Scholarly article on topic 'The importance of full spinal cord screening and assessment of trauma patients involved in motor vehicle accidents – A case report'

The importance of full spinal cord screening and assessment of trauma patients involved in motor vehicle accidents – A case report Academic research paper on "Clinical medicine"

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{كسر / "حوادث السيارات" / فرز / "العمود الفقري" / إصابة / أشعة / Fracture / MVA / Screening / Spine / Trauma / X-ray}

Abstract of research paper on Clinical medicine, author of scientific article — Bashir Alenazi, Abdul-Rehman Mohammad Qureshi, Siyad AlFaraidy, Ahmed Almulla

Abstract Traumatic spinal cord injury due to motor vehicle accidents is the predominant reason for emergency room visits in central Saudi Arabia 1 and developed countries. 2 If head and neck trauma is suspected, then cervical spine imaging is commonly performed to rule out spinal fracture. 3 But in instances where there seems to be mild trauma, the remainder of the spine is not imaged. 3 The proceeding case is about a 45-year-old motor vehicle accident survivor with a history of ankylosing spondylitis. Initial clinical examination revealed an apparent mild traumatic spinal injury without a cervical-spine fracture. To the attending physicians, this finding did not warrant for a thorough neurological examination along with a full imaging scan. Radiography of the thoracic spine was not performed until it became clear that there were symptoms suddenly emerging after patient stabilization. By that time however, it was too late: an undisclosed thoracic spine fracture caused significant spinal cord compression, and this in turn led to complete paraplegia. We therefore emphasize that all trauma survivors of road traffic accidents undergo a comprehensive spinal cord scanning and assessment, regardless of the initial severity and symptomology of the injury.

Academic research paper on topic "The importance of full spinal cord screening and assessment of trauma patients involved in motor vehicle accidents – A case report"

Journal of Taibah University Medical Sciences (2013) 8(3), 183-186

Taibah University Journal of Taibah University Medical Sciences

www.sciencedirect.com

Case Report

The importance of full spinal cord screening and assessment of trauma patients involved in motor vehicle accidents - A case report

Bashir Alenazi, MBBS a *, Abdul-Rehman Mohammad Qureshi, B.Sc.b1, Siyad AlFaraidy, MBBSa and Ahmed Almulla, MBBSa

a Department of Orthopedic Surgery, Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia b Department of Psychology & NeuroscienceUniversity of Toronto at Scarborough, Toronto, Ontario, Canada

Received 8 December 2012; revised 15 April 2013; accepted 7 July 2013

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Abstract

Traumatic spinal cord injury due to motor vehicle accidents is the predominant reason for emergency room visits in central Saudi Arabia1 and developed countries.2 If head and neck trauma is suspected, then cervical spine imaging is commonly performed to rule out spinal fracture.3 But in instances where there seems to be mild trauma, the remainder of the spine is not imaged.3 The proceeding case is about a 45-year-old motor vehicle accident survivor with a history of ankylosing spondylitis. Initial clinical examination revealed an apparent mild traumatic spinal injury without a cervical-spine fracture. To the attending physicians, this finding did not warrant for a thorough neurological examination along with a full imaging scan. Radiography of the thoracic spine was not performed until it became clear that there were symptoms suddenly emerging after patient stabilization. By that time however, it was too late: an undisclosed thoracic spine fracture caused significant spinal cord compression, and this in turn led to complete paraplegia. We therefore emphasize that all trauma survivors of road traffic accidents undergo a comprehensive spinal cord scanning and assessment, regardless of the initial severity and symptomology of the injury.

* Corresponding author. Address: Consultant Orthopedic Surgeon, Department of Orthopedic Surgery, Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia. Tel.: +966 (11) 477 7714x25667; fax: +966 (11) 475 7805.

E-mail: benazi11@yahoo.com (B. Alenazi), utqr@live.ca (A.-R.M. Qureshi), siyad.alfaraidy@facebook.com (S. AlFaraidy), ahmed.almulla@ facebook.com (A. Almulla).

1 Tel.: +1 647 400 4840. Peer review under responsibility of Taibah University.

1658-3612 © 2013 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/jjtumed.2013.08.003

Keywords: Fracture; MVA; Screening; Spine; Trauma; X-ray

© 2013 Taibah University. Production and hosting by Elsevier Ltd. All rights reserved.

Introduction

Traumatic spinal cord injury (TSCI) is a wound-inflicted damage to the spine that can result in associated motor and sensory deficits, such as paralysis and sensory loss.1 This is the most frequent cause of road traffic accidents in developed coun-tries,2 as well as in central Saudi Arabia.1 Despite the preponderance of such cases, many spinal injuries still go unnoticed, as the associated symptoms may not be present. In a comprehensive study assessing motor vehicle injuries, 88% of patients presented with spinal injuries without associated neurological deficits, while 12% showed clinical signs of spinal injuries.4

Ankylosing spondylitis (AS) falls under the spondyloarth-opathies, a class of interconnected chronic inflammatory rheumatoid diseases.5 The cause of this disease is unknown6, though a correlation has been made with the gene HLA-B27.7 The incidence of AS is two7 times greater among men than women. It is characterized by gradual, targeted deterioration of the vertebral column via the enhancement of spinal axis remodeling processes through disease states such as osteoporo-sis8 and kyphosis.9'10 The ultimate outcome of such reshaping is a frail vertebral column, which makes the spine prone to fracture from even a trivial trauma.8,10 In fact, a Finnish national prevalence study revealed that the presence of AS increases the likelihood of traumatic spinal cord injury by 11.4 times that of the general population.11

In trauma involving the head and neck, cervical spine imaging is performed to rule out spinal fracture.12 Given that there are symptoms present in other parts of the spine, the second step is to radiologically screen the entire spine during ATLS resuscitation.3 This may include X-ray and also CT scans, especially after the stabilization of the patient condition.3 In the absence of other clinical findings, the rest of the spine is usually not imaged.3 This report instead emphasizes the need to screen the entire spinal cord13, whether or not neurological symptoms are clearly present. Doing so can potentially prevents associated motor and sensory damage from developing into a subsequently severe and irreversible disability.14,15

Case report

A 45-year-old male with a history of ankylosing spondylitis was brought to the emergency department following a motor vehicle accident. Immediately upon arrival, Foley's catether was passed. He was conscious and fully oriented. There was no pain in the chest, abdominal, back, neck, limb or joint. Nor was there any headache, vomiting, shortness of breath, or loss of bladder or bowel control. Rather, he complained of painful right hip swelling without any radiation of pain to the lower right extremities. A physical examination showed mild right frontal head contusion. Upon examination of the right hip, skin contusion and swelling was noted, but no tenderness or visible deformity. An X-ray of his right leg revealed

a fracture of the right femur (see Figure 1a). His peripheral pulses were strong and palpable. C-Spine range of motion was normal, as was the chest X-ray (shown in Figure 1b).

After the successful repair of the femur fracture (depicted in Figure 1c), attention was directed toward sensory changes accompanied by weakness to the left leg. Accordingly, a further investigation of the complete spine was performed with MRI (Figure 2a), X-ray (Figure 2b), and CT scan (Figure 2c). Together, these neuroimaging techniques conclusively revealed the thoracic spine fracture: there was a dislocation at the T10-T11 level with full spinal cord injury, compression and possible cord hemi-section. Soon after, the patient became paraplegic.

Figure 1a: Right leg X-ray depicting a visible displacement and angulation at the right femur.

Figure 1b: Chest X-ray of a plausible arterial hypertension in the patient, though this was not attended to in the emergency room.

The importance of full spinal cord screening

Figure 1c: Right leg X-ray after repair of the right femur. Discussion

The aforementioned case represented a failure to detect a thoracic vertebral fracture in a road-traffic accident survivor suffering from AS. This AS patient, along with many others may fall under the category of no or acute spinal trauma at initial detection, as the ankylosed spine commonly develops in the context of trivial or no injury.10'16

The management of patients with acute spinal trauma hinges on radiographic imaging of the cervical spine.14'17 Depending on the patient's condition, a chest X-ray may commonly accompany this.12'13 Established protocols suggest that while cervical spine imaging is critical to the diagnosis and management of these patients,13'14 thoracic and lumbar segments of the spine are less often involved.

On the contrary, there are studies that find considerable proportions of individuals suffering from fractures in the thoracic and or lumbar spine. For instance, Shih et al. and Wang et al. reported more AS cases of thoracolumbar fracture than of cervical spine in their studies.16,18 Furthermore, Grosolia et al. used roentgenograms to discover that about 85% of their patients had old, unrecognized spinal fractures, of which there were more present in the thoracic and lumbar segments than in the cervical segment.19

In this case, however, since the femoral fracture was the major focus of management, thoracic spine imaging was postponed. In fact, the diversion of focus to the more easily

diagnosed non-vertebral fracture is one reported reason for the failure to diagnosis vertebral fracture.20 The physical examination of the lower extremities was difficult to complete due to the immobilization associated with the surgical reduction of the femoral fracture. Consequently, it was not possible to accurately assess the neurological response in the absence of diagnostic tests.14 Palpable pulses however, implied that the lesion was limited to the right femur and so no suspicion of thoracic cord compression was raised. As a result, the diagnosis of the T10-11 fracture in this patient was unfortunately missed due to medical attention directed toward the more obvious symptoms associated with the femoral fracture. Earlier diagnosis of the thoracic spine fracture would have significantly changed the direction of patient treatment toward early neurosurgical intervention to prevent lifelong disability.21,22

Akin to the patient in our report, there are cases in the literature that depict a lack of careful, comprehensive scanning and assessment of spinal fractures leading to devastating consequences. In parallel to our case, Grosolia et al. reported a 56-year-old male AS patient complaining of a left femur fracture upon arrival to an emergency room after a motor vehicle acci-dent.19 Several hours later however, he was found to have complete leg immobilization due to several undisclosed thoracic fractures.19 Levi et al. encountered a 47-year-old male entering their trauma center complaining of back pain following a high-velocity road traffic accident.23 Initial screening using plain radiographs found normal lumbar and thoracic spinal segments, though a subsequent round of imaging following his return a week later revealed a TL12L1 fracture dislocation, which was gradually repaired.23Aoki et al. reports a failure to detect a thoracic vertebral fracture from an initial radiological assessment on a 91-year-old male AS case hospitalized 24 h after a fall.15 Consequently, he suffered from a persistent, incomplete paralysis despite significant neurological improvements through surgery.15 Although we presented only a few cases here, the present case and many more have been published in the literature to emphasize that a scrupulous screening of the entire spine is necessary to avoid misdiagno-sis.9,10,24-26

Conclusion

Motor vehicle accidents are a common reason for emergency department visits. The typical routine is to perform the mandatory C-spine X-ray to rule out fracture, and not further visualize the other regions of the spine unless symptoms are noted. This methodology is clearly not comprehensive and can lead

(a) (b) (C)

Figure 2: (a) MRI, (b) X-ray and (c) CT scans of the patient thoracic and lumbar spine showing a vertebral fracture in the 10th and 11th thoracic vertebrae with full spinal cord compression and a possible hemi-section.

to unforeseen calamities that would otherwise have been treated earlier, as was the case for our paraplegic patient. Therefore, we argue that all spinal trauma cases of motor vehicle accident survivors should undergo a comprehensive spinal cord screening and assessment, regardless of the initial severity and symptomology.

Contributions

The corresponding author Bashir Alenazi as well as Ahmed Almulla and Siyad AlFaraidy supervised, treated the patient and made the initial contribution to this paper. In response to comments made by the reviewers, Abdul-Rehman Mohammad Qureshi made a significant contribution in editing and revising the manuscript.

Declaration of interest

The authors report no conflicts of interest. References

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