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SECTION I SYMPOSIUM: Treatment of Neglected Trauma

Neglected Spinal Injuries

Sengupta, Dilip K MD, DR. MED

Editor(s): Jain, Anil K MS(ORTHO), MAMS, GUEST EDITOR

Author Information
Clinical Orthopaedics and Related Research: February 2005 - Volume 431 - Issue - p 93-103
doi: 10.1097/01.blo.0000151878.67386.a1
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Abstract

Neglected spinal injuries are defined as injuries not treated in a timely fashion and found late when options are limited. Overlooked diagnosis is the most common cause of late presentation. These overlooked injuries commonly are associated with polytrauma or altered level of consciousness. Overlooked diagnosis is largely preventable by adhering to appropriate protocols for clearing the spine in a trauma patient. Obvious spinal injuries with late presentation after inadequate or no treatment are more frequently seen in the developing world. These are rarely reported in the indexed literature. Although potentially preventable, the underlying causes are more complex and involve medical and socioeconomic problems.

The present article reviews the current literature to identify the incidence, causes, and consequences of neglected spinal injuries, the principles of treatment and the recommendations for prevention.

Overlooked Diagnosis of the Cervical Spine

Overlooked spinal injuries are far more common in the cervical spine compared with the thoracolumbar spine and sacrum. The overall incidence of overlooked spinal column injuries with or without neurologic deficit varies between 4 and 30%.6,16,43,45 In a multicenter retrospective study of patients with trauma (n = 32,117) who were admitted to the emergency department of a hospital Davis et al13 reported 34 (4.6%) of 740 cervical spine injuries overlooked at initial evaluation. In a prospective study of 274 patients with spine injuries, Reid et al43 reported 38 (14%) spinal injuries misdiagnosed at initial assessment: 22.9% of the cervical injuries and 4.9% of the thoracolumbar injuries had a delayed proper diagnosis ranging from 1 to 36 days.

The single most common error made in not diagnosing these injuries is the failure to obtain an adequate series of cervical-spine radiographs.13,43 The initial diagnosis of cervical spine injury relies on proper patient selection on a clinical basis, obtaining appropriate radiographs, and properly interpreting them. Injuries to the cervical spine occur in approximately 3% of patients with major trauma and in 10% of patients with serious head injuries.10

Certain fractures are known to commonly escape detection on plain radiographs. Clark et al9 reported delayed radiologic diagnosis in 23% of odontoid, 16% of teardrop, 14% of facet, and 10% of hangman’s fractures. In a multicenter study, the Spinal Surgery Study Group of the Italian Society of Neurosurgery reviewed 172 patients with cervical spine injury who had surgical stabilization more than 20 days after the initial trauma. In 53 patients (30.8%), the surgical stabilization was delayed because the injury was overlooked at initial evaluation. Re-examination of the initial radiographs indicated presence of microfractures, dislocations smaller than 3 mm, and inversion of physiologic lordosis.14 In another study of 52 overlooked spinal cord injuries,40 failure to notice an obvious fracture on the radiograph occurred in 10 instances. Webb et al56 described seven cases of late vertebral deformity after flexion injuries of the cervical spine. In four of these, the clinical and radiologic features were subtle and because the patients walked into the emergency department the severity of the injury was not initially appreciated. They described a tetrad of signs that should warn the clinician of a possibility of unstable hyperflexion cervical spinal injury, which includes interspinous widening, anterior subluxation, teardrop fracture, and focal kyphosis (Figs 1, 2). Conversely, a hyperextension injury may show anterior disc space widening, focal lordosis, extension teardrop fracture at C-2, and posterior subluxation.10

Fig 1.
Fig 1.:
The lateral radiograph of the cervical spine shows signs of flexion injuries at the C-7 vertebra. Note the loss of lordosis at C6-C7, the teardrop fracture from the anterior superior edge of the C7 vertebral body, and an increased angular gap (arrow) between the spinous processes of C6 and C7. These findings may be easily overlooked in patients with a short, thick neck and broad shoulders, in whom the lower cervical spine may not be clearly observed on a radiograph. Note absence of any fullness of the anterior soft tissue shadow.
Fig 2. A–B.
Fig 2. A–B.:
(A) A 60-year old woman arrived at the emergency room with neck pain after a fall down stairs at home. The increased angular gap between the C5-C6 spinous processes and facets were overlooked in the initial lateral radiograph. She was treated in a collar symptomatically. (B) Eight years later she presented with progressive kyphosis and chronic neck pain, and the lateral radiograph clearly showed an anterior subluxation of C5 on C6.

In elderly patients with degenerative disc disease, presence of some degree of retrolisthesis is common and may be less likely to predict injury. Anterolisthesis on a cross-table lateral cervical spine radiograph is uncommon and is more likely to indicate a hidden injury.10 In a review of cervical spine injuries in the elderly (n = 41), 4 patients (10%) were misdiagnosed at the time of first examination.32

The initial plain radiographs are often inadequate to observe the craniocervical and cervicothoracic junction and also may fail to show ligamentous injuries. Many studies document that clearance of the cervical spine using plain radiographs alone will not reveal cervical spine fractures in 15 to 30% of cases.10,13,43,57 Because of the limitations of plain radiographs, the standard of care has shifted to include widespread use of flexion-extension radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) to evaluate for subtle cervical spine injury.10,18

Spinal cord injury without radiologic abnormality (SCIWORA) was first described by Pang and Wilberger in 1982.38,39 It is defined as spinal cord injury that is shown on MRI but that is not shown on a complete, technically adequate plain radiographic series. The spinal cord may be injured even though the vertebral column is spared from disruption. The inherent elasticity of the juvenile spine permits self-reducing but considerable intersegmental displacements when subjected to flexion, extension and distraction forces. This vulnerability is evident in children younger than 8 years. Pang and Wilberger38,39 described SCIWORA in 55 children. Ten were upper cervical (C1-C4) injuries, 33 were lower cervical (C5-C8) injuries, and 12 were thoracic cord injuries. Twenty-two of these injuries were complete or severe lesions and 33 were mild. Younger children also were more likely to have severe upper cervical lesions. Lower cervical lesions were distributed evenly through the ages 6 months to 16 years. Hendey et al22 reported 27 (0.08%) cases of SCIWORA in adults out of 34069 patients entered in National Emergency X-Radiography Utilization Study (NEXUS). None of the 30 children with cervical spine injury had SCIWORA out of 3000 enrolled. The adult cases showed central disc herniation, spinal stenosis, and cord edema or contusion on MRI. The central cord syndrome was described in 10 cases. They concluded that SCIWORA was an uncommon disorder that occurred only in adults. Gupta et al19 reported that 7 of the 15 adult patients with SCIWORA had disc protrusions and improved with surgery.

Goergen et al17 reported that less than 5% of patients who have suffered possible neck injury actually have an injury requiring medical treatment and raised a concern against overuse of radiologic investigation for clearance of the cervical spine, and described the need for evidence-based imaging guidelines to use when evaluating the cervical spine.

In a patient with trauma, plain radiographs must be obtained in the presence of cervical spine tenderness or neurologic deficit. These two indications have a sensitivity of 93% for cervical spine injury, but a specificity of only 16%.44 In addition to these two important indicators, radiologic evaluation is indicated in cases of all major trauma involving closed head injury or altered level of consciousness.46 Patients who are alert and have no neurologic deficit or neck pain do not need radiologic evaluation.10 The initial trauma series of roentgenograms include a cross-table lateral view, a supine anteroposterior view, and an open-mouth odontoid view. A cervical spine radiographic evaluation cannot be said to be complete without observing the cervicothoracic junction.24,47 Gentle traction of the arms to depress the shoulder is often valuable to achieve better observation of the lower cervical spine. However, such traction should not result in extension of the neck. Undue traction can result in neurologic deterioration, particularly in presence of spondylitic myelopathy or ankylosing spondylitis.40 A swimmer’s view is added when the initial lateral projection fails to demonstrate C7-T1 junction. The swimmer’s lateral view is somewhat limited secondary to the overlapping shadows of the clavicle and ribs. As a result, some centers obtain supine-oblique projections,24 in which the xray beam is angled 45° from the sagittal plane and aimed at the anterior margin of the middle of the sternomastoid muscle, and sliding a radiographic cassette under the scapulae without moving the patient (Fig 3).

Fig 3.
Fig 3.:
The supine-oblique view shows dislocation of the C3-C4 facet joint. The radiographs were obtained by sliding a radiograph cassette under the contralateral shoulder and the neck while the xray beam was aimed at 45° from the sagittal plane, centered at the anterior margin of the middle of the sternomastoid muscle (see inset). (Reprinted with permission from Poonnoose PM, Ravichandran G, McClelland MR: Overlooked and mismanaged injuries of the spinal cord. J Trauma 53:314–320, 2002.)

The NEXUS study described a “low-risk criteria” (NLC) and cervical spine radiography was indicated for patients with trauma unless they meet all the criteria (Table 1).22 A group of Canadian surgeons developed the alternative Canadian C-Spine Rule (CCR) for selection of alert patients for radiologic evaluation.52 In a multicenter study (n = 8283) the CCR was more sensitive than the NLC (99.4% versus 90.7%) and more specific (45.1% versus 36.8%) for injury.

Table 1
Table 1

According to the Advanced Trauma Life Support (ATLS) guideline, the lateral radiograph should be checked for alignment of four vertical lines, the anterior soft tissue line, the anterior vertebral body line, the posterior vertebral body line, and the line joining the tips of spinous processes.3 Normally the prevertebral soft tissue thickness is variable in front of the C-1 arch, and becomes narrowed to fewer than 5 mm in front of C2 to C4 vertebral bodies. It abruptly widens in front of C5 downward, equal to the width of the vertebral body. In absence of an obvious fracture or dislocation, one should look for signs of hidden spinal injuries, which may involve an abnormal widening of the prevertebral soft-tissue shadow (Fig 4); loss of alignment in any of the four lines described above, anterior subluxations exceeding 3 mm in adults or 4 mm in children, minor teardrop fractures, focal kyphosis exceeding 11°, or widening of the interspinous distance relative to the adjacent levels. In the upper cervical region, the anterior atlanto-dens interval exceeding 3 mm in adults and 5 mm in children indicates damage to the transverse ligament. The key is not the absolute measurements, but qualitative changes, especially an abrupt, focal change in angulation or alignment.10

Fig 4. A–B.
Fig 4. A–B.:
(A) A 37-year old woman with motor vehicle trauma presented in the emergency room with persistent neck pain without neurologic deficit 3 weeks after her initial accident. The initial plain lateral radiograph indicates increased soft-tissue shadow in front of the upper cervical spine (arrow), which should have raised a suspicion of a spinal injury. (B) The diagnosis of an undisplaced hangman’s fracture was overlooked until a CT scan was obtained.

Articular mass fractures often are difficult to diagnose and remain a common neglected cause of posttraumatic neck pain.40 The articular processes are best shown on supine-oblique views and lateral tomography. Smith et al49 described the plain radiographic findings suggestive of an articular mass fracture, which include neuroforaminal encroachment or narrowing, triangular appearance of the lateral mass in the oblique view, unilateral anterior displacement of the superior facet with respect to the inferior, minor anterior subluxation of one vertebral body over another, double outline sign on the lateral view, and abnormally visible posterior articulations on the routine AP view.

When the initial plain radiographs (3-view trauma series and additional swimmer’s view and/or supine-oblique views) fail to adequately show the craniocervical and cervicothoracic junction or if the results of these radiographs raise a suspicion of hidden injuries, further imaging studies are indicated.

Computed tomography scans are more reliable than plain radiographs in clearing the cervical spine in adult patients with blunt trauma. Griffen et al18 have suggested that CT scans should replace plain radiographs as the preferred screening test. However, CT scans have limitations in diagnosing axially oriented fractures (like Type II odontoid fractures), and ligamentous injuries with instability. If CT scans are used as a substitute for a 3-view spine series, then coronal and sagittal reconstructions are essential.10 Thin slice CT scans (2 mm or less) and multiplanar reconstructed images will show fractures that are oriented purely in the axial plane, subluxation of facet joints and vertebral bodies, and angular and rotational abnormalities. Several studies have found that the sensitivity of CT scans for detection of fractures ranges from 97 to 100%.1,10 Magnetic resonance imaging is highly sensitive in the detection of ligamentous injury, but much less sensitive than CT in detecting fractures of the posterior elements of the spine and injuries of the craniocervical junction.10

Flexion-extension views should never be used to determine stability of a cervical spine injury. Their only appropriate use, even today, is in assessing patients who might have anterior subluxation (hyperflexion sprain) of the cervical spine when the routine radiographic examination is done.20 The purpose is to assess the integrity of the posterior ligament complex. The degree of flexion-extension must be limited to the point of the patient’s pain tolerance. These may be safely done in awake and alert patients in the emergency room. However, it may produce an unacceptably high false-positive and false-negative rate of identifying ligamentous injuries in acute setting because pain and spasm may limit cervical spine motion.23,31 The examination should be done only when the patients actively can perform adequate motion, usually after 1 to 2 weeks.10,20 Magnetic resonance imaging provides direct observation of the posterior ligament complex and is therefore the definitive imaging examination for anterior subluxation, its lack of availability and its cost preclude its use as the initial or screening study for anterior subluxation. Patients with substantial neck pain but normal radiographs should be evaluated with an MRI scan, or treated presumptively with a hard cervical orthosis until flexion-extension views can be obtained at a later date.

Patients who are comatose may have passive flexion-extension views under fluoroscopic guidance.12 When MRI scanning is otherwise contraindicated this may be an acceptable method for clearing the spine for ligamentous injury. Care must be taken to assure that adequate motion does occur with this passive flexion-extension maneuver. The maneuver may be done with the patient log-rolled onto his side, taking extra care to protect the spine.10

Overlooked diagnosis of cervical spine injuries may result in progressive kyphotic deformity, pain, and even progressive neurologic deficit. A study in 195745 showed that up to 10% of patients with cervical column injury who initially did not have any neurologic deficit deteriorated after their admission to a trauma center. In a more recent study, Poonnoose et al40 reviewed traumatic spinal cord injuries (n = 569) and reported on 52 (9.1%) patients in whom the diagnosis was overlooked. The most common levels were C3-C6 (n = 28) and thoracic (n = 14; Table 2). Thirty-four of the patients in whom the diagnosis was overlooked had therapeutic intervention that was deemed inappropriate and were therefore designated as mismanaged. In 26 of the 52 cases, mismanagement of the spinal cord injury resulted in neurologic deterioration. In seven of these patients, the neurologic deficit at the time of initial presentation was minimal. In nine patients, mismanagement caused neurology to deteriorate to complete paralysis. Six patients died as a direct result of the delay in diagnosis. Thus, the need to prevent overlooked diagnosis and to minimize secondary damage to the spinal cord in trauma centers and emergency departments cannot be overstated.

Table 2
Table 2:
Vertebral Level of the Missed Injury in 52 Cases out of 569 Patients with Spinal Cord Injuries

Ten of the 34 patients (29%) of overlooked diagnosis reported by Davis et al13 developed permanent sequelae. The single most common error was the failure to obtain an adequate series of C-spine roentgenograms. In the study reported by the Italian Society of Neurosurgery Study Group (n = 172), which identified 53 cases of neglected cervical spine injuries, 25 patients developed delayed instability requiring surgical stabilization.14 The time interval between the acute phase and surgical treatment ranged from 21 days to 640 days (mean 41.5 days). During this interval the primary symptoms were persistent pain in 11 patients, sensory impairment in five, and motor impairment in 10. In comparison with initial clinical evaluation, motor deficit deteriorated in four patients by at least one grade. The most frequently involved levels were C4-C5 and C5-C6. Surgical stabilization were done by anterior (n = 11), posterior (n = 10), or combined (n = 4) approach. Of the 25 patients treated, 22 improved, three showed no change, and none of them worsened in a followup period ranging between 2 and 96 months.

Rao et al41 reported neurologic recovery after late anterior decompression and fusion in 25 patients with cervical spine injuries with incomplete paralysis. Seventeen patients had return of sensation and bladder and bowel function and seven patients had good motor recovery. Four patients became community ambulators. However, two patients died in the early postoperative period because of cardiopulmonary complications. In another study of cervical dislocation (n = 67), more than 3 weeks since injury, significant recovery of neurologic deficit was reported in 60% of cases, following late reduction with or without surgery.27

The delay in initiation of the treatment makes it difficult to reduce the deformity, which may require an unnecessary surgical intervention, frequently associated with an unsatisfactory outcome. C1-C2 rotatory subluxation in children is an ideal example, which can be easily reduced by traction and treated in a halo-vest or collar when diagnosed early. If the diagnosis is delayed by over seven days, the reduction may be difficult or incomplete and the deformity tends to recur.25,34 Often the residual deformity may be acceptable (Fig 5). Open reduction is difficult and unstatisfactory.11 For unacceptable deformity, the preferred treatment option may be C1-C2 fusion in situ after initial traction.5,25,34

Fig 5. A–D.
Fig 5. A–D.:
(A) A 10-year-old girl presented with C1-C2 rotatory subluxation 3 months after injury, with a fixed deformity. (B) Cervical traction for 2 weeks corrected the deformity largely, but the subluxation could not be reduced. (C) The position was held in a halo-vest for 3 months. (D) The cosmetic appearance at final followup was acceptable despite persistent dislocation.

Overlooked Diagnosis of Thoracolumbar Spinal Injuries

Overlooked or delayed diagnosis of thoracolumbar spine fractures have been reported to be as high as 16.5% in a recognized trauma center in North America.36 Overlooked injuries of this frequency are alarming, considering the fact that in one large review, secondary (presumably preventable) neurologic deficits occurred in 10.5% of patients with overlooked spinal injuries compared with only 1.4% of patients whose injuries were identified on initial screening.43 Overlooked diagnosis may be 4.5 times less common in thoracolumbar spine compared with the cervical spine (22.9 versus 4.9%),43 but secondary neurologic deficits are more frequent because of the relatively narrow spinal canal in the thoracolumbar region. In the 52 cases of overlooked spinal cord injury reported by Poonnoose et al40 19 (36%) occurred in the thoracolumbar region.

In patients who are unconscious or intoxicated, a diagnosis of thoracolumbar fractures may be easily overlooked. In a multicenter review of polytrauma patients with trauma (n = 160), six patients had thoracolumbar fracture, even though these patients did not have back pain and bony tenderness. In each of these cases the diagnosis was either overlooked or delayed.35

Even when thoracolumbar spine injuries are identified, the magnitude of severity and instability of these injuries may not always be properly assessed after radiographic evaluation. In a study comparing preoperative and postoperative diagnosis Leferink et al30 (n = 160) reported that 30% of Type B fractures33 (ligamentous distraction type of fracture) were misdiagnosed as Type A (compression fractures), when plain radiographs and CT scans with 2-D reconstructions were used as the only preoperative diagnostic tools. Analyzing the various radiographic predictive factors they found that the kyphotic angle and loss of anterior vertebral height did not show significant differences between the obvious and unrecognized Type B fractures. The unrecognized Type B fractures were more frequently found when the preoperative radiographs showed an apparently simple Type A fractures with minimal comminution. The importance of this study is that although Type A injuries (compression fractures) are often stable and may be treated conservatively, the ligamentous distraction in Type B fractures are frequently unstable and need surgical stabilization (Fig 6).

Fig 6. A–B.
Fig 6. A–B.:
(A) A 30-year-old woman who was in a traffic accident was transferred from a peripheral hospital with an obvious hangman’s fracture (inset) and acute respiratory distress syndrome with a chest tube in the right side. A week later, when she recovered from the respiratory distress, no major rib fracture was found on the chest radiograph. A radiologic examination of the whole spine was ordered. An increase between the right sixth and seventh ribs (arrow) was seen in the AP view. (B) A CT scan showed an unstable distraction type of injury, which was stabilized with posterior fixation and a fusion. The hangman’s fracture, which was the primary cause for referral to the spine unit, was treated conservatively.

Transverse process fractures of the lumbar spine are often considered benign and related to direct trauma or avulsion by the psoas muscle. However, considerable force is required to cause these injuries, and other injuries may occur concomitantly. Krueger et al28 reviewed apparently benign lumbar transverse process fractures (n = 28), for which further imaging studies showed additional fractures of the body in three patients (11%), which were overlooked on plain radiographs. The authors recommended that all the patients with transverse process fracture be evaluated with CT scan.

In a patient with trauma the usual indications for obtaining radiographs of the thoracolumbar spine include neurologic deficit, altered level of consciousness, and presence of back pain or tenderness.

Whether thoracolumbar injury can be asymptomatic is a debatable issue.26,29,55 Meldon et al36 reported (n = 145) presence of back pain or tenderness in all cases of thoracolumbar fractures except in 27 patients (19%). All of these patients had altered sensorium, concomitant major injuries, or neurologic deficit. Several authors have suggested that in the absence of back pain and/or tenderness, the thoracolumbar spine can be clinically cleared even in the presence of other serious injuries, if the patient is otherwise awake, alert, and not intoxicated.48,53 However, when the “distracting remote injury” results from high-velocity blunt trauma or involves pelvic or lower extremity injuries, complete spinal radiography is indicated.26,51

The incidence of noncontiguous fractures of the spine has been reported to be around 10 to 15%. Therefore, once a fracture is recognized at any level, imaging of the entire spine is indicated.2–4,36,54

The current protocols for initial radiologic evaluation for thoracolumbar injuries include plain AP and lateral radiographs. In patients with many injuries, often a CT scan of the chest, abdomen, and pelvis (CT-CAP) is also done to rule out visceral injuries. Frequently, minor spinal fractures are better recognized in these CT scans than on the plain radiographs. Hauser et al21 prospectively studied 222 high-risk trauma patients requiring thoracolumbar spine screening because of clinical findings or altered mentation. They compared the initial diagnosis of the thoracolumbar fractures from plain radiographs and from CT-CAP, with the final diagnosis at discharge from thin-cut CT scan of the spine. The accuracy of the CT-CAP for thoracolumbar spine injury was 99% compared with 87% with plain radiographs. However, no unstable fracture was overlooked by either modality. The authors concluded that CT screening is more accurate and does not result in greater radiation exposure than plain radiographs and recommended that CT-CAP should replace plain radiographs in screening high-risk trauma patients.

The neglected fracture of the thoracolumbar spine may result in progressive neurologic deficit, progressive kyphotic deformity, or pain. Deterioration of neurologic deficit has been discussed earlier in the cervical spine injury section. However, neural deficit occurs more frequently in overlooked thoracolumbar injury secondary to relatively narrow spinal canal.40,50

Progressive posttraumatic kyphotic deformity with or without pain may result from delay in the stabilization of unstable Type A burst fractures or inability to notice instability, as in unrecognized Type B fractures. In thoracolumbar burst fractures requiring surgical stabilization, if the initial diagnosis is overlooked and surgery is delayed more than 3 weeks, indirect reduction by a simple posterior surgery alone may not be able to achieve adequate correction of kyphosis. In this setting an otherwise avoidable and more extensive anterior procedure may be needed.37,58 Type B fractures33 are usually unstable injuries and can be easily stabilized by restoration of a posterior tension band with a simple short-segment stabilization procedure like interspinous wiring. As mentioned earlier, Type B fractures are overlooked more often and may result in neurologic deterioration or progressive kyphotic deformity, requiring a more extensive anterior or combined anterior and posterior surgery.30

Bohlman et al7 reported 45 patients who had anterior decompression for chronic pain or paralysis at an average of 4.5 years after having thoracolumbar fractures. Pain was improved in 41 of 45 patients, with complete relief in 30 and partial relief in 11. In 25 patients with neurologic deficit, 21 noted improvement, 14 of which improved one or more grades. The authors concluded that anterior decompression of the thoracolumbar spine for chronic pain and paralysis after thoracolumbar fractures is a safe and effective treatment for patients with this uncommon and difficult problem.

Untreated or Inadequately Treated Injuries with Late Presentation

In the facilities where adequately equipped spine services are not available, the majority of the spinal trauma with or without stability or neural deficit, is treated conservatively. Severe kyphotic deformity is common in these situations. It may be surprising to see how often these cases remain neurologically spared or considerably improved, despite canal compromise (Fig 7). Luque segmental instrumentation over a long segment likely is the most commonly used instrumentation in developing world8,15 because it is relatively inexpensive and readily available. However, it causes unnecessary fusion of motion segments, and when implanted without arthrodesis, eventually it fails. Harrington instrumentation, when used in unrecognized distraction (Type B) injury, may cause profound distraction of the segment, which is destined to fail.

Fig 7. A–B.
Fig 7. A–B.:
(A) An 18-year-old man from a remote village presented with persistent low back pain and deformity after a fall from the roof. A CT scan with 3-D reconstruction showed complete dislocation of L4-L5. He was neurologically intact. (B) A 2-year followup radiograph after in situ fusion with posterior instrumentation is shown. The deformity was improved and pain was completely relieved. Figures 7A and 7B have been reprinted courtesy of Professor Anil K. Jain, New Delhi, India.

DISCUSSION

Despite the considerable advances made in the treatment of patients with acute trauma, incidence of neglected fractures of the spine is not uncommon. Unfortunately, these are likely under-reported because of medicolegal concerns. Therefore the reported incidence rate in the literature varies widely (4–30%).6,16,43,45

Overlooked diagnosis of minor injuries may not have any adverse long-term effect,43 but serious consequences like persistent pain, progressive deformity, and even deterioration of neurologic deficit are not uncommon. Authors of a study42 from a spinal cord injury center in 1981 reported (n = 353) that spinal cord injuries were overlooked in 15 (4%) cases at the time of initial diagnosis. Twenty years later, a repeat study of similar nature (n = 569) showed that spinal cord injury was overlooked in 52 cases (9.1%).40 The increased incidence may reflect an increase in awareness and reporting. But the fact that half the cases (25/52) of overlooked diagnosis resulted in deterioration of the neurologic deficit after admission to the emergency department raises serious medical and medicolegal concerns. Brief and cryptically described neurologic assessments made in the emergency department without a thorough neurologic assessment may imply that the patient with spinal cord lesion had relatively normal movements and/or sensation. Such reports may encourage the patients and their legal advisors to allege that the health authority either caused or contributed to subsequent “loss of function”—even in patients who had overlooked symptoms and signs from the onset.40,42 The situation becomes more complicated when the patient with trauma may be intubated and sedated in the emergency department after the brief initial assessment, which remains the only available record of the neurologic status on arrival. If detailed assessment could not be done, it is more appropriate to state that the limited examination did not reveal any gross neurological deficit, was normal and the patient should be assessed again later.40

Overlooked spinal injuries are more common in the cervical spine,43 but serious damage like progressive deformity or secondary neurologic deficit are seen more frequently in overlooked thoracolumbar and lumbar injuries.40 In general, overlooked injuries are more frequently observed in patients who are unconscious or intoxicated and in patients with polytrauma and distracting remote injuries. Overlooked cervical spine injuries are more frequently seen in patients with injuries in the head and face, particularly in elderly patients or patients with ankylosing spondylitis.40 These cases need more careful assessment before the spine is cleared of injury.

Prevention of overlooked spinal injuries depends on anticipation and careful assessment. The pressures on the medical team during any major resuscitation are well known. Immobilization of the spinal column is essential until a formal reevaluation of the patient (secondary survey) is carried out after resuscitation. Sadly, on a few occasions, secondary surveys are not carried out because resuscitated patients are sent to the intensive care units. The limited clinical impressions obtained during the primary survey may be deemed adequate for several days. This practice can lead to failure to recognize the underlying spinal column or spinal cord injury.40

At secondary survey, the patient should be “log-rolled” and the whole spine should be carefully palpated for pain, tenderness, gap between the spinous processes, and edema and ecchymoses over the spine. Radiologic investigation must be obtained and carefully studied according to the established guidelines. Any suspicion of spinal injury either in clinical examination or initial radiographs should be followed by appropriate further imaging studies like CT and/or MRI scans. One should not accept suboptimal quality of initial radiographs to clear the spine. The craniocervical and cervicothoracic junctions often are obscured in the initial radiographs obtained in the emergency department, and one should not hesitate to ask for swimmer’s views or supine oblique views24 or a CT scan. Unless one is certain there is no spinal injury, it is safer the keep the spine protected and immobilized until the patient is awake and alert and the clinical examination of spine and neurologic assessment can be completed. In patients who are unconscious or intoxicated, even if the initial radiographs and CT scan do not show any fracture, the spine can not be cleared of injury because ligament injury cannot be ruled out without an MRI scan. If the patient needs to be anesthetized before the cervical spine can be cleared of injury, endotracheal intubation may be done using a fiber optic laryngoscope, with the neck immobilized in a rigid cervical collar. The use of flexion-extension views of the cervical spine should be limited to assess posterior ligamentous disruption in hyperflexion injuries when the initial radiographs are equivocal about the minor anterior subluxations.20 These should only be done in absence of notable muscle spasm, when the patient regains adequate active range of motion, usually after 1 or 2 weeks from the date of injury.

In developed countries, people without medical insurance find it difficult to meet the cost of medical treatment. In developing countries the majority of the population does not have medical insurance or ready access to care. For these patients the only medical facilities are provided by the state-run hospitals, which have limited resources and often lack modern medical equipments and technologies. The people living in remote villages do not seek medical attention in the absence of serious neurologic damage or severe painful disabilities. When the patients report immediately after trauma to the hospital where the best of the infrastructure and equipment may not be available, the treating surgeon improvises to serve the need of these spinal injury patients. Hence the definition of neglected injury used in the Western medical literature may not be applicable in true sense in the developing world. The ingenious improvised techniques used in these situations are rarely reported in the published literature. Further, no data on the magnitude of the problem are available.

Treatment of neglected spinal injuries often requires more extensive surgical procedures, with less satisfactory clinical outcome, compared with the same injury that is diagnosed and treated early. Persistent pain and progressive deformity may require surgical stabilization for an injury that could have been treated conservatively. An extensive anterior or combined anterior and posterior surgical procedure may be necessary for an overlooked posterior ligamentous injury that could have been stabilized with a simple posterior surgical procedure alone at an early stage. With adequate care and adhering to the established guidelines3,22,52 for obtaining imaging studies before clearing a patient with trauma for spinal injury, it is possible to detect many lesions that would otherwise have been overlooked.

Acknowledgments

I thank Dr. Samir K. Gupta, FRCS, MCh (Orth), from Kolkata, India for forwarding references from the Indian Journal of Orthopaedics and Professor Anil K. Jain, MS, from New Delhi, India for communicating about clinical case reports.

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