a 48 y.o. male loses control of his bicycle and skids off a slick road into a ditch. He has an obvious partial avulsion of the R ear.
because of ED overcrowding he waits hours and is never placed in a room. The triage MD orders a head and Cspine CT and a plastics consult. Plastics repairs his ear. While waiting for his ride he has an episode of syncope and is placed in a room. The head CT done previously is shown below.
do you agree with the radiologists read?
The pt actually had a subdural along the falx
There was an overread the next day on the head CT confirming the posterior subdural along the L falx. The pt was admitted to ICU. In addition, although the CT had been read as normal the pt continued to have severe neck pain and MRI confirmed all the interspinous ligaments on the L side from C2-C5 were torn. He was admitted to neurosurgery for both injuries and was instructed to were a cervical collar for although the anterior and posterior spinous ligaments were intact, he was unstable in lateral movement of the neck.
On T2 MRI the injury appears white over tthe posterior cervical spines
Cervical spine injuries occur in 3% of major trauma patients. Morbidity and mortality from cervical injuries are high. The litigation pay out for missed cervical spine injury on average in the US is $2.9 million. If the injury is missed on the initial presentation, the pt is ten times more likely to have neurologic sequelae.
an 84 y.o. fell out of his wheelchair and had neck pain with a negative CT of the C spine
He returned with persistent pain and an odontoid fracture was seen on MRI requiring treatment.
In a prospective study of 767 patients who had MRI because of persistent neck pain after a negative neck CT, the MRI was abnormal in 23.6% of patients with injuries ranging from ligamentous injuries(16%), soft tissue swelling 4%, Disc injury 1.4%, and dural hematomas in 1.3%. 11 patients underwent cervical spine surgery after the MRI results and five of those had no neurologic findings. Another prospective study of 10,765 patients found 2% of patients with neg CT and persistent neck pain had significant neck injuries requiring intervention. The teaching point is that a neg neck CT is not able to completely rule out significant neck injury.
Most of the patients with missed injuries on CT had degenerative spine disease: our patient had a large posterior osteophyte which pushed the clinicians to order an MRI. He was discharged with a collar and neurosurgical follow up.
Maung A, Johnson D, Barre K, et al. Cervical spine MRI in patients with negative CT: A prospective, multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). 2017 J Trauma Acute Care Surg. Feb 82(2):263-269.
Inaba K, Byerly S, Buysh L, et al. Cervical spinal clearance: A prospective Western Trauma Association Multi-Institutional Trial. 2016 J Trauma Acute Care Surg, Dec:81(6):1122-1130.
Resnick S, et al. Clinical relevance of Magnetic resonance imaging in cervical spine clearance. 2014 JAMA Surgery , vol 149 (9) jan: p 934, doiP10.1001/jamasurg.2014.867.
Diaz J, et al. The early work-up for isolated ligamentous injury of the cervical spine: does CT-scan have a role?2004 The Journal of Trauma: Injury, Infection and Critical Care, vol 57(2):453.