Missed Cervical Spinal Cord Injuries

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Missed Cervical Spinal Cord Injuries

• Harris, John H. Jr., MD, DSc
• The Journal of Trauma
• Volume 53(2)
• August 2002
• pp 392-393

Intern ??? 91-10-19
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Analysis
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• by Dr. Poonnoose
• 569 patients
• accident and emergency departments in the United
  Kingdom
• from April 1989 to April 1998
• proven spinal cord injuries

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• the spinal cord injury was initially missed in
  52 (9.1) of 569 patients, of whom 34 (65) of 52
  were mismanaged and of whom 26 (50) of 52
  patients the management was declared negligent

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CLINICAL
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• Maintain a constantly active, extremely high
  degree of suspicion regarding the possibility of
  spinal cord injury in all blunt trauma patients.
• Protect the spine, particularly the cervical
  spine
• appropriate NE.

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• Rely on radiologic, orthopedic, and neurosurgical
  consultants
• a negative conventional radiographic
  examination in the presence of an abnormal
  clinical evaluation of the cervical spine
  requires either computed tomography (CT) or
  magnetic resonance imaging (MRI).

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RADIOLOGIC
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supine (trauma) oblique projections

• While supine (trauma) oblique projections remain
  useful, in the United States they have been
  largely replaced by CT, which provides a more
  complete and accurate assessment of the posterior
  vertebral elements.

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swimmers view

• The swimmers view, always inherently limited by
  superimposed ribs and clavicles, should be
  replaced by CT as the definitive imaging
  examination of the cervicothoracic junction

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malalignment

• The authors have very appropriately stressed the
  value of recognition of malalignment, not only of
  vertebral bodies, but malalignment of the
  articular masses

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Flexion-extension views

• Flexion-extension views should never be used to
  determine stability or instability of a cervical
  spine injury
• The only appropriate use for flexion-extension
  views is in assessing the patient suspected of
  anterior subluxation (hyperflexion sprain) of the
  cervical spine when the routine radiographic
  examination is equivocal

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• The degree of flexion-extension must be limited
  to the point of the patients pain tolerance
• The purpose of the flexion-extension lateral
  radiographs is to assess the integrity of the
  posterior ligament complex

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• While MRI provides direct visualization of the
  posterior ligament complex and is therefore the
  definitive imaging examination for anterior
  subluxation, its lack of availability and its
  cost preclude its use as the initial or screening
  study for anterior subluxation

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multiply injured patients

• the incidence of cervical spine injury is less
  than 6 in multiply injured patients
• in these patients in whom the cervical spinal
  cord cannot be adequately clinically assessed, an
  anteroposterior and lateral radiograph of the
  cervical spine, the latter of which must include
  from the cervicocranium through the
  cervicothoracic junction, should be part of the
  initial patient assessment

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• The necessity for cervical spine imaging at this
  stage of patient evaluation is to preclude
  causing or aggravating cervical cord injury
  caused by an unrecognized cervical spine injury
  during the secondary patient assessment.

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quality

• Cervical spine radiographs obtained for emergency
  center patients should not be of poor quality

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unconscious or multiply injured patients

• In unconscious or multiply injured patients, the
  primary attending physician must not accept a
  lateral radiograph in which the lower cervical
  vertebrae and the cervicothoracic junction are
  obliterated by the density of the shoulders

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• Such patients require immediate CT of the
  cervical spine. Justification of a missed
  mechanically or neurologically unstable cervical
  injury based on a poor radiographic examination
  is unacceptable