Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation, and outcome.
BACKGROUND
The potential for ligamentous injury of the cervical spine (C-spine) may mandate prolonged neck immobilization via a hard cervical collar in the blunt trauma victim (BTV) with altered sensorium. We investigated the incidence of ligamentous C-spine injuries, and whether applying (post hoc) the practice management guidelines from the Eastern Association for the Surgery of Trauma (three radiograph views plus computed tomographic scan of C1-C2) would have detected the injuries.


METHODS
The study was a 3-year retrospective review of BTVs admitted to the state's Primary Adult Resource Center for trauma from 1996 to 1998. Unreliable patients were defined as those with admission Glasgow Coma Scale score < 15. A rigorous algorithm to clear the C-spine was used. Pure ligamentous C-spine injury was defined as a C-spine having abnormal anatomic alignment, dislocation, subluxation, or listhesis, but without fracture. Demographics, diagnostic studies, presence of neurologic deficit, therapy, survival, and disposition were analyzed.


RESULTS
There were 14,577 BTVs with 614 (4.2%) patients having C-spine injury. There were 2,605 (18%) unreliable patients, with 143 (5.5%) of these having C-spine injury, 129 (90%) having fracture and 14 (10% of BTVs; 0.5% of unreliable patients) having no fracture. Of the 14 unreliable patients with pure ligamentous C-spine injury, 13 had initial diagnosis by supine cross-table lateral radiograph. The one exception had a normal three-view radiographic series, but atlanto-occipital dislocation was diagnosed by computed tomographic scan. Eight patients had upper level injury (C0-C4) and six were lower (C4-C7). Four patients died within 30 minutes after admission, 4 underwent cervical fusion, and 6 were treated with collar only. Five (50%) of the survivors had no apparent neurologic deficit attributed to the C-spine at admission. Nine patients remained institutionalized after discharge and one was discharged home.


CONCLUSIONS
Ligamentous injuries without fracture of the C-spine are rare. Application of the practice management guidelines developed by the Eastern Association for the Surgery of Trauma for identifying C-spine instability is effective and should facilitate early removal of the cervical collar in unreliable patients.
R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA. wchiu@umm.edu
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Chiu
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Haan
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Cushing
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Kramer
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Scalea
D000328:Adult; D000465:Algorithms; D001268:Atlanto-Axial Joint / Q000293:injuries*; D001269:Atlanto-Occipital Joint / Q000293:injuries*; D015142:Baltimore / Q000453:epidemiology; D001915:Braces; D002574:Cervical Vertebrae / Q000293:injuries*; D002985:Clinical Protocols / Q000592:standards*; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis* / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy; D015600:Glasgow Coma Scale; D006801:Humans; D015994:Incidence; D004204:Joint Dislocations / Q000175:diagnosis* / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy; D008023:Ligaments, Articular / Q000293:injuries*; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic / Q000592:standards*; D012189:Retrospective Studies; D013123:Spinal Fusion; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000175:diagnosis* / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy