a b s t r a c t

Cervical spinal fracture is a rare, but potentially disabling complication of trauma to the neck. Clinicians often rely on clinical decision rules and guidelines to decide whether or not imaging is necessary when a patient presents with neck pain. Validated clinical guidelines include the Canadian C-Spine Rule and the Nexus criteria. Studies suggest that the risks of a Pathologic fracture from a simple rear end collision are negligible. We present a case of an individual who presented to an emergency department (ED) after a low speed motor vehicle collision complaining of lateral neck pain and had multiple subsequent visits for the same complaint with negative exam findings. Ultimately, he was found to have a severely pathologic cervical spine fracture with notable cord compression. Our objective is to discuss the necessity to incorporate clinical decision rules with physician gestalt and the need to take into account co-morbidities of a patient presenting after a minor MVC.

(C) 2017

Cervical spinal fracture is a rare, but potentially disabling complica- tion of trauma to the neck. Clinicians often rely on clinical decision rules and guidelines to decide whether or not imaging is necessary when a patient presents with traumatic neck pain. Validated clinical guidelines to assess for C-spine injury in trauma patients include the Ca- nadian C-Spine Rule and the Nexus criteria. Studies suggest that the risks of a pathologic fracture from a simple rear end collision are negli- gible [1]. We present a case of an individual who presented to an emer- gency department (ED) after a low speed motor vehicle collision complaining of lateral neck pain and had multiple subsequent visits for the same complaint with negative exam findings. Ultimately, he was found to have a pathologic cervical spine fracture. Our objective is to discuss the necessity of incorporating physician gestalt and medical co-morbidities along with clinical decision rules in patients presenting after a minor MVC.

A 68-year-old man presented to the ED after being the restrained driver in a low speed MVC. There was no air bag deployment, and the car was drivable. His PMH was significant for chronic kidney disease, hepatitis, and chronic pain which was being treated with narcotics by his primary care provider. On presentation he complained of “mild neck and right shoulder pain.” His review of systems was negative for any Neurological complaints, and his physical exam was noted to have no spinous process tenderness and normal range of motion. Imaging was not performed and he was discharged home. He returned 17 days later with continued complaints of shoulder pain, requesting narcotic

* Corresponding author at: Department of Emergency Medicine, 1 Boston Medical Center Pl, Boston, MA 02118, United States.

E-mail addresses: [email protected] (A. Hunter), [email protected] (J. McGreevy), [email protected] (J. Linden).

pain medication. His exam continued to show normal range of motion with no other findings noted and review of systems was negative for any neurological complaints. He was again discharged.

The patient returned to the ED approximately 3 months later after being referred from Physical therapy. He complained of midline neck pain. The neurological review of systems was negative and his Physical exam findings revealed no neurologic deficits though did note reduced range of motion and left para-spinal tenderness. A 3-view cervical spine X-ray was performed which revealed “acute kyphotic deformity at C5- C6 where there are anterior wedge compression deformities of the bod- ies of the C5 and C6. There is suggestion of sclerosis along the fracture marking of C6, which would be appropriate given the interval between injury and the current presentation” (Fig. 1).

An MRI revealed a pathologic compression fracture of C6 with severe canal narrowing with associated cord edema (Fig. 2).

The orthopedic spine service was consulted, and the patient was placed in cervical traction.

This case incorporates several pertinent aspects of emergency care. With reference to cervical spinal injuries, some experts suggest that physical exam can rule out cervical spine fracture in cases with low sus- picion [2]. Others state that numerous fractures can be missed with this technique [3]. According to the NEXUS criteria, there is no older age cut- off and while subsequent studies have shown decreased sensitivity in the elderly patient population, one study validates it’s use in low risk el- derly falls [4,5]. However, the Canadian Cervical Spine Rules (CCR) would have recommended imaging for this patient, as he is older than age 65 and one study has shown superiority of the CCR [6].

Important too, is that underlying medical conditions can potentially have a significant impact on the presentation and outcome of cases of

http://dx.doi.org/10.1016/j.ajem.2017.05.038

0735-6757/(C) 2017

Fig. 1. X-Ray Cervical Spine, Lateral View.

Fig. 2. MRI Cervical Spine.

traumatic injury. While the effect of Chronic kidney disease (CKD) on traumatic C-spine injuries has not been studied, CKD is associated with known alterations in bone density and mineralization [7].

It is essential to incorporate all aspects of a patient’s medical condi- tions, along with the history and physical examination when utilizing established guidelines in addressing cervical spinal fracture. Despite a reassuring exam, history, and use of clinical decision tools, it is critical to carefully evaluate a patient’s complaint, especially on repeat visits.

References

1. Thompson WL, Stiell IG, Clement CM, Brison RJ, Canadian C-Spine Rule Study Group. Association of injury mechanism with the risk of cervical spine fractures. CJEM Jan 2009;11(1):14-22.
2. Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, et al. Practice manage- ment guidelines for identification of Cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma practice management guide- lines committee. J Trauma Sep 2009;67(3):651-9.
3. Duane TM, Dechert T, Wolfe LG, Aboutanos MB, Malhotra AK, Ivatury RR. Clinical ex- amination and its reliability in identifying cervical spine fractures. J Trauma Jun 2007; 62(6):1405-8.
4. Tran John, Jeanmonod Donald, Agresti Darin, Hamden Khalief, Jeanmonod Rebecca K. Prospective validation of modified NEXUS cervical spine injury criteria in low-risk el- derly fall patients. West J Emerg Med May 2016;17(3):252-7.
5. Touger M, Gennis P, Nathanson N, Lowery DW, Pollack Jr CV, Hoffman JR, et al. Valid- ity of a decision rule to reduce Cervical spine radiography in elderly patients with blunt trauma. Ann Emerg Med Sep 2002;40(3):287-93.
6. Stiell Ian G, et al. N Engl J Med 2003;349:2510-8.
7. Thomas Robert, Kanso Abbas, Sedor John R. Chronic kidney disease and its complica- tions. Prim Care Jun 2008 Jun;35(2):329-vii.