1887
Volume 2017, Issue 1
  • ISSN: 1999-7086
  • E-ISSN: 1999-7094

Abstract

Prevention of secondary spinal injury via spinal protection measures is a standard component of trauma management, and a high-quality spinal clearance process is imperative in achieving this aim. To evaluate the current practice with a view to achieving best practice, we sought to examine the spinal clearance process and outcomes at a regional Australian referral hospital, which services a large geographical catchment area. A retrospective review of medical records of all patients with major trauma who presented to an Australian regional hospital during 2014 was conducted. The primary outcome measure was missed or delayed diagnosis of spinal injury. Secondary outcome measures included compliance with internationally accepted spinal clearance process measures, timing and choice of appropriate imaging modalities, rates of spinal injury and documentation of spinal clearance. Of the 112 patients with major trauma who met the study eligibility criteria and were discharged from hospital during the study period from 1 January to 31 December 2014, 11 spinal injuries were missed or delayed in diagnosis. The injuries occurred in 3.6% of patients and all were thoracolumbar spine (TLS) injuries. The predominant reasons for missed or delayed diagnosis were reduced sensitivity of plain X-ray compared with computed tomography for spinal injury screening and incomplete full spinal imaging to detect non-contiguous fractures. Evidence-based clinical decision rules are imperative in ascertaining the need for imaging in the TLS and would be enhanced by an internationally recognised definition of clinical significance based on injury morphology rather than clinician management decision alone. In addition, regional hospitals may have limited capacity to achieve spinal clearance, and other trauma quality assurance standards commensurate with national and international benchmarks without the valuable performance feedback provided by state trauma registries, as is currently the case in Queensland.

Loading

Article metrics loading...

/content/journals/10.5339/jemtac.2017.5
2017-05-12
2019-10-22
Loading full text...

Full text loading...

/deliver/fulltext/jemtac/2017/1/jemtac.2017.5.html?itemId=/content/journals/10.5339/jemtac.2017.5&mimeType=html&fmt=ahah

References

  1. [1]. Clancy   MJ. . Clearing the cervical spine of adult victims of trauma. . J Accid Emerg Med . 1999; ;16: 3 : 208– 214 .
    [Google Scholar]
  2. [2]. Ackland   HMCD., , Malham   GM., , Kossmann   T. . Factors predicting cervical collar-related decubitus ulceration in major trauma patients. . Spine . 2007; ;32: 4 : 423– 428 .
    [Google Scholar]
  3. [3]. Napolitano   LM., , Garlapati   VS., , Heard   SO., , Silva   WE., , Cutler   BS., , O'Neill   AM., , Anderson   FA Jr., , Wheeler   HB. . Asymptomatic deep venous thrombosis in the trauma patient: Is an aggressive screening protocol justified?.   J Trauma . 1995; ;39: 4 : 651– 657 .
    [Google Scholar]
  4. [4]. Platzer   PHN., , Jaindl   M., , Chatwani   S., , Vecsei   V., , Gaebler   C. . Delayed or missed diagnosis of cervical spine injuries. . J Trauma . 2006; ;61: 1 : 150– 155 .
    [Google Scholar]
  5. [5]. Miller   C., , Brubacher   J., , Biswas   D., , Lawrence   B., , Whang   P., , Grauer   J. . The incidence of noncontiguous spinal fractures and other traumatic injuries associated with cervical spine fractures: A 10-year experience at an academic medical center. . Spine . 2011; ;36: 19 : 1532– 1540 .
    [Google Scholar]
  6. [6]. Victorian State Trauma Outcome Registry and Monitoring Group. Victorian State Trauma System and Registry 1 July 2013 to 30 June 2014 Summary Report. Melbourne, Australia: Monash University and State Government of Victoria, Department of Health and Human Services; 2015 .
  7. [7]. Cairns and Hinterland Hospital and Health Service. The State of Queensland. Cairns and Hinterland Hospital and Health Service 2014–15 Annual Report. 2015 .
  8. [8]. Department of Health and Human Services. Victorian State Trauma System and Registry: Summary Report. Melbourne, Australia: Monash University, 2013–2014 .
  9. [9]. British Orthopaedic Association. Standards for Trauma: BOAST 2: Spinal Clearance in the Trauma Patient, volume 2, 2015. Available at: https://http://www.boa.ac.uk/wp-content/uploads/2015/03/BOAST-2-March-2015.pdf (accessed on May 2015) .
  10. [10]. Patel   MB., , Humble   SS., , Cullinane   DC., , Day   MA., , Jawa   RS., , Devin   CJ., , Delozier   MS., , Smith   LM., , Smith   MA., , Capella   JM., , Long   AM., , Cheng   JS., , Leath   TC., , Falck-Ytter   Y., , Haut   ER., , Como   JJ. . Cervical spine collar clearance in the obtunded adult blunt trauma patient: A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. . J Trauma Acute Care Surg . 2015; ;78: 2 : 430– 441 .
    [Google Scholar]
  11. [11]. Inaba   K., , Nosanov   L., , Menaker   J., , Bosarge   P., , Williams   L., , Turay   D., , Cachecho   R., , de Moya   M., , Bukur   M., , Carl   J., , Kobayashi   L., , Kaminski   S., , Beekley   A., , Gomez   M., , Skiada   D., , the AAST TL-Spine Multicenter Study Group. . Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma Multi-Institutional Trials Group Study. . J Trauma Acute Care Surg . 2015; ;78: 3 : 459– 465 .
    [Google Scholar]
  12. [12]. Sixta   S., , Moore   FO., , Ditillo   MF., , Fox   AD., , Garcia   AJ., , Holena   D., , Joseph   B., , Tyrie   L., , Cotton   B. . Screening for thoracolumbar spinal injuries in blunt trauma: An Eastern Association for the Surgery of Trauma practice management guideline. . J Trauma Acute Care Surg . 2012; ;73: 5 Suppl. 4 : S326– S332 .
    [Google Scholar]
  13. [13]. Como   JJ., , Diaz   JJ., , Dunham   CM., , Chiu   WC., , Duane   TM., , Capella   JM., , Holevar   MR., , Khwaja   KA., , Mayglothling   JA., , Shapiro   MB., , Winston   ES. . Practice management guidelines for identification of cervical spine injuries following trauma: Update from the Eastern association for the surgery of trauma practice management guidelines committee. . J Trauma . 2009; ;67: 3 : 651– 659 .
    [Google Scholar]
  14. [14]. Easton   R., , Sisak   K., , Balogh   Z. . Time to computed tomography scanning for major trauma patients: The Australian reality. . ANZ J Surg . 2011; ;82: : 644– 647 .
    [Google Scholar]
  15. [15]. Bernhard   M., , Becker   TK., , Nowe   T. . Introduction of a treatment algorithm can improve the early management of emergency patients in the resuscitation room. . Resuscitation . 2007; ;73: 3 : 362– 373 .
    [Google Scholar]
  16. [16]. Winslow   III JE., , Hensberry   R., , Bozeman   WP., , Hill   KD., , Miller   PR. . Risk of thoracolumbar fractures doubled in victims of motor vehicle collisions with cervical spine fractures. . J Trauma . 2006; ;61: 3 : 686– 687 .
    [Google Scholar]
  17. [17]. Nelson   DW., , Martin   MJ., , Martin   ND., , Beekley   A. . Evaluation of the risk of noncontiguous fractures of the spine in blunt trauma. . J Trauma Acute Care Surg . 2013; ;75: 1 : 135– 139 .
    [Google Scholar]
  18. [18]. Holmes   J., , Akkinepalli   R. . Computed tomography versus plain radiography to screen for cervical spine injury: A meta-analysis. . J Trauma . 2005; ;58: 5 : 902– 905 .
    [Google Scholar]
  19. [19]. Smith-Bindman   R., , Lipson   J., , Marcus   R., , Kim   KP., , Mahesh   M., , Gould   R., , Berrington de González   A., , Miglioretti   DL. . Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. . Arch Intern Med . 2009; ;169: 22 : 2078– 2086 .
    [Google Scholar]
  20. [20]. Cason   B., , Rostas   J., , Simmons   J., , Frotan   MA., , Brevard   SB., , Gonzalez   RP. . Thoracolumbar spine clearance: Clinical examination for patients with distracting injuries. . J Trauma Acute Care Surg . 2016; ;80: 1 : 125– 130 .
    [Google Scholar]
  21. [21]. The Victorian State Trauma System. Major Trauma Guidelines and Education. Available at: http://trauma.reach.vic.gov.au/. 2016 .
  22. [22]. Harvey   K., , Pollard   C., , Lang   J., , Dallow   N., , Spanagel   C., , Carroll   J. . Established trauma systems – Queensland Trauma Registry. . Injury . 2010; ;41: Suppl 1:S31 .
    [Google Scholar]
  23. [23]. Hoffman   JR., , Mower   WR., , Wolfson   AB., , Todd   KH., , Zucker   MI. . Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. . N Engl J Med . 2000; ;343: : 94– 99 .
    [Google Scholar]
  24. [24]. Stiell   IG., , Wells   GA., , Vandemheen   KL., , Clement   CM., , Lesiuk   H., , De Maio   VJ., , Laupacis   A., , Schull   M., , McKnight   RD., , Verbeek   R., , Brison   R., , Cass   D., , Dreyer   J., , Eisenhauer   MA., , Greenberg   GH., , MacPhail   I., , Morrison   L., , Reardon   M., , Worthington   J. . The Canadian C-spine rule for radiography in alert and stable trauma patients. . JAMA . 2001; ;286: : 1841– 1848 .
    [Google Scholar]
http://instance.metastore.ingenta.com/content/journals/10.5339/jemtac.2017.5
Loading
/content/journals/10.5339/jemtac.2017.5
Loading

Data & Media loading...

  • Article Type: Research Article
Keyword(s): Major trauma , spinal clearance , spinal injury and thoracolumbar spine
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error