia, difficulty with understanding and producing spoken and written language. Problems with spoken language may occur if the part of the brain that controls speech muscles is damaged. In this disorder, called dysarthria, the patient can think of the appropriate language, but cannot easily speak the words because they are unable to use the muscles needed to form the words and produce the sounds. Speech is often slow, slurred, and garbled.21
     On sensory deficits, traumatic brain injured patients may have sensory problems, especially problems with vision; they may not be able to register what they are seeing or may be slow to recognize objects. Also, often they have difficulty with hand-eye coordination, causing them to seem clumsy or unsteady. Other sensory deficits include problems with hearing, smell, taste, or touch.22
     On emotional and behavioral problems, traumatic brain injury may cause emotional or behavioral problems and changes in personality. Emotional symptoms that can follow it include emotional instability, depression, anxiety, hypomania, mania, apathy, irritability, and anger. About one quarter of people with such trauma suffer from clinical depression, and about 9% suffer mania. The prevalence of all psychiatric illnesses is 49% in moderate to severe traumatic brain injury and 34% in mild traumatic brain injury within a year of injury, compared with 18% of controls23. People with such trauma continue to be at greater risk for psychiatric problems than others even years after an injury.23
     Behavioral symptoms that can follow traumatic brain injury include inability to control anger, impulsiveness, lack of initiative, inappropriate and changes in personality. Different behavioral problems are characteristic of the location of injury; for instance, frontal lobe injuries often result in  inappropriate or childish behavior, and temporal lobe injuries often cause irritability and aggression.23
     Physical complications of traumatic brain injury include pain, especially headache, also being unconscious and lying still for long periods can cause blood clots to form deep venous thrombosis which can cause pulmonary embolism.24
     Writing on the equipment appropriate for imaging of trauma patients, Knoff, a CT technologist, Department of  Radiology, Body CT, Johns Hopkins Hospital Baltimore, Maryland was of the view that multi-detector computed tomography (MDCT) is useful in the evaluation of  many anatomical parts and has become the gold standard for diagnostic imaging of trauma patients. Many of the reasons are related to the core strength of MDCT: speed, specificity and accuracy.25
     Also in support of the above, Mayberry writes that in the field of emergency radiology, the most dramatic cases involve trauma patients, who have suffered severe and sometimes life threatening injuries and require immediate treatment to prevent substantial complications. When it comes to evaluating trauma patients, MDCT is a useful imaging tool for fast assessment of critical injuries. MDCT allows physicians to make faster and more accurate diagnosis of injuries sustained by the trauma patient, thus reducing the time spent treating distracting, non life threatening injuries and minimizing any delays in treating life threatening injuries. This saves money by providing more efficient care to the critically injured.26