Too quick to clear the spine

Twenty-eight-year-old Miss T was a pillion passenger on her boyfriend’s motorbike going at high speed on a motorway. He lost control of the vehicle and tried to regain it by braking, which threw them both over the handles, landing some distance away. Unfortunately, Miss T’s boyfriend was certified dead at the scene of the accident.

The paramedics who dealt with Miss T removed her helmet, following appropriate guidelines, and then immobilised her neck with a rigid collar and head blocks. She was then moved on a long spinal board and rushed to the local emergency department (ED).

Dr W was the consultant in charge and was already expecting Miss T in the resuscitation room, where he took a brief handover from the ambulance crew. Miss T was fully conscious on arrival with a GCS of 15/15 and was hemodynamically stable. Dr W performed a primary survey and then requested a series of trauma x-rays, including c-spine, pelvis and thorax. On a full secondary survey, Dr W suspected fractures of left clavicle, left wrist, right hand and left tibia and fibula, which were all confirmed soon after by x-rays.

Dr W removed the collar and felt for tenderness in Miss T’s cervical spine processes, but Miss T said that it was not painful; neurological examination was also normal. The cervical spine x-ray only showed down to the top of C6 but didn’t show any fractures so Dr W removed the collar and wrote in his notes: “C-spine cleared”.

The orthopaedic team took over Miss T’s care and she was then moved to theatre for surgical management of her fractured tibia and manipulation of her wrist. When she was still in the recovery room following surgery, Miss T mentioned that she had some tingling in her legs and that her legs felt heavy and weak. This was documented in the nursing notes but was not acted upon.

In severe trauma cases, getting a detailed history and an accurate description from the paramedics is always a good start

Once she was moved to the orthopaedic ward, Miss T continued to complain about paraesthesias in all her limbs; she also mentioned that her head felt unstable as if “it was falling backwards”. She also had a long episode of hypotension that did not respond to fluids. Two different orthopaedic junior doctors made entries in her clinical notes about this and they both commented that Miss T’s c-spine had been cleared earlier on by the ED consultant. They both felt that the symptoms could be related to the multiple limb fractures.

Three days after the accident, the orthopaedic consultant in charge requested a c-spine CT during the ward round since Miss T continued to mention that her limbs felt weak and numb. The CT was done but it was not reviewed by the radiologist until the following morning, when he immediately acted upon it and contacted the orthopaedic team; it was finally confirmed that Miss T had a displaced fracture of C6.

Unfortunately, the final outcome was not good and Miss T was left tetraplegic. She made a claim against all the doctors involved in her care and following expert review it became obvious that the case could not be defended. The case was settled for a high sum.

Learning points

• It is important to ensure that all investigations are followed up
  In severe trauma cases, getting a detailed history and an accurate description from the paramedics is always a good start. The presence of fatally injured victims in the same accident is an indicator of the severity of the trauma sustained by survivors. The kind of vehicles involved, approximate speed, description of surroundings, distance between motorbike and victims, description of witnesses and so on will give you invaluable information.
• Distracting injuries make clinical evaluation of the cervical spine less useful and sometimes completely unreliable. Localising the pain to the neck becomes far more difficult when there is severe pain in other areas of the body, particularly the torso. In most cases of major trauma an adequate three view cervical spine plain film series will be necessary. When clinical assessment is complicated by multiple injuries or mental obtundation, or the plain films are inadequate, further imaging should be considered. Clinical guidelines are available on The College of Emergency Medicine website.
• Most trauma centres would consider doing a full trauma CT scan from the head to pelvis. You should check the adequacy of cervical spine x-rays and make sure that they are reliable; in this case you should ensure that the cervical spine down to C7 has been visualised.
• Relying on the diagnosis of other colleagues when there are worrying symptoms could result in a missed or delayed diagnosis. Diagnosis is a dynamic process and, when necessary, previous clinical impressions by other colleagues need to be challenged, even those of senior colleagues by more junior doctors.
• When patients do not respond as expected, the situation needs reviewing. A hypotensive trauma patient not responding to fluids might be suffering with neurogenic shock, secondary to spinal injury, but unless it is thought about, the diagnosis will remain missed.
• It is important to ensure that all investigations are followed up – remember your responsibilities when you are part of a multidisciplinary team. Ensure that there is continuity of care.