Nonskeletal cervical spine injuries: Epidemiology and diagnostic pitfalls

Background: Cervical spine injuries are the most commonly missed severe inj uries with serious implications for the patient and physician. The diagnosi s of subluxations or spinal cord injuries in the absence of vertebral fract ures, especially in unevaluable patients, poses a major challenge. The obje ctive of this study was to study the incidence and type of cervical spine t rauma according to mechanism of injury; identify problems and pitfalls in t he diagnosis of nonskeletal cervical spine injuries. Methods: Retrospective study of all C-spine injuries caused by traffic acci dents or falls admitted over a 5-year period at a large Level I trauma cent er, Data were obtained from the trauma registry, review of patient charts, and radiology reports. Results: During the study period, there mere 14,755 admissions due to traff ic injuries or falls who met trauma center criteria. There were 292 patient s with C-spine injuries, for an overall incidence of 2.0% (3.4% in car occu pants, 2.8% for pedestrians, 1.9% for motorcycle riders, and 0.9% for falls ), The incidence of C-spine injuries in patients with a Glasgow Coma Scale score of 13 to 15 was 1.4%, 9 to 12 was 6.8%, and in less than or equal to 8 was 10.2% (p < 0.05). Of C-spine injuries, 85.6% (250 patients) were a ve rtebral fracture, 10.6% of the injuries (31 patients) were subluxation with out fractures, and 3.8% (11 patients) were an isolated spinal cord injury w ithout fracture or subluxation. Of the 31 patients with isolated subluxatio ns, one-third required an early endotracheal intubation before clinical eva luation of the spine, because of associated severe head injury or hypotensi on. Adequate lateral C-spine films diagnosed or suspected 30 of the 31 subl uxations (96.8%). The combination of plain films and computed tomographic ( CT) scan diagnosed or suspected all injuries. Of the 11 patients with isola ted cord injury, 27.3% required early intubation before clinical evaluation of the spine, The diagnosis of ford injury was made on admission in only f ive patients (45.5%). In three patients, the neurologic examination on admi ssion was normal and neurologic deficits appeared a few hours later. In the remaining three patients (two intubated, one intoxicated), the diagnosis w as missed clinically and radiologically, Conclusions: isolated nonskeletal C-spine injuries are rare but potentially catastrophic because of the high incidence of neurologic deficits and miss ed diagnosis. In subluxations, the combination of an adequate lateral film and CT scan was reliable in diagnosing or highly suspecting the injury. A l arge prospective study is needed to confirm these findings, before a recomm endation is made to remove the cervical collar if the findings of these inv estigations are normal. However, in isolated cord injuries, the diagnosis w as often missed because of associated severe head trauma and the low sensit ivity of the plain films and CT scans.