Despite a growing awareness of the association between automobile accidents and spinal cord injuries, a recent British study shows that nearly one in 10 such injuries is being missed in acute care settings.
Poonnoose and associates conducted a retrospective analysis of records for 569 patients who experienced neurologic deficits as a result of traumatic spinal cord injury. All were admitted to a specialized facility (directly from an emergency unit or from a referring hospital after acute care) for comprehensive management between April 1989 and April 1999. Most injuries were associated with traffic accidents or falls.
Of the 569 patients under study, the diagnosis of spinal cord injury was missed initially in 52 (9.1%) and not made until 10 hours to six weeks later. Of these patients, 33 (63%) experienced paralysis that went unrecognized, in some cases by neurosurgeons or orthopedic surgeons. In 34 of the 52 patients, inappropriate treatment was administered (defined as mismanagement by the study authors), and in 30 of these cases, the offered treatment was considered “negligent and inappropriate.”
In 26 patients, mismanagement reportedly led to neurologic deterioration–in nine cases, to complete paralysis. Six patients died because diagnosis was delayed.
Rarely were spinal cord injuries missed because of a single factor, the investigators report. Several factors, often in combination, were felt to contribute to practitioners’ failure to recognize spinal cord injuries. These included the circumstances surrounding the accident and manifestations of injury (including patients who were inebriated, hysterical, unconscious, or in need of ventilation), inadequate neurologic assessment, associated injuries (multisystem injuries and/or significant head trauma), and radiographs that were of poor quality or that were misinterpreted. In eight cases, the first clinician to assess the patient did not think that imaging was warranted.
While the researchers acknowledge the importance of carefully reviewed radiographs in assessing trauma patients, they emphasize that “The diagnosis of spinal cord injury is made on the basis of clinical examination”–including a detailed, systematic Motor and sensory examination to exclude paralysis. To reduce the risk of inflicting further injury through inappropriate treatment (and possibly subjecting themselves to “expensive medical litigation”), the authors urge clinicians to immobilize the patient’s spine until a clear diagnosis is made.
Poonnoose PM, Ravichandran G, McClelland MR. Missed and mismanaged injuries of the spinal cord./Trauma. 2002;53:314-320.
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