Clinical Presentation of Patients with Acute Cervical Spine Injury - - PDF document

SLIDE 1

ORIGINAL CONTRIBUTION cervical spine, fracture, occult; fracture, cervical spine,

• ccult; spine, cervical, fracture

Clinical Presentation of Patients with Acute Cervical Spine Injury

A retrospective review of 67 patients with acute cervical spine fracture and/

• r dislocation was conducted at two suburban community hospital emer-

gency departments. The mean age was 39, and two-thirds of the patients were male. Motor vehicle accidents and falls accounted for more than 80%

• f all injuries. On emergency department evaluation, it was found that there

was no history of loss of consciousness in 42 patients (63%), no associated crania-facial injuries in 31 patients (46%), and a normal sensorimotor exam- ination in 59 patients (88%). Thirty-four patients (50%) were evaluated for cervical range of motion, which was found to be normal in one-third of the

• cases. The absence of mental status changes, crania-facial injuries, range of

motion abnormalities, and focal neurological findings is, therefore, not un- common in patients who have sustained cervical spine injury. [Walter J, Doris PE, Shaffer MA: Clinical presentation of patients with acute cervical spine injury. Ann Emerg Med July 1984;13:512-515.] INTRODUCTION Published studies on cervical spine injury for the most part have cited data derived from experience in tertiary care centers. These studies have concen- trated on patients with injury to the cervical cord, detailing the types of associated cervical spine lesions, reviewing the mechanics of physical disrup- tion of the cervical spine, and describing the neurological sequelae seen with cervical trauma. Controversies in treatment have received extensive discus-

• sion. 1~4

Such data, however, may not be entirely applicable to emergency practice. In fact, the population bias of available studies may have led to significant distortions in our understanding of the clinical presentation of patients seen in primary care facilities with an acute cervical spine lesion. Our study is a retrospective analysis of a series of patients who were evalu- ated in the emergency departments of two suburban community hospitals and diagnosed as having sustained acute cervical spine fracture and/or dis-

• location. The patient population and etiology of injury are described. Special

attention is given to the clinical presentation of these patients.

James Walter, MD* Peter E Doris, MD*I¢** Mark A Shaffer, MD*§ Chicago From the Departments of Emergency Medicine* and Radiology, t University of Chicago Hospitals and Clinics, Chicago; the Department of Radiology, St James Hospital,¢ Chicago Heights; the Department of Radiology, Edward Hospital,** Naperville; and the Department

• f Emergency Medicine, Hinsdale

Hospital,§ Hinsdale, Illinois. Presented at the University Association for Emergency Medicine Annual Meeting in Salt Lake City, April 1982. Received for publication October 18,

• 1982. Revision received July 20, 1983.

Accepted for publication December 1, 1983. Address for reprints: James Walter, MD, Department of Emergency Medicine, University of Chicago Hospitals and Clinics, Box 488, 950 East 59th Street, Chicago, Illinois 60637.

MATERIALS AND METHODS The charts of 67 patients with a hospital discharge diagnosis of cervical spine fracture and/or dislocation were reviewed retrospectively. These pa- tients were evaluated and treated from 1977 through 1980 at two suburban community hospitals located approximately 30 miles from Chicago. The emergency departments of the two hospitals have a combined volume of 60,000 visits per year. The patients' emergency department and hospital charts were analyzed retrospectively for age, sex, and etiologic event. Presenting symptoms were determined by reviewing information offered spontaneously by the patient or elicited in questioning by the triage officer and the examining physician. The physician's initial examination was reviewed carefully, with particular atten- tion to data regarding mental status, neck tenderness, cervical range of mo- tion, neurological findings, and associated injuries. If necessary, additional information concerning physical findings was obtained from the triage of- ficer's notes and the consulting physician's summary. The results of all radio-

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ACUTE CERVICAL SPINE INJURY Walter, Doris & Shaffer

TABLE 1. Cervical spine injuries in the 12 patients with no documented complaints of neck pain

• r stiffness on presentation

Age (y)/ Sex (M/F) 45/M 63/M 43/M Mental Status Etiology Lesion Changes Associated Injuries MVA Fracture of odontoid Unknown/h/o Fracture body C2 seizures MVA Avulsion anterior/ inferior aspect C2 29/M MVA Avulsion anterior/ inferior aspect C2 59/M Fall Anterior compression fracture C7 61/F MVA Fracture spinous process 0 7 23/M MVA Anterior subluxation C5 on C6, fracture posterior elements C5 and C6, fracture lateral mass C7, anterior subluxation

C 7 on T1

32/F MVA Posterior subluxation C2 on C3 40/M MVA Anterior subluxation C5 on C6, fracture posterior element C6 21/M Pedestrian Avulsion fracture hit by motor anterior/inferior vehicle aspect C6 14/M MVA Posterior subluxation C2 on C3, compression fracture C6 36/M MVA Hangman's fracture, Fracture body C EtOH Did not recall EtOH EtOH, h/o loss of conciousness ? loss of consciousness h/o loss of consciousness, incoherent h/o loss of consciousness Rib fractures, fracture right femur, forehead laceration Multiple abrasions/ lacerations/ contusions Compression fractures T8 and Tlo Forehead laceration Wrist fracture, scalp laceration Right frontal hematoma Multiple lacerations/ contusions Left pulmonary contusion, multiple abrasions Pelvic fracture, fracture right clavicle Splenic rupture, renal injury, large scalp flap, Multiple abrasions Additional Comments Injury missed on initial presentation after MVA. Returned 3 weeks later with hemorrhagic gastritis. Began complaining of neck pain several days after admission. Pain elicited on palpation Pain elicited on palpation Pain elicited on palpation 4 h after presentation developed T1 sensory/motor level Full range of cervical motion. C-spine initially read as negative. Complained

• f neck stiffness the following day

when called back to ED Full range of cervical motion, neurological deficit right C5/C6 distribution Full range of cervical motion Pain elicited on palpation

graphic studies of the cervical spine were recorded and classified according to distribution and probable mecha- nism of injurg. RESULTS Of the 67 patients with acute cer- vical spine injury, 45 (67%) were male. The mean age was 39. Sixty percent of the injuries occurred in patients be- tween 21 and 50 years of age. Motor vehicle accidents were etio- logic in 45 patients (70%). Falls accounted for the injury in eight pa- tients (12%). Five patients (7%)suf- fered sports-related trauma, three div- ing into shallow water, one attempting a back flip, and one hitting his head

• n the backboard while playing bas-
• ketball. Three patients (4%) were pe-

destrians hit by a motor vehicle. In two inebriated patients, there was no

• bvious history or signs of trauma.

One patient with breast cancer meta- static to the cervical spine sustained a fall and presented with neck pain of four days duration. One patient was status post cervical laminect0my and fusion with a recent increase in neck pain. Analysis of the clinical presenta- tions of this series of patients revealed that 42 patients (63%) presented with-

• ut a history of loss of consciousness.

Four patients (6%) had an equivocal history with regard to loss of con-

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TABLE 2. Cervical spine injuries in the 1I patients with full range of cervical motion

Age (y)t Sex (M/F) Etiology 33/M Playing basketball, hit head on backboard 24/M MVA 18/M MVA 79/M MVA 49/F MVA 32/F MVA 40/M MVA 21/M Pedestrian hit by motor vehicle 41/F MVA 27/F MVA 21/M MVA Lesion Posterior subluxation C 1 on C 2, fracture body C 2 Anterior subluxation C 4 on C 5, fracture lamina C 4 Fracture spinous process C7 Anterior subluxation C 6 on C 7, fracture spinous process C 6 Posterior subluxation C 3 on C 4 Posterior subluxation C 2 on C 3 Anterior subluxation C 5 on C 6, fracture posterior element C 6 Avulsion fracture anterior/ inferior aspect C 6 Posterior subluxation C 3 on C 4 Fracture spinous process C 7 Anterior subluxation C 2 on C 3 *Patients with documented full range of cervical motion who also had no complaints of neck pain or stiffness on presentation.

• sciousness. Twenty-one patients (31%)

had a documented episode of loss of consciousness. In 12 patients (18%) there was no documented complaint of neck pain

• r stiffness during the initial evalua-

tion in the emergency department. However, four of these patients had al- tered mental status secondary to alco- hol or trauma. The majority of the 12 patients had multiple injuries or at least multiple lacerations/contusions. Moreover, in four of these 12 patients some neck tenderness was discovered

• n careful palpation of the cervical

spine (Table 1). Thirty-one patients (46%) presented without evidence of cranio-facial trau-

• ma. In 59 patients (88%) a normal

neurological examination (excluding mental status changes) was docu- mented by the emergency physician. Thirty-four patients (50%) were evalu- ated prior to radiographic examination for cervical range of motion, which was found to be normal in one-third of the cases (Table 2). In seven patients (10%) the diag- nosis of cervical spine injury was not made on initial presentation to the emergency department because the ra- diographic examinations were inade- quate or misinterpreted. The injuries missed in these seven patients were as follows: 1) two simple odontoid frac- tures; 2) odontoid fracture with asso- ciated Jefferson fracture; 3) C2/C3 subluxation; 4) C2 pedicle fracture with C2/C3 subluxation; 5) subluxa- tion injury of C3/C4 and C4/C5 with an associated fracture of the posterior element of C4 and a compression frac- ture of the body of C5; and 6) C6/C7 unilateral facet dislocation. Radiographic examination of the cervical spine revealed bony injury alone in 31 patients (46%), a purely ligamentous injury in 16 patients (24%), and a combined injury in 20 pa- tients (30%). There were 62 fractures,

• f which 45% involved the vertebral

bodies; 40%, the posterior elements; and 15%, the odontoid process. Of the total fractures, C2 injuries accounted for 26% and C5, C6, and C7 injuries for 56%. Subluxation injuries were rather evenly distributed, with C4/C5 affected most frequently, Analysis of the radiographs, using the classification for mechanism of injury as proposed by Harris and Har- ris, 5 revealed the presumed force of injury to be flexion in 36 patients (54%), extension in 22 patients (33%), vertical compression in seven patients (10%), and flexion/rotation and lateral flexion in one patient each. DISCUSSION We have presented a retrospective review of 67 patients with acute cer- vical spine fracture and/or dislocation evaluated initially in the emergency departments of two suburban commu- nity hospitals. In terms of patient pop- ulation and etiology of injury, our se- ries is similar to others reported in the literature.6-8 The etiology of the injuries in our series, most occurring secondary to motor vehicle accidents and fails, is also similar to that attributed in prior studies,9, lo although an occasional se- ries shows a higher frequency of ath- letic or missile-induced trauma.~ Analysis of the location and types of lesions found on cervical radiographs resulted in figures comparable to those noted in other studies.2,g,9,nA 2 While the population, method of in- jury, and types of lesions in this series are similar to what has been reported previously, the clinical presentation of the patients is substantially different. The traumatic event was associated in fewer than 40% of patients with docu- mented or suspected loss of con-

• sciousness. We also found that ahnost

half the patients had no documented evidence of associated cranio-facial in- jury, Eighty-eight percent of the patients had normal motor, sensory, and reflex findings, demonstrating that abnormal neurological signs may not be com- monly encountered in patients with acute cervical injury seen in a primary care facilitg A much higher incidence

• f neurological deficits has been cited

previously, with 47% to 65% of pa- tients in other series showing physical signs of cord or nerve root dam- age.2,7,io,13,14 In a recent study 1 of 300 patients with acute fractures and dis- locations of the cervical spine, 180 had some form of motor paralysis. We be- lieve that this incidence of neu- rological damage may be secondary to the bias inherent in referral center populations, and is not representative

• f the general population suffering cer-

vical spine injury, The emergency phy- sician typically will see a much less dramatic presentation than that pre- dicted by much of the literature. The frequent discrepancy between clinical presentation and severity of

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ACUTE CERVICAL SPINE INJURY Walter, Doris & Shaffer the underlying lesion is highlighted by the fact that cervical range of motion was mistakenly assessed to be normal in one-third of the patients tested. The presence of these signs and symptoms has been suggested as a basis for the decision to radiograph pa- tients with suspected cervical spine injury, is The absence of these signs and symptoms may have an even more important implication for emer- gency medicine practice.8,16 As we have seen, patients with serious injury to the cervical spine commonly will present with no history of mental sta- tus changes, without evidence of cranio-facial injury, and with a normal neurological examination. Some pa- tients will not offer any spontaneous complaints of neck pain or stiffness. The presentation may not include any abnormalities on range of motion test-

• ing. Clearly a high index of suspicion

must be maintained regarding the pos- sibility of cervical spine trauma in pa- tients known to be at risk. Seven patients in our group (10%) had cervical spine fracture and/or dis- location that was missed on initial presentation because of inadequate or misinterpreted radiographs. This high frequency emphasizes the need for careful study of cervical spine films and for obtaining radiological con- sultation if any suspicion exists.7, 8 That 18% of these patients had no complaints of neck pain or stiffness documented during initial questioning is a surprising finding, whether re- flecting the patients' actual clinical presentation or current emergency de- partment recordkeeping practices. Our retrospective study did not benefit from a checklist history or physical examination form, and the lack of such complaints may mean that they were not elicited or perhaps were elic- ited and not recorded. However, specif- ic physical complaints were carefully documented in eight of these 12 pa-

• tients. Neck pain was at least not a

spontaneous complaint in these pa-

• tients. Our data suggest that the

painless cervical fractures alluded to in the literaturei, lh is may exist, es- pecially in inebriated or confused pa- tients, those with multiple organ sys- tem injury, or those with multiple lacerations/contusions. Whether the concept of the painless or occult cer- vical spine injury is an important clinical entity awaits a carefully mon- itored prospective study.

SUMMARY

After retrospectively analyzing 67 patients with cervical spine injury, we have detected a substantial difference between the experience reported from tertiary care centers and that seen in suburban community practice. The majority of cervical spine injuries in

• ur series did not present with a histo-

ry of loss of consciousness or with neurological deficits. Many had no ev- idence of cranio-facial trauma. Some

• f the patients exhibited full range of

cervical motion when this was mis- takenly assessed. The inebriated, the confused, and the multiply injured pa- tients were especially likely to have clinically inapparent cervical spine le-

• sions. Cervical spine injury com-

monly will have a more subtle presen- tation than heretofore realized.

REFERENCES

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• 3. Holdsworth F: Fractures, dislocations

and fracture-dislocations of the spine. J Bone Joint Surg 1970;52A:1534-1551.

• 4. Martin SH: Injury of the head and cer-

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• 5. Harris JH, Harris WH: The Radiology
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liams and Wilkins, 1981, p 114.

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the cross table lateral view in detecting cervical spine injuries: A retrospective

• analysis. Ann Emerg Med 1981;10:508-

513.

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JACEP 1979;8:504-507.

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Essentiality of the lateral cervical spine

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198-204.

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853.

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spine injuries. J Trauma 1968;8:597-604.

• ll. Whitley JE, Forsyth HF: The classifi-

cation of cervical spine injuries. Am J Roentgenol 1960;83:633-644.

• 12. Miller MD, Gehweiler JA, Martinez S:

Significant new observations on cervical spine trauma. Am J Roentgenol 1978; 130:659-663.

• 13. Norton WL: Fractures and disloca-

tions of the cervical spine. J Bone Joint Surg 1962;44A:115-139.

• 14. Rogers WA: Fractures and dislocations
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1957;39A:341-376.

• 15. Wales LR, Knopp RK, Morishima MS:

Recommendations and evaluation of the acutely injured cervical spine: A clinical radiologic algorithm. Ann Ernerg Med 1980;9:422-428.

• 16. Bucholz RW, Burkhead WZ, Graham

W, et al: Occult cervical spine injuries in fatal traffic accidents. J Trauma 1979; 19:768-771.

• 17. Maull KI, Sachatello CR: Avoiding a

pitfall in resuscitation: The painless cer- vical fracture. South Med J 1977;70: 477-478.

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spine fracture in an ambulatory patient. Ann Emerg Med 1982;11:440-442.

ACEP Funding for Emergency Medicine Fellowships

Beginning July 1, 1985, the American College of Emergency Physicians will award funds for fellowship stipends to support research related to emergency medicine. Four fellowship stipends of $25,000 each ~ be awarded to nonprofit institutions that possess the basic facilities for research. Institutions interested in applying should request application forms by writing to the Research Committee, ACEP, PO Box 619911, Dallas, Texas 75261-9911. The deadline for submitting applications is November 1, 1984. Notification of awards Hill be made by February 1, 1985.

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