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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. An appropriate
procedure for the evaluation of the potentially
unstable spine must be robust and easy to implement,
with a high sensitivity, given the potential importance
of such injuries. It must also address the main
issues raised by the modalities available for
diagnosis.
For spinal trauma, the main concerns are which
patients can be cleared by clinical exam alone,
how many plain X-rays are necessary and when should
additional imaging using Computed Tomography (CT)
or Magnetic Resonance Imaging (MRI) be used. An
assessment for ligamentous injury in the absence
of a fracture is also important, especially in
unconscious patients who are unable to complain
of neck pain or tenderness.
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While it is tempting to focus on the cervical spine,
it is important to assess and clear the entire spinal
column. The thoracolumbar spine, while more protected,
is at risk in major trauma and must be assessed both
clinically and radiologically. Additionally, 5% of spinal
injuries have a second, possibly non-adjacent, fracture
elsewhere in the spine.
These pages discuss the initial assessment and management
of the potentially spine injured patient. The actual
protocol implemented at any given institution will depend
on the expertise and facilities available. Where the
required expertise or imaging are not available in a
given institution, the protocol should encompass criteria
for expeditious transfer of patients to specialist care.
References
Incidence of Cervical Spine Injury
Bohlman HH. Acute Fractures and Dislocations of
the Cervical Spine J Bone Joint Surg 1979; 61A:
p. 1119-1140
Roberge RJ, Samuels JR. Cervical spine injury in
low-impact blunt trauma. Am J Emerg Med. 17:125-9,
1999
Ryan MD, Henderson JJ. The epidemiology of fractures
and fracture-dislocations of the cervical spine.
Injury 23(1): 38-40, 1992
Associated Injuries
Bayless P, Ray VG: Incidence of cervical spine injuries
in association with blunt head trauma. Am J Emerg
Med 7:139-42, 1989
Hills MW, Deane SA: Head injury and facial injury:
Is there an increased risk of cervical spine injury?
J Trauma 34:549-54, 1993
Iida H, Tachibana S, Kitahara T, Horiike S, et al.
Association of head trauma with cervical spine injury,
spinal cord injury, or both. J Trauma 46(3): 450-452,
1999
Neifeld GL, Keene JG, Hevesy G, et al: Cervical
injury in head trauma. J Emerg Med 6:203-7, 1988
Reiss SJ, Raque GH Jr, Shields CB, et al: Cervical
spine fractures with major associated trauma. Neurosurgery
18:327-30, 1986
Williams J, Jehle D, Cottington E, et al: Head,
facial, and clavicular trauma as a predictor of cervical-spine
injury. Ann Emerg Med 21:719-22, 1992
Multiple Level Injuries
Calenoff L, Chessare JW, Rogers LF, Toerge J, Rosen
JS. Multiple Level Spinal Injuries: Importance of
Early Recognition. Am J Roentgenology 1978; 130:
p. 665-669
Gleizes V, Jacquot FP, Signoret F and Feron JM Combined
injuries in the upper cervical spine: clinical and epidemiological
data over a 14-year period Eur Spine J 9(5): 386-392,
2000
Kewalramani LS, Taylor RG. Multiple Non-contiguous
Injuries to the Spine. Acta Orthop Scand 1976; 47:
p. 52-58
Powell JN, Waddell JP, Tucker WS, Transfeldt EE. Multiple-level
Non-contiguous Spinal Fractures. J of Trauma 1989;
29: p. 1146-1151
Penetrating trauma
Apfelbaum JD, Cantrill SV and Waldman N. Unstable
cervical spine without spinal cord injury in penetrating
neck trauma. Am J Emerg Med 18(1): 55-57.
Chong CL, Ware DN and Harris JH, Jr. Is cervical
spine imaging indicated in gunshot wounds to the cranium?
J Trauma 44(3): 501-502, 1998
Kaups KL, Davis JW. Patients with gunshot wounds
to the head do not require cervical spine immobilisation
and evaluation. J Trauma 44:865-7, 1998
Kennedy FR, Gonzalez P, Beitler A, Sterling-Scott
R, et al. Incidence of cervical spine injury in patients
with gunshot wounds to the head. South Med J 87(6):
621-623, 1994
Missed Injuries
Davis JW, Phreaner DL, Hoyt DB, et al: The etiology
of missed cervical spine injuries. J Trauma 34:342-6,
1993
Gerrelts BD, Petersen EU, Mabry J, et al: Delayed
diagnosis of cervical spine injuries. J Trauma 31:1622-6,
1991
Mace SE: Unstable occult cervical-spine fracture.
Ann Emerg Med 20:1373-5, 1991
Reid DC, Henderson R, Saboe L, et al: Etiology
and clinical course of missed spine fractures. J
Trauma 27:980-6, 1987
Sweeney JF, Rosemurgy AS, Gill S, et al: Is the
cervical spine clear? Undetected cervical fractures
diagnosed only at autopsy. Ann Emerg Med 21:1288-90,
1992
Protocols
Ajani AE, Cooper DJ, Scheinkestel CD et al. Optimal
assessment of cervical spine trauma in critically ill
patients: a prospective evaluation. Anaesth Intensive
Care 26:487-91, 1998
Banit DM, Grau G and Fisher JR. Evaluation of the
acute cervical spine: a management algorithm. J
Trauma 49(3): 450-456, 2000
Brohi K, Wilson-Macdonald J. Evaluation of unstable
cervical spine injury: a 6-year experience. J Trauma
49(1): 76-80, 2000
Cohn SM, Lyle WG, Linden CH, et al: Exclusion of
cervical spine injury: A prospective study. J Trauma
31:570-4, 1991
Gabram SGA, Schwartz RJ, Jacobs LM: The impact
of a cervical spine radiographic protocol on cost and
prophylactic spinal immobilization. Ann Emerg Med
18:453, 1989
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