title: Missed cervical spine injuries: a national survey of the practice of evaluation of the cervical spine in confused and comatose patients.
abstract: OBJECTIVE
  Identifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals.
  
  
  METHODS
  All hospitals in England with an Emergency Department were asked about the protocols which they use for assessing the cervical spine. All 22 Major Trauma Centres (MTCs) and 141 of 156 non-MTCs responded (response rate 91.5%).
  
  
  RESULTS
  Written guidelines were used in 138 hospitals (85%). CT scanning was the first-line investigation in 122 (75%). A normal CT scan was sufficient to clear the cervical spine in 73 (45%). However, 40 (25%) would continue precautions until the patient regained full consciousness. MRI was performed in all confused or comatose patients with a possible cervical spinal injury in 15 (9%). There were variations in the grade and speciality of the clinician who had responsibility for deciding when to discontinue precautions. A total of 31 (19%) reported at least one missed cervical spinal injury following discontinuation of spinal precautions within the last five years. Only 93 (57%) had a formal mechanism for reviewing missed injuries.
  
  
  CONCLUSIONS
  There are significant variations in protocols and practices for the clearance of the cervical spine in multiply injured patients in acute hospitals in England. The establishment of trauma networks should be taken as an opportunity to further standardise trauma care. Cite this article: Bone Joint J 2016;98-B:825-8.
authors.affiliation: Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK.
authors.forename: S
authors.initials: S
authors.lastname: Craxford
authors.affiliation: Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK.
authors.forename: E
authors.initials: E
authors.lastname: Bayley
authors.affiliation: Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK.
authors.forename: M
authors.initials: M
authors.lastname: Walsh
authors.affiliation: Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK.
authors.forename: J
authors.initials: J
authors.lastname: Clamp
authors.affiliation: Nottingham University Hospitals, Derby Road, Nottingham NG7 2UH, UK.
authors.forename: B M
authors.initials: BM
authors.lastname: Boszczyk
authors.affiliation: Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, UK.
authors.forename: O M
authors.initials: OM
authors.lastname: Stokes
mesh_terms: D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries*; D002985:Clinical Protocols; D003951:Diagnostic Errors / Q000517:prevention & control*; D004636:Emergency Service, Hospital; D004739:England / Q000453:epidemiology; D006801:Humans; D007103:Immobilization / Q000706:statistics & numerical data; D008279:Magnetic Resonance Imaging / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D013124:Spinal Injuries / Q000175:diagnosis*; D011795:Surveys and Questionnaires; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D014193:Trauma Centers
keywords: Cervical spine injury; Cervical spine protocols; Confused patients; Missed cervical injury