American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Unstable Cervical Spine Fracture with Normal Computed Tomography Imaging: A Case Report☆,☆☆,★ The disposition for neurologically intact and alert patients complaining of persistent symptoms despite negative computed tomography (CT) imaging is controversial. Computed tomography has excellent sensitivity for osseous injuries but is insensitive for ligamentous injuries. Some advocate that these patients undergo early magnetic resonance imaging (MRI) because, although it is insensitive for osseous injury, it is highly sensitive for ligamentous and spinal cord injuries. We present the case of an alert and neurologically intact 84-year-old patient presenting with neck pain after a mechanical fall. Computed tomography demonstrated no acute osseous pathology. The patient was discharged home with persistent neck pain and advised to return to care within 2 days if his symptoms did not resolve. In 2 days, the patient returned to the emergency department and repeat CT imaging was negative. Magnetic resonance imaging demonstrated an unstable type 2 odontoid fracture. The patient was admitted, underwent cervical collar immobilization for 3 and a half months without neurologic sequelae at which time repeat imaging demonstrated no instability, and the collar was discontinued. We searched the peer-reviewed literature and identified 2 prior patients with CT-negative cervical spine fractures detected on MRI and requiring cervical collar immobilization. However, in neither case was the indication for immobilization documented to be an unstable fracture (vs associated ligamentous injuries). Our unique case adds to the growing literature suggesting a significant prevalence of actionable cervical spine injuries in patients with blunt trauma with persistent symptoms after negative CT imaging. Emergency physicians should consider early MRI for these patients instead of discharge with cervical collar. Unstable cervical spine injuries can result in catastrophic neurologic disability. Computed tomography (CT) has largely supplanted plain radiography for first-line imaging of patients with blunt cervical spine trauma given increasing data suggesting superior accuracy in identifying unstable injuries with CT [1]. Computed tomography imaging is highly sensitive for osseous injuries but relatively insensitive for ligamentous and spinal cord injuries, whereas the converse is true for magnetic resonance imaging (MRI) [2]. Hence, early MRI in alert and neurologically intact patients with neck blunt trauma with negative CT scans but persistent symptoms is controversial but, when performed, is generally intended to identify occult ligamentous or spinal cord injuries [3]. We present an unusual case of an unstable cervical spine fracture (type 2 dens injury) missed by CT then detected on subsequent MRI in an alert ☆ Funding Sources: None. ☆☆ Conflicts of interest: None. ★ Disclaimer: The view(s) expressed herein is those of the author(s) and does not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army and Department of Defense, or the US Government.
and neurologically intact patient with persistent midline pain to palpation after a mechanical fall. Our case contributes to the growing body of literature highlighting the caution that clinicians must exercise in clearing the cervical spine of patients with persistent symptoms after negative CT imaging. An 84-year-old nursing home patient presented to the emergency department after a mechanical fall while transferred from wheelchair to bed approximately 10 hours previously. The patient struck his head on the ground without loss of consciousness. On arrival, the patient complained of head and neck pain but otherwise had no symptoms. Specifically, he had no altered mental status, chest pain, fever, or focal neurologic deficits. His medical history was notable for chronic obstructive pulmonary disease, hypertension, and intermittent atrial fibrillation. Medications were notable for apixaban. The patient’s vital signs were temperature of 97.8°F, heart rate of 58 beats per minute, blood pressure of 196/87 mm Hg, respiratory rate of 18 breaths per minute, and oxygen saturation of 95% on room air. On physical examination, he had midline cervical tenderness to palpation and tolerated minimal neck range of motion. His neurologic exam was nonfocal. Head and cervical spine helical CT scans with 0.6-mm axial bone reconstructions and multiplanar reformations were negative for acute abnormality. The patient was discharged and instructed to follow-up with a health care provider within 2 days for repeat imaging if he continued to have pain. Two days later, the patient returned to the emergency department with persistent midline cervical tenderness to palpation and limited neck range of motion. Repeat cervical spine CT was again negative for any acute abnormality (Fig. 1). Cervical spine MRI demonstrated a type 2 dens fracture (Fig. 2). Neurosurgery was consulted and the patient admitted. He was determined to be a poor surgical candidate, so nonoperative management with prolonged cervical spine immobilization was pursued. He was immobilized with a cervical collar for 3 and a half months after which time he remained without any neurologic symptoms. Flexion/extension cervical spine plain films were determined to be stable, and neurosurgery discontinued the patient’s cervical collar. The disposition for neurologically intact and alert patients with persistent neck pain despite negative CT imaging is controversial. Guidelines endorse continuation of cervical collar immobilization or additional workup with either MRI or flexion-extension radiography [3]. The reason for this controversy is the fact that, although CT is highly sensitive for osseous injury (95%-100%), it is insensitive for ligamentous and spinal cord injuries (0%-12%). Conversely, MRI has relatively poor sensitivity for fractures (50%) but excellent sensitivity for ligamentous and spinal cord injuries (100%) [2]. We searched the peer-reviewed literature for previous reports of CTnegative unstable cervical spine fractures detected by MRI. Four studies
0735-6757/Published by Elsevier Inc.
Please cite this article as: April MD, et al, Unstable Cervical Spine Fracture with Normal Computed Tomography Imaging: A Case Report, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.043
2
M.D. April et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
cal fracture (not otherwise specified) [4]. The second patient was noted to have fractures of the C3 pedicle, C2 spinous process, and C7 transverse process with associated ruptures of the interspinous and supraspinous ligaments and the ligamentum flavum [5]. Both patients were treated with immobilization by cervical collar; neither underwent operative repair. Interpretation of the cervical spine imaging literature is complex and often contradictory in its findings [7,8]. This reflects both its size and heterogeneity in imaging technology and patient characteristics. To our knowledge, the present case is unique in its clear documentation of an unstable cervical spine fracture in a neurologically intact patient missed by repeat imaging with a modern CT scanner and detected by MRI. This case adds to the growing evidence base suggesting a significant prevalence of actionable cervical spine injuries in patients with blunt trauma with persistent symptoms after negative CT imaging, although this literature has previously focused on missed ligamentous and spinal cord injuries [9]. The emergency physician should strongly consider early MRI in lieu of discharge with prolonged cervical collar immobilization for alert and neurologically intact patients with persistent midline pain to palpation despite negative CT imaging.
Fig. 1. Sagittal CT image of the cervical spine. Multilevel cervical spondylosis without acute osseous abnormality. No cortical irregularity or prevertebral swelling is identified to suggest a fracture.
Michael D. April MD, DPhil, MSc ⁎ Robert E. Watts MD Austin T. Folley MD Michael Barakat DO Lisa M. Mannina MD James A. Pfaff MD Departments of Emergency Medicine and Radiology, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX ⁎Corresponding author. E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.04.043 References
Fig. 2. Sagittal T1-weighted MRI of the cervical spine. Linear hypointensity extending through the base of the odontoid consistent with a minimally displaced type 2 odontoid fracture.
reported CT-negative cervical spine fractures identified on MRI, but none of these fractures were reported to be unstable [2,4-6]. Two patients with cervical spine fractures detected on MRI after negative CT were subsequently treated. The first patient was reported to have an isolated cervi-
[1] Mathen R, Inaba K, Munera F, Teixeira P, Rivas L, Mckenney M, et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J Trauma 2007;62:1427–31. [2] Holmes JF, Mirvis SE, Panacek EA, Hoffman JR, Mower WR. Variability in computed tomography and magnetic resonance imaging in patient cervical spine injuries. J Trauma 2002;53:524–9. [3] Como JJ, Diaz JJ, Dunham M, Chiu WC, Duane TM, Capella JM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. J Trauma 2009;67:651–9. [4] Menaker J, Stein DM, Philp AS, Scalea TM. 40-slice multidetector CT: is MRI still necessary for cervical spine clearance after blunt trauma? Am Surg 2010;76:157–63. [5] Fisher BM, Cowles S, Matulich JR, Evanson BG, Vega D, Dissanaike S. Is magnetic resonance imaging in addition to a computed tomographic scan necessary to identify clinically significant cervical spine injuries in obtunded blunt trauma patients? Am J Surg 2013;206:987–93. [6] Sarani B, Waring S, Sonnad S, Schwab CW. Magnetic resonance imaging is a useful adjunct in the evaluation of the cervical spine of injured patients. J Trauma 2007;63: 637–40. [7] Panczykowski DM, Tomycz ND, Okonkwo DO. Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: a meta-analysis of 14,327 patients with blunt trauma. J Neurosurg 2011;115:541–9. [8] Schoenfeld AJ, Bono CM, McGuire KJ, Warholic N, Harris MB. Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma 2010;68: 109–14. [9] Ackland HM, Cameron PA, Varma DK, Fitt GJ, Cooper DJ, Wolf R, et al. Cervical spine magnetic resonance imaging in alert neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. Ann Emerg Med 2011;58:521–30.
Please cite this article as: April MD, et al, Unstable Cervical Spine Fracture with Normal Computed Tomography Imaging: A Case Report, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.043
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Unstable Cervical Spine Fracture with Normal Computed Tomography Imaging: A Case Report☆,☆☆,★ The disposition for neurologically intact and alert patients complaining of persistent symptoms despite negative computed tomography (CT) imaging is controversial. Computed tomography has excellent sensitivity for osseous injuries but is insensitive for ligamentous injuries. Some advocate that these patients undergo early magnetic resonance imaging (MRI) because, although it is insensitive for osseous injury, it is highly sensitive for ligamentous and spinal cord injuries. We present the case of an alert and neurologically intact 84-year-old patient presenting with neck pain after a mechanical fall. Computed tomography demonstrated no acute osseous pathology. The patient was discharged home with persistent neck pain and advised to return to care within 2 days if his symptoms did not resolve. In 2 days, the patient returned to the emergency department and repeat CT imaging was negative. Magnetic resonance imaging demonstrated an unstable type 2 odontoid fracture. The patient was admitted, underwent cervical collar immobilization for 3 and a half months without neurologic sequelae at which time repeat imaging demonstrated no instability, and the collar was discontinued. We searched the peer-reviewed literature and identified 2 prior patients with CT-negative cervical spine fractures detected on MRI and requiring cervical collar immobilization. However, in neither case was the indication for immobilization documented to be an unstable fracture (vs associated ligamentous injuries). Our unique case adds to the growing literature suggesting a significant prevalence of actionable cervical spine injuries in patients with blunt trauma with persistent symptoms after negative CT imaging. Emergency physicians should consider early MRI for these patients instead of discharge with cervical collar. Unstable cervical spine injuries can result in catastrophic neurologic disability. Computed tomography (CT) has largely supplanted plain radiography for first-line imaging of patients with blunt cervical spine trauma given increasing data suggesting superior accuracy in identifying unstable injuries with CT [1]. Computed tomography imaging is highly sensitive for osseous injuries but relatively insensitive for ligamentous and spinal cord injuries, whereas the converse is true for magnetic resonance imaging (MRI) [2]. Hence, early MRI in alert and neurologically intact patients with neck blunt trauma with negative CT scans but persistent symptoms is controversial but, when performed, is generally intended to identify occult ligamentous or spinal cord injuries [3]. We present an unusual case of an unstable cervical spine fracture (type 2 dens injury) missed by CT then detected on subsequent MRI in an alert ☆ Funding Sources: None. ☆☆ Conflicts of interest: None. ★ Disclaimer: The view(s) expressed herein is those of the author(s) and does not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army and Department of Defense, or the US Government.
and neurologically intact patient with persistent midline pain to palpation after a mechanical fall. Our case contributes to the growing body of literature highlighting the caution that clinicians must exercise in clearing the cervical spine of patients with persistent symptoms after negative CT imaging. An 84-year-old nursing home patient presented to the emergency department after a mechanical fall while transferred from wheelchair to bed approximately 10 hours previously. The patient struck his head on the ground without loss of consciousness. On arrival, the patient complained of head and neck pain but otherwise had no symptoms. Specifically, he had no altered mental status, chest pain, fever, or focal neurologic deficits. His medical history was notable for chronic obstructive pulmonary disease, hypertension, and intermittent atrial fibrillation. Medications were notable for apixaban. The patient’s vital signs were temperature of 97.8°F, heart rate of 58 beats per minute, blood pressure of 196/87 mm Hg, respiratory rate of 18 breaths per minute, and oxygen saturation of 95% on room air. On physical examination, he had midline cervical tenderness to palpation and tolerated minimal neck range of motion. His neurologic exam was nonfocal. Head and cervical spine helical CT scans with 0.6-mm axial bone reconstructions and multiplanar reformations were negative for acute abnormality. The patient was discharged and instructed to follow-up with a health care provider within 2 days for repeat imaging if he continued to have pain. Two days later, the patient returned to the emergency department with persistent midline cervical tenderness to palpation and limited neck range of motion. Repeat cervical spine CT was again negative for any acute abnormality (Fig. 1). Cervical spine MRI demonstrated a type 2 dens fracture (Fig. 2). Neurosurgery was consulted and the patient admitted. He was determined to be a poor surgical candidate, so nonoperative management with prolonged cervical spine immobilization was pursued. He was immobilized with a cervical collar for 3 and a half months after which time he remained without any neurologic symptoms. Flexion/extension cervical spine plain films were determined to be stable, and neurosurgery discontinued the patient’s cervical collar. The disposition for neurologically intact and alert patients with persistent neck pain despite negative CT imaging is controversial. Guidelines endorse continuation of cervical collar immobilization or additional workup with either MRI or flexion-extension radiography [3]. The reason for this controversy is the fact that, although CT is highly sensitive for osseous injury (95%-100%), it is insensitive for ligamentous and spinal cord injuries (0%-12%). Conversely, MRI has relatively poor sensitivity for fractures (50%) but excellent sensitivity for ligamentous and spinal cord injuries (100%) [2]. We searched the peer-reviewed literature for previous reports of CTnegative unstable cervical spine fractures detected by MRI. Four studies
0735-6757/Published by Elsevier Inc.
Please cite this article as: April MD, et al, Unstable Cervical Spine Fracture with Normal Computed Tomography Imaging: A Case Report, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.043
2
M.D. April et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
cal fracture (not otherwise specified) [4]. The second patient was noted to have fractures of the C3 pedicle, C2 spinous process, and C7 transverse process with associated ruptures of the interspinous and supraspinous ligaments and the ligamentum flavum [5]. Both patients were treated with immobilization by cervical collar; neither underwent operative repair. Interpretation of the cervical spine imaging literature is complex and often contradictory in its findings [7,8]. This reflects both its size and heterogeneity in imaging technology and patient characteristics. To our knowledge, the present case is unique in its clear documentation of an unstable cervical spine fracture in a neurologically intact patient missed by repeat imaging with a modern CT scanner and detected by MRI. This case adds to the growing evidence base suggesting a significant prevalence of actionable cervical spine injuries in patients with blunt trauma with persistent symptoms after negative CT imaging, although this literature has previously focused on missed ligamentous and spinal cord injuries [9]. The emergency physician should strongly consider early MRI in lieu of discharge with prolonged cervical collar immobilization for alert and neurologically intact patients with persistent midline pain to palpation despite negative CT imaging.
Fig. 1. Sagittal CT image of the cervical spine. Multilevel cervical spondylosis without acute osseous abnormality. No cortical irregularity or prevertebral swelling is identified to suggest a fracture.
Michael D. April MD, DPhil, MSc ⁎ Robert E. Watts MD Austin T. Folley MD Michael Barakat DO Lisa M. Mannina MD James A. Pfaff MD Departments of Emergency Medicine and Radiology, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX ⁎Corresponding author. E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.04.043 References
Fig. 2. Sagittal T1-weighted MRI of the cervical spine. Linear hypointensity extending through the base of the odontoid consistent with a minimally displaced type 2 odontoid fracture.
reported CT-negative cervical spine fractures identified on MRI, but none of these fractures were reported to be unstable [2,4-6]. Two patients with cervical spine fractures detected on MRI after negative CT were subsequently treated. The first patient was reported to have an isolated cervi-
[1] Mathen R, Inaba K, Munera F, Teixeira P, Rivas L, Mckenney M, et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J Trauma 2007;62:1427–31. [2] Holmes JF, Mirvis SE, Panacek EA, Hoffman JR, Mower WR. Variability in computed tomography and magnetic resonance imaging in patient cervical spine injuries. J Trauma 2002;53:524–9. [3] Como JJ, Diaz JJ, Dunham M, Chiu WC, Duane TM, Capella JM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. J Trauma 2009;67:651–9. [4] Menaker J, Stein DM, Philp AS, Scalea TM. 40-slice multidetector CT: is MRI still necessary for cervical spine clearance after blunt trauma? Am Surg 2010;76:157–63. [5] Fisher BM, Cowles S, Matulich JR, Evanson BG, Vega D, Dissanaike S. Is magnetic resonance imaging in addition to a computed tomographic scan necessary to identify clinically significant cervical spine injuries in obtunded blunt trauma patients? Am J Surg 2013;206:987–93. [6] Sarani B, Waring S, Sonnad S, Schwab CW. Magnetic resonance imaging is a useful adjunct in the evaluation of the cervical spine of injured patients. J Trauma 2007;63: 637–40. [7] Panczykowski DM, Tomycz ND, Okonkwo DO. Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: a meta-analysis of 14,327 patients with blunt trauma. J Neurosurg 2011;115:541–9. [8] Schoenfeld AJ, Bono CM, McGuire KJ, Warholic N, Harris MB. Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis. J Trauma 2010;68: 109–14. [9] Ackland HM, Cameron PA, Varma DK, Fitt GJ, Cooper DJ, Wolf R, et al. Cervical spine magnetic resonance imaging in alert neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. Ann Emerg Med 2011;58:521–30.
Please cite this article as: April MD, et al, Unstable Cervical Spine Fracture with Normal Computed Tomography Imaging: A Case Report, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.043
