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A 46-year-old man fell four steps, striking his neck and having associated neck pain and discomfort. He was evaluated at a local emergency department and reported no neurological deficit but focal mid cervical tenderness. Radiographs and computed tomography (CT) scan were “negative” for cervical spine fracture, dislocation or pre-vertebral soft tissue swelling. He was discharged home in a cervical collar with a scheduled outpatient follow-up. Over the proceeding hours neurologic deterioration occurred, including hand and lower limb weakness with the inability to urinate. The patient returned to the local emergency room and was transferred to a tertiary care hospital where examination revealed C5ASIAB deficits. Repeat high resolution CT scan of the cervical spine with reformatted images was unremarkable for osseous fractures except some loss of definition in the posterior cervical musculature. Emergency magnetic resonance imaging MRI revealed a subluxation of C5/6 right facet (not evident on CT) with disruption of the posterior longitudinal ligament, ligamentum flavum, and disc space with abnormal T2 weighted spinal cord hyperintense signal at C5/6. He underwent emergency C5–C6 anterior and posterior decompression and fusion. One week later an examination showed improved C5ASIAD. This case reveals the difficulty of assessing the cervical spine for instability and potential limitations of current management schemes.
Cervical spine injuries are infrequent and account for a paucity of blunt trauma injuries.1 Davis et al reported, in a retrospective analysis of 740 patients with cervical spine injuries, an incidence of 4.6% of delay or misdiagnosed cervical spine injury.2 Reviews of the current literature or guidelines are incomplete in evaluating cervical spine injury.3,4
Patients with blunt trauma presenting awake and alert (no intoxicating medications), without distracting injury or neck tenderness, can be “cleared” if they have a full range of motion without pain.4 However, in the presence of neck pain, cervical radiographs and computed tomography (CT) scan are relied upon to evaluate for traumatic cervical spine injury.5 We present a case in which the patient was managed in a collar and still had a progressive neurologic deterioration.
The case is important for the following reasons:
A 42-year-old man presented to a local emergency department with neck pain after reportedly falling asleep and falling from four steps. He denies loss of consciousness. His reported physical examination was normal except for focal neck pain including neurologic status. Imaging, including x-rays and CT scan of the cervical spine, were reported as “normal” according to the patient. He was discharged and recalled mild difficulty getting out of the taxi when he arrived home, requiring help. Overnight he developed difficulty with urination and weakness in his lower limbs progressing to his upper limbs. He returned to the emergency department with obvious neurologic deficit, and was transferred to a tertiary care facility where he was classified as a C5ASIAB.
Motor examination revealed 5/5 strength in the upper limbs with the exception of 2/5 in left elbow extensors, 3/5 strength of left wrist extensors, 1/5 in right elbow and wrist extensors, and 0/5 in bilateral finger flexors and abductors. Low limb motor power was 0/5. Sensory examination to pinprick and light touch was diminished caudally from C5 bilaterally. Proprioception at the great toes and ankles was absent. Bilateral biceps reflexes were 2/4 with absent triceps, brachioradialis, patella, and Achilles reflexes. Hoffman’s, plantar response and ankle clonus were absent. General tone was decreased in the lower limbs and normal in the upper limbs. Rectal examination had normal sensation to light touch and pinprick, voluntary anal contraction, and present bulbocavernosus reflex. Repeat cervical spine CT illustrated no osseous fractures or pre-vertebral soft tissue swelling, but did identify loss of the posterior muscle tissue lines (fig 1). Cervical spine MRI done immediately after completion of the CT revealed subluxation of C5 on C6 with disruption of the posterior longitudinal ligament, ligamentum flavum and disc space with abnormal T2 weighted spinal cord hyperintensity from C5 through C6 (fig 2). The subluxation of the facet with minimal motion in a controlled environment while having his collar on illustrates the instability of this lesion. He underwent C5/6 anterior cervical discectomy, allograft fusion, anterior cervical plate, and subsequent posterior decompression and fusion. A week after the injury, his exam had improved to C5 ASIA D. He was discharged to the spinal cord injury model systems acute rehabilitation hospital.
The identification of clinically significant ligamentous and osseous injuries can be extremely difficult. Clinical guidelines are an important aspect of evaluation and the treatment algorithm and their goals are to provide optimal patient care while limiting expense and costs to society. In this unique presentation the severity of the injury was not identified until the patient had a neurologic injury and subsequent MRI scan. Current literature and spine clearance guidelines do not justify performing a cervical MRI in the initial evaluation if the initial cervical CT scan is normal without concomitant high velocity trauma, unconsciousness or neurological deficit.3,4
Review of this particular case draws attention to our current treatment algorithm for neck trauma without neurologic deficits, loss of consciousness, high velocity trauma, and normal cervical CT. MRI is an extremely valuable imaging modality. Vaccaro et al reported 25% of patients with neurological deficits had their management altered with MRI.5 However, there are a limited number of resources and increased cost associated with their implementation. Also these studies can often lead to further confusion in the management of the patient. MRI is oversensitive and an increased T2 signal which is clinically insignificant may lead to unnecessary surgical intervention and/or prolonged immobilisation with their associated risks and increased health care costs.6
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.