[Delayed diagnosis of inferior cervical spine injury]

Abstract

Purpose of the study: According to data in the literature, traumatic injury of the inferior cervical spine is not recognized in 4.5 to 33% of victims. The purpose of our study was to evaluate the rate of delayed diagnosis, search for causes, and propose a diagnostic approach.

Material and methods: This prospective study included 284 patients recruited by eleven referral centers between November 1999 and March 2001. Each participating center completed a data chart and classified lesions. Exclusion criteria were whiplash without neurological disorder and without imaging anomaly, spinal ankylosis, and trauma more than three weeks before the first examination.

Results: Among the 284 patients included, 240 had a unique lesion of the inferior cervical spine, 44 had multiple injuries. In all, 338 spinal lesions were recorded. There were 35 patients with multiple trauma injuries and 95 patients with spinal cord injuries. Time to diagnosis was less than 24 hours for 211 patients (74%), one day to one week for 38 patients (14%), and more than one week for 35 patients (12%). Defective management was noted in 13% of the cases. Late diagnosis was considered to have had a prejudicial effect in nine patients (3%). There was no correlation between time to diagnosis and type of lesion, level of lesion, or presence of multiple injuries.

Discussion: Late diagnosis of inferior cervical spine injury can be an inevitable result of the context. This is particularly true for patients with multiple injuries or patients with purely discal or ligament injuries whose first manifestations occur late after the trauma. Beyond these specific situations, there is no logical explanation for late diagnosis other than insufficient diagnostic management. Spinal injury should always be suspected in trauma victims and the initial neurological status must be noted. If the subject is conscious, plain x-rays should be obtained in the event of pain in the cervical spine. A computed tomography is the exploration of choice. Dynamic views should be performed in all cases to search for pure ligament injury. The correct time for such explorations can only be determined on an individual basis. If the patient is unconscious, standard procedure includes x-ray of the cervical spine, and computed tomography of the skull-spine junction and the cervico-thoracic spine. Widespread systematic use of spiral and multiple array computed tomography should limit the number of late diagnoses.

Conclusion: Late diagnosis of inferior cervical spine injury is probably not uncommon. Improved management can be achieved through better medical awareness, better knowledge of cervical spine injuries, and routine imaging in application of the rule of prudence.