Delayed Diagnosis of a Patient with Cervical Spine Injury resulting in Complete Cervical Spine Dislocation without Serious or Lingering Neurological Signs: A Case Report

摘要

Background: Following a car accident, patient complains of hip and neck pain, and weakness in the right upper extremity. Evaluation in the emergency room, as well as radiographs revealed a normal cervical spine with mild degenerative changes. The following day, the patient complained of neck pain and bilateral hand numbness. Preparation for flexion-extension radiograph led to a complete anterior dislocation at C5-C6. Results: Following anterior and posterior fusion of the cervical spine, Physical Therapy and Occupational Therapy evaluation revealed mild non-fatigable weakness of the bilateral upper extremities and negative neurological testing. Conclusion: Initial physical examination did not reveal cervical spine pathology. However, physical and neurological examinations were incomplete. A proper diagnostic exam, including a detailed physical and neurological examination, as well as a proper series of diagnostic tests may have eliminated the possibility that the cervical spine injured patient would face the dire consequences of a severely unstable cervical spine. Introduction Patients that sustain multiple injuries in traumatic accidents are susceptible to neglected spinal injuries. Neglected spinal injuries are defined as injuries not treated in a timely fashion and found late when options for care are limited 1 . According to Sengupta 1 , this type of overlooked spinal injury is often associated with polytrauma or altered level of consciousness. However, he states that the overlooked diagnosis is largely preventable by adhering to appropriate protocols for clearing the cervical spine in a trauma patient. Lin, Lee and Lee 2 state that a missed cervical spine fracture may potentially result in devastating consequences, and there has been much discussion on the appropriate management for patients with these fractures. Fracture with dislocation of the cervical spine presents even more complications, especially when the initial fracture is occult. One of the 68 radiographs that Lin et al 2 examined for occult fractures of the cervical spine contained a fracture dislocation of the C6-C7 level. However, the initial radiographs were negative for fracture, except for evidence of a subtle disc space widening at the affected level. Of all the radiographs examined by the investigators, occult fractures in cervical spine fracture patients were missed on initial radiographs in 40% of the cases. The investigators suggest that radiographs are not 100% sensitive in ruling out fracture, and state that CT scan is clearly superior in imaging bony pathology. Furthermore, Sengupta 1 recommends the use of magnetic resonance imaging (MRI) in addition to radiograph and CT scan with their purpose to assess the integrity of the posterior ligament complex.There remains controversy regarding the choice of appropriate diagnostic tests with regards to the cervical spine injury. Although Sengupta 1 stated that the standard of care included the use of flexion-extension radiographs, he did not recommend their use in the acute cervical spine injury secondary to the possible injury to the posterior ligamentous complex. Therefore, the recommendation has been made to include CT scan and MRI as routine diagnostic tests. Hoffman et al 3 supports the use of a decision instrument based on clinical criteria which would assist physicians in reliably identifying patients requiring radiography after blunt trauma. Furthermore, Poonoose, Ravichandran and McClelland 4 report that inadequate neurologic assessment is a factor in missed and mismanaged injuries of the spinal cord.The following case report describes the examination, treatment, outcomes, and mismanagement for a polytraumatic patient with neglected spinal injury, followed by complete cervical spine dislocation, subsequent reduction, and surgery, without serious or lingering neurological deficits. Many of the issues regarding the neglected or mismanaged cervical spine injury are addressed and contributed to this