LITIGATION OF MISSED CERVICAL SPINE INJURIES IN PATIENTS PRESENTING WITH BLUNT TRAUMATIC INJURY

Abstract BACKGROUND Approximately 800,000 cervical spines are cleared in emergency departments each year. Errors in diagnosis of cervical spine injury are a potentially huge medicolegal liability, but no established protocol for clearance of the cervical spine is known to reduce errors or delays in diagnosis. METHODS The Lexis-Nexis, Westlaw, and Medline databases were queried for cases of missed cervical injury. Errors were categorized according to a novel system of classification. Type I errors occurred when inadequate or improper tests were ordered. Type II errors occurred when adequate tests were ordered, but were either misread or not read. Type III errors occurred when adequate tests were ordered and read accurately, but the ordered test was not sensitive enough to detect the injury. RESULTS Twenty cases of missed or delayed diagnosis of cervical spine injury were found in 10 jurisdictions. Awards averaged $2.9 million (inflation adjusted to 2002 dollars). Eight cases resulted in verdicts in favor of the defendant, but none of these cases involved an alleged Type II error. CONCLUSION Fear of lawsuits encourages defensive medicine and complicates the process of clearing a patient's cervical spine. This analysis adds medicolegal support for the judicious use of imaging studies in current cervical spine clearance protocols. However, exposure to significant liability suggests that a low threshold for computed tomography is a reasonable alternative.

Download Full-text

Cervical Spine Clearance: A Review and Understanding of the Concepts

Journal of Nepal Medical Association ◽

10.31729/jnma.169 ◽

2008 ◽

Vol 47 (172) ◽

Author(s):

Amit Agrawal

Keyword(s):

Cervical Spine ◽

Cervical Spine Injury ◽

Pediatric Trauma ◽

Spine Injury ◽

Team Approach ◽

Optimal Management ◽

Imaging Studies ◽

Cervical Injury ◽

Cervical Spine Injuries ◽

Spine Injuries

Cervical spine injury is relatively rare, occurring in only 2% to 3% of patients with blunt traumawho undergo imaging studies. However, timely and accurate recognition of cervical spine injuryis essential for the optimal management of patients with blunt trauma as subsequent morbidity includesprolonged immobilization. Evaluation of cervical spine injuries should begin in the emergencydepartment and involves a combination of pediatric, trauma, orthopedic, and neurosurgeons fordeﬁnitive management. Knowing which patients are at highest risk for injuries will undoubtedlyinﬂuence decisions on how aggressively to pursue a potential cervical spine injury and can be achievedby establishing a multidisciplinary team approach that provides cervical spine immobilization,assessment, and clearance. Implementation of such guidelines will decrease time for cervical spineclearance and incidence of missed injuries. In this article different aspects of cervical spine injuriesand cervical spine clearance protocols are reviewed.Key words: cervical, injury, trauma, spine, vertebrae

Download Full-text

Can emergency physicians accurately rule out clinically important cervical spine injuries by using computed tomography?

CJEM ◽

10.2310/8000.2013.130978 ◽

2014 ◽

Vol 16 (02) ◽

pp. 131-135 ◽

Cited By ~ 3

Author(s):

Hendrik P. Van Zyl ◽

James Bilbey ◽

Alan Vukusic ◽

Todd Ring ◽

Jennifer Oakes ◽

...

Keyword(s):

Cervical Spine ◽

Cervical Spine Injury ◽

Clinical Skills ◽

Ct Scans ◽

Spine Injury ◽

Emergency Physicians ◽

Cervical Spine Injuries ◽

Spine Ct ◽

Spine Injuries ◽

Rule Out

ABSTRACT Objective: Emergency physicians are expected to rule out clinically important cervical spine injuries using clinical skills and imaging. Our objective was to determine whether emergency physicians could accurately rule out clinically important cervical spine injuries using computed tomographic (CT) imaging of the cervical spine. Method: Fifteen emergency physicians were enrolled to interpret a sample of 50 cervical spine CT scans in a nonclinical setting. The sample contained a 30% incidence of cervical spine injury. After a 2-hour review session, the participants interpreted the CT scans and categorized them into either a suspected cervical spine injury or no cervical spine injury. Participants were asked to specify the location and type of injury. The gold standard interpretation was the combined opinion of two staff radiologists. Results: Emergency physicians correctly identified 182 of the 210 abnormal cases with cervical spine injury. The sensitivity of emergency physicians was 87% (95% confidence interval [CI] 82–91), and the specificity was 76% (95% CI 74–77). The negative likelihood ratio was 0.18 (95% CI 0.12–0.25). Conclusion: Experienced emergency physicians successfully identified a large proportion of cervical spine injuries on CT; however, they were not sufficiently sensitive to accurately exclude clinically important injuries. Emergency physicians should rely on a radiologist review of cervical spine CT scans prior to discontinuing cervical spine precautions.

Download Full-text

An unusual presentation and resolution of syringomyelia after cervical spine injury

Journal of Neurosurgery Spine ◽

10.3171/spi.2005.3.6.0482 ◽

2005 ◽

Vol 3 (6) ◽

pp. 482-484 ◽

Cited By ~ 1

Author(s):

Joseph Cusick ◽

Zvi Lidar

Keyword(s):

Cervical Spine ◽

Cervical Spine Injury ◽

Spine Injury ◽

Type I ◽

Cervical Spine Trauma ◽

Spine Trauma ◽

Resonance Imaging ◽

Chiari Malformation Type I ◽

Content Type ◽

Sequence Of Events

✓ The authors describe a case of noncommunicating syringomyelia associated with Chiari malformation Type I in a patient in whom acute symptomatic exacerbation occurred following cervical spine trauma. Surgical stabilization and realignment of the spine resulted in marked resolution of the neurological abnormalities, and subsequent magnetic resonance imaging demonstrated persistent collapse of the syrinx. The authors review the various factors in the pathogenesis of this unusual sequence of events.

Download Full-text

Neck Injury

Pediatrics in Review ◽

10.1542/pir.16.1.28 ◽

1995 ◽

Vol 16 (1) ◽

pp. 28-28

Author(s):

Jeffrey R. Avner

Keyword(s):

At Risk ◽

Cervical Spine ◽

Cervical Spine Injury ◽

Pediatric Patients ◽

Neck Injury ◽

Spine Injury ◽

Clinical Markers ◽

Cervical Spine Injuries ◽

Spine Injuries ◽

Spine Radiographs

Although rare in pediatrics, cervical spine injuries still are associated with serious morbidity, disability, and mortality. Many of these injuries are exacerbated by inadequate neck immobilization or improper manipulation. Thus, the physician should be aware of which children are at risk for cervical spine injury and how to assess these patients properly. To find clinical markers that identify children who actually have cervical spine injuries, Rachesky et al reviewed 2133 cervical spine radiographs obtained in pediatric patients during a 7-year period. Of these children, 25 (1.2%) had abnormalities confirmed on radiographs. The incidence of injury increased with age; only four of the children who had cervical spine injuries were less than 8 years old.

Download Full-text

LO027: Cervical spine injury in trauma patients 65 years and older immobilised in the prehospital setting

CJEM ◽

10.1017/cem.2016.64 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S39-S39

Author(s):

L. Lamy ◽

J. Chauny ◽

D. Ross

Keyword(s):

Cervical Spine ◽

Cervical Spine Injury ◽

Fracture Dislocation ◽

Spine Injury ◽

Trauma Patients ◽

Minor Trauma ◽

Cervical Injury ◽

Geriatric Population ◽

Spinal Immobilisation ◽

A Minor

Introduction: Following a protocol derived from the Canadian C-spine Rule (CCR), patients 65 years and older transported by ambulance after trauma require full spinal immobilisation. Immobilisation complicates the transport and the evaluation; potential side effects have been recognized. The aim of this study was to evaluate the effect of mechanism of trauma and age on the rate of cervical injury in a geriatric population. Methods: We conducted a retrospective observational study on patients 65 years and older transported by ambulance to a level-one trauma center from March 2008 to October 2013. The outcome was the rate of clinically important cervical spine injury (CICSI), defined as any fracture, dislocation or ligamentous injury needing treatment or specialised follow up. The rate was calculated in the geriatric population and in the subgroup of patients with minor trauma, defined as a fall from a standing height, a chair or a bed. We then looked at the rate of CICSI based on age to define a subgroup at lower risk of lesion. Results: We included 1221 patients with a mean age of 80 y.o. (SD = 8), 739 women (61%). CICSI was found in 53 patients (4.3%, 95% CI 3.2-5.4). This is similar to the rate found in patients 65 years and older in the NEXUS population (4.6%) and the CCR population (6.0%). The mechanism of injury was a minor trauma for 716 patients (59%). Of those, 24 patients (3.4%, 95% CI 2.1-4.7) had CICSI. The rate increased after 85 y.o in both the overall population (3.4% vs 6.4%) and the minor trauma subgroup (2.6% vs 4.4%). Conclusion: The subgroup of patients 65-84 y.o. with a minor trauma had the lower rate of cervical spine injury (2.6%). In a lot of prehospital systems, those patients are not systematically immobilised for transport. It will be interesting to review the files of all patients with CICSI to identify any possible case that would have been missed without the age criteria.

Download Full-text

Cervical spine injuries in pediatric athletes: mechanisms and management

Neurosurgical FOCUS ◽

10.3171/foc.2006.21.4.7 ◽

2006 ◽

Vol 21 (4) ◽

pp. 1-5 ◽

Cited By ~ 21

Author(s):

Jay Jagannathan ◽

Aaron S. Dumont ◽

Daniel M. Prevedello ◽

Christopher I. Shaffrey ◽

John A. Jane

Keyword(s):

Cervical Spine ◽

Cervical Spine Injury ◽

Pediatric Patients ◽

Head Injuries ◽

Axial Loading ◽

Cervical Region ◽

Spine Injury ◽

Severe Injuries ◽

Cervical Spine Injuries ◽

Cord Injury

✓Sports-related injuries to the spine, although relatively rare compared with head injuries, contribute to significant morbidity and mortality in children. The reported incidence of traumatic cervical spine injury in pediatric athletes varies, and most studies are limited because of the low prevalence of injury. The anatomical and biomechanical differences between the immature spine of pediatric patients and the mature spine of adults that make pediatric patients more susceptible to injury include a greater mobility of the spine due to ligamentous laxity, shallow angulations of facet joints, immature development of neck musculature, and incomplete ossification of the vertebrae. As a result of these differences, 60 to 80% of all pediatric vertebral injuries occur in the cervical region. Understanding pediatric injury biomechanics in the cervical spine is important to the neurosurgeon, because coaches, parents, and athletes who place themselves in positions known to be associated with spinal cord injury (SCI) run a higher risk of such injury and paralysis. The mechanisms of SCI can be broadly subclassified into five types: axial loading, dislocation, lateral bending, rotation, and hyperflexion/hyperextension, although severe injuries often result from a combination of more than one of these subtypes. The aim of this review was to detail the characteristics and management of pediatric cervical spine injury.

Download Full-text

Subaxial cervical spine injury classification system: is it most appropriate for classifying cervical injury?

Neural Regeneration Research ◽

10.4103/1673-5374.165508 ◽

2015 ◽

Vol 10 (9) ◽

pp. 1416 ◽

Cited By ~ 4

Author(s):

Rafael Martínez-Pérez ◽

Francisco Fuentes ◽

VíctorS Alemany

Keyword(s):

Cervical Spine ◽

Classification System ◽

Cervical Spine Injury ◽

Spine Injury ◽

Cervical Injury ◽

Subaxial Cervical Spine ◽

Injury Classification

Download Full-text

Detection of Cervical Spine Injuries in Alert, Asymptomatic Geriatric Blunt Trauma Patients: Who Benefits from Radiologic Imaging?

The American Surgeon ◽

10.1177/000313480607200903 ◽

2006 ◽

Vol 72 (9) ◽

pp. 773-777 ◽

Cited By ~ 1

Author(s):

Adrian W. Ong ◽

Aurelio Rodriguez ◽

Robert Kelly ◽

Vicente Cortes ◽

Jack Protetch ◽

...

Keyword(s):

Computed Tomography ◽

Cervical Spine ◽

Blunt Trauma ◽

Cervical Spine Injury ◽

Motor Vehicle ◽

Spine Injury ◽

Trauma Patients ◽

Cervical Spine Injuries ◽

Spine Injuries ◽

Anatomic Locations

There are differing recommendations in the literature regarding cervical spine imaging in alert, asymptomatic geriatric patients. Previous studies also have not used computed tomography routinely. Given that cervical radiographs may miss up to 60 per cent of fractures, the incidence of cervical spine injuries in this population and its implications for clinical management are unclear. We conducted a retrospective study of blunt trauma patients 65 years and older who were alert, asymptomatic, hemodynamically stable, and had normal neurologic examinations. For inclusion, patients were required to have undergone computed tomography and plain radiographs. The presence and anatomic location of potentially distracting injuries or pain were recorded. Two hundred seventy-four patients were included, with a mean age of 76 ± 10 years. The main mechanisms of injury were falls (51%) and motor vehicle crashes (41%). Nine of 274 (3%) patients had cervical spine injuries. The presence of potentially distracting injuries above the clavicles was associated with cervical injury when compared with patients with distracting injuries in other anatomic locations or no distracting injuries (8/115 vs 1/159, P = 0.03). There was no association of cervical spine injury with age greater or less than 75 years or with mechanism of injury. The overall incidence of cervical spine injury in the alert, asymptomatic geriatric population is low. The risk is increased with a potentially distracting injury above the clavicles. Patients with distracting injuries in other anatomic locations or no distracting injuries may not need routine cervical imaging.

Download Full-text

Detected and overlooked cervical spine injury in comatose victims of trauma: report from the Pennsylvania Trauma Outcomes Study

Journal of Neurosurgery Spine ◽

10.3171/spi.2006.5.3.210 ◽

2006 ◽

Vol 5 (3) ◽

pp. 210-216 ◽

Cited By ~ 17

Author(s):

Joseph H. Piatt

Keyword(s):

Logistic Regression ◽

Cervical Spine ◽

Decision Tree ◽

Cervical Spine Injury ◽

Spine Injury ◽

Cervical Injury ◽

Trauma Outcomes ◽

Severe Tbi ◽

Outcomes Study ◽

Gcs Score

Object This study was undertaken to determine whether a clinically useful rule could be formulated for identifying the presence of traumatic brain injury (TBI) in patients who are at exceptionally low risk of cervical spine injury. Methods The Pennsylvania Trauma Outcomes Study database was searched for cases of TBI in which the admission Glasgow Coma Scale (GCS) score was less than or equal to 8. Cases of cervical injury were identified based on diagnostic codes. Associations between cervical injury and various clinical variables were tested using chi-square analysis. The probability of cervical injury was modeled using logistic regression. Decision tree models were constructed. Statistical determinants of overlooked cervical injury were examined. The prevalence of cervical injury among 41,142 cases of TBI was 8%. Mechanism of injury, thoracolumbosacral (TLS) fracture, age, limb fracture, admission GCS score, hypotension, and facial fracture were associated with cervical injury and were incorporated into the following logistic regression model: probability = 1 / (1 + exp[4.248 − 0.417 × mechanism −0.264 ×age −0.678 ×TLS −0.299 ×limb −0.218 ×GCS −0.231 ×hypotension −0.157 ×facial]). The results of applying this model provided a rule for cervical spine clearance applicable to 28% of the cases with a negative predictive value (NPV) of 97.0%. Decision tree analysis yielded a rule applicable to 24% of the cases with an NPV of 98.2%. The prevalence of overlooked cervical injury in all individuals with severe TBI was 0.3%; the prevalence of overlooked cervical injury in patients with cervical injury was 3.9%. Overlooked cervical injury was less common in patients with associated TLS fractures (odds ratio 0.453, 95% confidence interval 0.245–0.837). Conclusions This analysis identified no acceptable rule to justify relaxing vigilance in the search for cervical injury in patients with severe TBI. Provider vigilance and consequent rates of overlooked cervical injury can be affected by environmental cues and presumably by other behavioral and organizational factors.

Download Full-text