Missed cervical spine injuries: a national survey of the practice of evaluation of the cervical spine in confused and comatose patients.

Abstract

AIM: Identifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals. PATIENTS AND METHODS: All hospitals in England with an Emergency Department were asked about the protocols which they use for assessing the cervical spine. All 22 Major Trauma Centres (MTCs) and 141 of 156 non-MTCs responded (response rate 91.5%). RESULTS: Written guidelines were used in 138 hospitals (85%). CT scanning was the first-line investigation in 122 (75%). A normal CT scan was sufficient to clear the cervical spine in 73 (45%). However, 40 (25%) would continue precautions until the patient regained full consciousness. MRI was performed in all confused or comatose patients with a possible cervical spinal injury in 15 (9%). There were variations in the grade and speciality of the clinician who had responsibility for deciding when to discontinue precautions. A total of 31 (19%) reported at least one missed cervical spinal injury following discontinuation of spinal precautions within the last five years. Only 93 (57%) had a formal mechanism for reviewing missed injuries. TAKE HOME MESSAGE: There are significant variations in protocols and practices for the clearance of the cervical spine in multiply injured patients in acute hospitals in England. The establishment of trauma networks should be taken as an opportunity to further standardise trauma care.