Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: Incidence, evaluation, and outcome

Background: The potential for ligamentous injury of the cervical spine (C-s pine) may mandate prolonged neck immobilization via a hard cervical collar in the blunt trauma victim (BTV) with altered sensorium. We investigated th e incidence of ligamentous C-spine injuries, and whether applying (post hoc ) the practice management guidelines from the Eastern Association for the S urgery of Trauma (three radiograph views plus computed tomographic scan of C1-C2) would have detected the injuries. Methods: The study was a 3-year retrospective review of BTVs admitted to th e state's Primary Adult Resource Center for trauma from 1996 to 1998, Unrel iable patients were defined as those with admission Glasgow Coma Scale scor e < 15, A rigorous algorithm to clear the C-spine was used. Pure ligamentou s C-spine injury was defined as a C-spine having abnormal anatomic alignmen t, dislocation, subluxation, or listhesis, but without fracture, Demographi cs, diagnostic studies, presence of neurologic deficit, therapy, survival, and disposition were analyzed. Results: There were 14,577 BTVs with 614 (4.2%) patients having C-spine inj ury, There were 2,605 (18%) unreliable patients, with 143 (5.5%) of these h aving C-spine injury, 129 (90%) having fracture and 14 (10% of BTVs; 0.5% o f unreliable patients) having no fracture. Of the 14 unreliable patients wi th pure ligamentous C-spine injury, 13 had initial diagnosis by supine cros s-table lateral radiograph, The one exception had a normal three-view radio graphic series, but atlanto occipital dislocation was diagnosed by computed tomographic scan. Eight patients had upper level injury (C0-C4) and six we re lower (C4-C7), Four patients died,within 30 minutes after admission, 4 u nderwent cervical fusion, and 6 were treated with collar only. Five (50%) o f the survivors had no apparent neurologic deficit attributed to the C-spin e at admission. Nine patients remained institutionalized after discharge an d one was discharged home. Conclusion: Ligamentous injuries without fracture of the C-spine are rare, Application of the practice management guidelines developed by the Eastern Association for the Surgery of Trauma for identifying C-spine instability i s effective and should facilitate early removal of the cervical collar in u nreliable patients.