Failure to Diagnose Spine Injury
April 1, 1998 34 minutes read
Failure to Diagnose Spine Injury
By Michael A. Gibbs, MD, FACEP, Clinical Instructor of Emergency Medicine, University of North Carolina at Chapel Hill, Department of Emergency Medicine, Carolinas Medical Center, Medical Director, MedCenter Air; Andrew Perron, MD, Chief Resident, Department of Emergency Medicine, Carolinas Medical Center; Daniel J. Sullivan, MD, JD, FACEP, Chairman, Department of Emergency Medicine, Ingalls Memorial Hospital, Harvey, Illinois
It has been estimated that up to 12,000 new spinal cord injuries occur each year in the United States. Currently, more than 200,000 people suffer from debilitating cord injuries.1,2 Spinal injury is predominantly a disease of productive adult males younger than 40 years old. The economic effect of this devastating injury is estimated to be more than $4 billion per year.3
Motor vehicle crashes (MVCs) are responsible for 85% of vertebral injuries; major contributors include speeding, alcohol, and failure to use restraints. One in every 300 MVC victims suffers a spinal injury; one in 14 if the occupant is ejected. About 14% of spinal injuries result from falls, and 1% from "miscellaneous" causes (diving accidents, missile injuries).1 Cervical spine injuries occur in 5-6% of trauma patients, while fractures of the thoracolumbar spine occur in 2-3%. Roughly 65% of vertebral injuries involve the cervical spine, 20% the thoracic spine, and 15% the lumbar spine.1
Prior to 1980, the majority of cord injuries arriving in the ED were complete injuries. With improved EMS capabilities, as many as 60% of all contemporary spinal injuries are incomplete. The physician caring for the patient with a spinal injury must be continually aware of the fact that excessive manipulation and inadequate immobilization can cause additional neurologic damage and worsen the patient's condition. Between 5-10% of lesions progress after the traumatic event during the initial resuscitation.4
Essentials of the Neurologic Evaluation
A detailed and precise neurological examination is critical in the initial evaluation of the patient with a possible spinal injury. Serial examination is of equal importance in order to identify and document evolving neurologic pathology. Guidelines for motor and sensory evaluations have been established by the American Spinal Injury Association (ASIA).5 In the awake, interactive patient, light touch sensation may be assessed by dermatome to localize the most cephalad extent of the spinal cord injury. Pain sensation can be used to test contralateral spinothalamic tract function. Motor function, indicative of ipsilateral corticospinal tract integrity, is assessed on a 0-5 scale. Dorsal column testing should not be neglected as it will differentiate between a complete lesion and an anterior cord syndrome. This is best examined with proprioception or vibration in the distal extremities. Special attention should be paid to rectal tone, sacral sensation, and bowel and bladder function to avoid missing injuries to the conus medullaris and cauda equina, as well as documenting complete vs. incomplete cord injury. Also remember that spinal shock may eliminate all spinal function and reflexes for the first 24-48 hours following injury. Reversal of spinal shock is heralded by the return of the bulbocavernosus reflex.6
Indication for Cervical Spine Radiography
The indications for cervical spine radiography have evolved considerably during the past decade. In the 1980s, the American College of Surgeons recommended cervical radiography in "any patient with major blunt trauma."7 While this approach was effective at excluding injury, it came at the expense of a large number of negative radiographs. In addition to the obvious financial implications, this resulted in unnecessary exposure to radiation and potential delays in trauma patient evaluation and treatment. More recent evidence suggests that in many cases patients at low risk for cervical spine injury can be identified clinically and safely managed without radiography.
Seven large case-series, with a combined total of 3877 patients, have used low-risk clinical criteria to exclude cervical spine injury.8-14 In these studies there were no cervical spine fractures in alert patients without spinal tenderness who were neurologically intact, not intoxicated, and did not suffer from other severely painful injuries. Similar criteria have been successfully used in children.15,16 A recent consensus statement by the American College of Radiology stated that cervical radiography could be safely excluded in this subgroup of patients.17
Cervical spine radiography is mandatory in blunt trauma patients who: 1) have neck pain and midline cervical tenderness on palpation; 2) have altered mental status as a result of brain injury, intoxication, or metabolic dyshomeostasis; 3) have neurologic deficits; or 4) have injuries that are considered severe enough to "distract" them from a cervical spine fracture. (See Table.) Similar indications have recently been validated for assessment of the thoracic and lumbar spine.18,19 The interrater reliability of these criteria is substantial, although it should be remembered that they can be subjective.20
There are occasional case reports of clinically occult cervical spine injuries in the literature.21-25 A careful review of these cases by Saddison et al26 revealed that these injuries were not truly asymptomatic. Several patients did have cervical pain or tenderness; those without clinical findings were either brain-injured, under the influence of drugs or alcohol, or victims of severe multisystem trauma.
Which X-Ray Views Should Be Obtained?
In 1989, Mirvis et al11 surveyed 125 North American trauma centers to assess different practice parameters for the evaluation of cervical spine injury. Two-thirds of the centers had established protocols for obtaining cervical radiographs, which varied widely. Thirty-five percent of respondents cleared the cervical spine with a cross table lateral (CTL) alone; 29% used a standard "three-view" series (CTL, AP, and open-mouth odontoid view [OMO]), and 24% routinely performed the "five-view" series (oblique views, in addition to the CTL, AP, and OMO).11 So, which views are needed to reliably exclude injury?
Is The CTL View Sufficient?
No. It has been demonstrated that the use of a CTL view alone is inadequate to rule-out cervical spine injury, with a sensitivity of between 57% and 85%.27-29 MacDonald et al28 found that the addition of the AP and OMO views to the CTL increased the sensitivity from 83% to 99%. For this reason, at least three views should be obtained in all cases.
It has been argued that a cross table lateral may be useful to "clear" the cervical spine prior to endotracheal intubation. This approach has several important pitfalls: 1) it may delay definitive airway management; 2) it does not exclude cervical injury and thus may provide the operator with a false sense of security; and 3) there is no evidence to support an increased risk of neurologic injury during endotracheal intubation, provided in-line stabilization and effective immobilization is maintained at all times.31-34
Three Views Or Five Views?
The issue of whether the oblique view is routinely needed remains an area of controversy. This view is held by some to be essential because it provides superior visualization of the posterior column (pedicles, articular pillars, neural foramina, and lamina).35 Turetsky et al36 found that the oblique views demonstrated certain fractures not detected on the three-view series. Conversely, Freemyer et al37 found no fractures or dislocations detected on the five-view series that were not identified on the three-view series. The authors noted that the oblique views provided better anatomic definition of laminar fractures and unilateral facet dislocations. While there is no consensus concerning the necessity for routine oblique radiographs in cervical trauma, this view may be useful in evaluating poorly visualized areas of the posterior column. In addition, the supine oblique view provides excellent definition of the cervicothoracic junction and may be used instead of the often inadequate swimmer's view.38,39 It is reasonable to use the oblique view selectively, after a three-view series has been evaluated.
What Is The Role Of Flexion-Extension Views?
Neurologically intact patients with persistent neck pain and tenderness despite normal plain radiographs should have flexion and extension views performed to exclude ligamentous injury.40 It is essential that the patient be alert and cooperative, as all neck movement must be initiated by the patient and discontinued immediately should pain occur. Manipulation of the neck by the physician or radiology technologist to overcome spasm is absolutely contraindicated. Filming in the erect position is preferred because this position better demonstrates ligamentous instability.41 In the obtunded or uncooperative patient with normal radiographs, dynamic fluoroscopy through the full range of flexion and extension may be safely performed to rule-out ligamentous injury.42
When Should Computed Tomography or MRI Be Performed?
Computed Tomography
Computed tomography (CT) scanning has proven to be an excellent method for evaluating cervical spine fractures and dislocations. Its advantages include speed, wide availability, axial imaging, and excellent cortical detail. Due to cost and high dose of ionizing radiation, it should be reserved to delineate bony anatomy at the level of identified fractures/dislocations, or in those cases where the upper or lower cervical spine cannot be adequately visualized.43 Several authors have also suggested that patients undergoing cranial tomography for the evaluation of traumatic brain injury should have CT imaging extending through the upper cervical spine (C1 and C2), as this area is often not well visualized using plain radiography.44,45 The primary limitation of CT imaging is that it does not adequately visualize the spinal cord or adjacent soft tissues.
Magnetic Resonance Imaging
The magnetic resonance image (MRI) is playing an increasing role in spinal cord injury evaluation. It has currently usurped the role of myelography for intracanal assessment in the evaluation of spinal trauma patients.43 Advantages of MRI include its lack of ionizing radiation, multiplanar imaging capabilities, and, most importantly, its ability to delineate all soft tissue structures (i.e., cervical discs, anterior and posterior ligamentous structures, as well as the spinal cord).44 MRI is indicated for 1) complete or incomplete neurologic deficits to search for and quantify the degree of root or cord injury; 2) deterioration of neurologic function; 3) suspicion of ligamentous injury despite negative flexion/extension films. Notable disadvantages of MRI include a prolonged acquisition time, unavailability at many institutions, and contraindications, including patients with pacemakers, ferromagnetic aneurysm clips, metallic fragments in the spinal cord, and claustrophobia.
Special Situations
Are Head and Maxillofacial Injuries Predictive of Cervical Spine Injuries?
No. The old dictum that "any patient with an injury above the clavicle needs cervical spine radiography" has not held up to scientific scrutiny. Several studies indicate that there is little, if any, relationship between head and facial injury and cervical spine injury. Williams et al45 reviewed 5021 consecutive trauma patients and found that the incidence of spinal injury in patients with maxillofacial trauma was 4-5%, no greater than the overall population of trauma patients. Sinclair et al46 reviewed the cases of 168 patients with facial fractures and found the incidence of cervical injury to be 4%. O'Malley et al47 compared 664 blunt trauma patients with significant head injury to 608 patients without head injury and found no difference in the incidence of cervical spine injury. Davidson et al48 reviewed 2555 patients admitted with facial fractures following motor vehicle crashes and found the incidence of cervical spine injury to be 5.5%. In other words, maxillofacial and head trauma in and of itself is not an indication for spinal radiography. These patients should be evaluated as all other victims of blunt trauma. Altered mental status as a result of head trauma is a clear indication for cervical radiography in this setting.
Pediatric Considerations
Cervical spine injuries are infrequent in children; fewer than 1% occur in patients younger than 12 years of age. In contrast to adults, the majority of pediatric injuries involve the occipito-atlantoaxial segment.49,50 Several anatomic factors predispose to this level of injury:51
1. a proportionally heavier head and a higher fulcrum of flexion;
2. laxer ligaments, allowing for more mobility at C1-C2;
3. unfused physes; and
4. horizontally inclined articular facets that facilitate sliding.
There are also a number of anatomic characteristics unique to the pediatric cervical spine that may mimic injury. These include pseudosubluxation at either C2-C3 or C3-C4 (this should not be associated with soft-tissue swelling or disruption of the spinolaminal line); anterior wedging of vertebral bodies; secondary ossification centers that may mimic avulsions; variable interspinous distances; widening of the predental space (up to 5 mm); and lateral displacement of the lateral masses of C1 on C2. These normal variants can make the interpretation of pediatric cervical spine radiographs particularly challenging.
Why Are Cervical Spine Fractures Missed?
It has been estimated that between 3% and 25% of patients with cervical spine injuries suffer extension of those injuries (paralysis or death) from delays in diagnosis or unwarranted manipulation in the ED. With more than 12,000 spinal injuries each year and settlements and jury verdicts in the millions, emergency physicians should carefully analyze the causes of missed or delayed spinal injuries. Despite an improved understanding of injury patterns, advances in diagnostic imaging, and a heightened awareness among well-trained emergency physicians, these injuries continue to be missed.
In 1979, Bohlman reported that 100 of 300 cervical fractures were missed during ED evaluation.52 The authors found that causes of delay in diagnosis included misreading of cervical spine films, brain injury with altered level of consciousness, alcohol intoxication, and multiple concurrent injuries.
In a recent review of 32,000 trauma patients, Davis et al53 found delayed or missed diagnoses of cervical spine injuries in 34 of 740 patients (4.6%). More than 70% of these missed injuries were unstable. The authors report major neurologic consequences in 10 of the 34 patients (29%) as a result of the missed or delayed diagnoses. The neurologic consequences included two deaths, four quadriplegic or paraplegic patients, and four patients with permanent limb paresis. The two most common reasons for missing a fracture were inadequate radiographs and misinterpretation of radiographs. The authors point out a fundamental problem-the lack of even a minimum standard cervical spine series. The authors concluded that most errors (94%) leading to the missed/delayed diagnosis were fundamental and did not require sophisticated interpretive skills or advanced diagnostic technology.
Orenstein et al reported on several cases of delayed diagnosis of pediatric cervical spine injury.51 In a study of 72 patients with cervical spine injury, nine patients had delays ranging from 1 day to 2 months before a correct diagnosis was established. Five of the nine patients (56%) had positive or suspicious x-ray findings that were initially misread as being normal. These errors resulted from misinterpretation of subtle findings on standard cervical spine views . In one case, the fracture was missed because the physician ordered a single lateral view. Two children with falls in the home did not have x-rays ordered despite neck pain.
Reid et al studied 274 patients with spinal injuries, and found 22.9% of cervical injuries and 4.9% of thoracolumbar injuries had a delayed diagnosis. The causes of the delays included the failure to take x-rays; fractures misread on the x-rays, and the failure of patient's to seek medical attention. Associated factors such as intoxication, multiple injuries, level of consciousness, or two levels of spinal injury (8% of patients had 2 or more fractures) contributed to the delayed diagnosis of these injuries. In 17 cases there was a failure to take x-rays, and in 20 patients the fracture was missed despite adequate films. The researchers found the development of secondary deficits was significant in the delayed diagnosis group (10.5% in the delayed diagnosis group, vs 1.4% among those whose fractures were identified).
Frequent causes of x-ray misreads included a failure to identify subluxation, significant soft-tissue swelling in front of the spine, or simply overlooking a very obvious fracture probably by inadequate attention to the film. In 20% of cases, the films were of such poor quality that even careful scrutiny did not identify the fracture.
These results highlight two crucial concepts: 1) the emergency physician must never settle for inadequate radiographs, and 2) a thorough, systematic approach to radiograph interpretation is absolutely essential. It is also important to remember that 5-20% of spinal fractures are multiple.54,55 The identification of a single fracture should always prompt a search for injury at all spinal levels with appropriate radiographs. A zero-tolerance philosophy for missed cervical spine injury will help avoid potentially devastating complications, and minimize costly litigation.
Pharmacotherapy for Acute Spinal Cord Injury
A number of agents have been studied in an attempt to improve neurologic outcome following spinal cord injury, including naloxone, glucocorticoids, nimodipine, tirilazad meyslate, and GM1 ganglioside. Of these, only methylprednisolone is currently recommended for use in humans. The exact mechanism through which steroids exert their effects following spinal cord injury are still unknown. The leading theory is that steroids inhibit lipid peroxidation after spinal cord injury and enhance recovery by inhibiting the injury-induced degenerative cascade that follows.56 The First57 and Second58 National Acute Spinal Cord Injury Studies demonstrated improved neurologic outcome at 6 weeks and 1 year in patients receiving methylprednisolone (30 mg/kg intravenous bolus followed by an infusion of 5.4 mg/kg/hr for 23 hours). Despite questions about mechanism of action, therapy with methylprednisolone has arguably become "standard of care."
Treatment with methylprednisolone is indicated for all patients with known or suspected spinal cord injury from blunt injury, providing this can be initiated within eight hours from the injury. There is no benefit to initiating treatment greater than eight hours after the injury. In fact, these patients may do worse with steroids than without. The protocol is not indicated for those patients with spinal cord injury from penetrating trauma.
Transfer Issues
When transferring a patient with a known c-spine injury to another institution, immobilization should be performed with a rigid cervical collar as well as sand bags or taped blocks. For transport, the patient should be kept on a long spine board. This facilitates both stabilization as well as maintains the ability to turn the patient on his side should vomiting occur. Every effort should be made to minimize time spent on the long board once at the receiving facility to reduce the development of pressure sores.
Litigation Review
A review of spinal injury malpractice lawsuits reveals several common fact patterns. The most common allegations include the failure to take spine x-rays; missed x-ray reading; missed reading caused by inadequate films; failure to recognize a spinal cord injury without radiologic abnormality; and failure to provide adequate immobilization resulting in a spinal injury, or exacerbation of a pre-existing injury.
Case # 1
P, a 62 year-old retired man had a riding lawnmower topple over onto him and he was transported to the defendant hospital ED. The emergency physician misinterpreted the cervical x-rays as negative and admitted during litigation that the films were not of adequate quality. The patient was discharged with follow up to his private physician. Four days later the patient saw his physician, complaining of mid-back and neck pain. Additional x-rays taken revealed a stable T11-12 thoracic fracture, for which the physician prescribed physical therapy and occupational therapy. The plaintiff continued complaining of neck pain, however, and eventually was unable to move his legs.
Ultimately a diagnosis of an additional (C6-7) fracture was made, though by then plaintiff was already a spastic quadriplegic. The plaintiff claimed that the physicians were negligent for missing the cervical fracture, which, it was claimed, should have been spotted if not by the ordering of better x-rays then at least by additional radiologic investigation after the plaintiff continued complaining of extreme pain. The plaintiff did have a history of ankylosing spondylitis. The plaintiff also alleged that hospital employees were additionally causally negligent with related care and treatment. The plaintiff is now wheelchair bound and needs assistance with normal daily activities. The case settled for $1.5 million.59
This case typifies the spinal injury lawsuit related to poor quality or misread films. The other important point in this case is that morbidity and mortality associated with fractures in cervical spines affected with ankylosing spondylitis are much greater than in fractures of cervical spines not involved with this disease. The difference is due to the tremendous loss of flexibility of the spine with ankylosing spondylitis. The emergency physician should have a much lower threshold for injury, as trivial trauma can result in a fracture.60 The emergency physician should consider co-existing medical problems in order to assess whether the patient is at increased risk for spinal injury.
Case # 2
A 21-year-old male was involved in a MVA, in which he was thrown 20 feet. Paramedics placed the patient in a C collar and backboard and transported him to the Oconee Memorial Hospital ED. The patient was intoxicated. The EMTs recorded that he had good movement of the extremities at the scene of the accident.
The ED physician removed the hard collar and "other immobilizing devices" to take the x-ray. The physician took the patient's arm and holding the back of his neck lifted him into a sitting position. The patient yelled in pain and subsequently became quadriplegic as a result of a cervical fracture.
The jury returned a $5 million dollar verdict.61
Although the facts of the case are outrageous, it does present several learning points. Spinal injury cases are extremely expensive, often far exceeding the limits of the emergency physicians typical $1 million, $3 million insurance coverage. The case also presents a warning to the emergency physician to consider the alcohol-impaired patient a high risk for traumatic injury. The collar should stay on this patient until the routine C-spine series has ruled out a fracture. Finally, this case is typical of a large number of lawsuits where the alleged injury occurred not as a result of the injury, but at the hands of the ED staff.
In this next group of cases, the patient has not suffered a demonstrable cervical vertebral fracture, but has suffered a spinal cord injury, the so called "spinal cord injury without radiographic abnormality" (SCIWORA). Again, the plaintiff alleges that the removal of immobilizing devices and excessive neck manipulation and movement has resulted in patient injury.
This is a critical area in EM risk management. Emergency physicians can significantly impact their exposure to liability by maintaining a low threshold for recognition of clinical clues of possible soft tissue cord injury. As you review these cases, think about the opportunities to recognize and prevent secondary spinal injury.
Case # 3
The plaintiff commenced this medical malpractice action against the emergency physician, alleging permanent injury resulting from negligent medical treatment following a single-car accident. The patient lost control of the car he was driving and ran off the road. The vehicle skidded more than 200 feet, rolled over, and came to rest upside down. After the patient was extricated from the wreckage, he was immobilized with a neck collar and spine board and was transported to the ED at Baldwin County Hospital. At the scene of the accident, the patient had no movement or sensation in his arms and legs, but by the time he arrived at the hospital, he had regained motor function and sensation in his arms, as well as sensation in his legs.
Within 20 minutes of the patient's arrival, the emergency physician ordered the removal of the neck collar and spine board. Based upon the neurological and x-ray examination of the patient, which the physician interpreted as normal, the emergency physician released the patient from the cervical collar and discharged him from the ED. However, when two attempts to discharge the patient failed because he could not stay on his feet, the emergency physician ordered a neurological consultation.
A neurologist eventually examined the patient, approximately seven hours after his admission to the ED and transferred him to the Medical Center of Central Georgia, where he was diagnosed as having a central cord syndrome. The patient was later admitted to the Shepherd Spinal Center. The patient regained full use of his legs, but the neurological impairment of his arms and hands is permanent. The jury returned a verdict against the emergency physician for $1,400,000.
At trial, expert witnesses testified that the patient most likely sustained an injury to the ligaments of his cervical spine during the MVA, causing some instability of the cervical spine. These experts opined that if the patient had been properly immobilized, his recovery probably would have been complete. However, the premature removal of the immobilization devices subjected him to a secondary injury to his spinal cord caused by movement, and the patient's permanent impairment to his arms and hands resulted from that secondary injury.62
It appears that the EP concluded that the spinal cord was intact because the c-spine films were negative. Both the medical and the legal literature make it very clear that this is not always the case. If there is any evidence of neurologic impairment at any point in time from the moment the accident occurred, the physician should assume that there is a spinal injury until proven otherwise. In this type of case, the EP should diligently gather information from all providers, including the EMTs, parents or other family members, or nursing staff.
In the following case, the EP should have considered the parents history of their child's behavior as suggestive of a SCIWORA.
Case # 4
The patient was a 2-year-old male who was playing at home early in the day and hit his head against the wall without loss of consciousness or any apparent problems at that time. According to the mother, that night while the child was jumping on furniture he fell onto his neck and shoulder and injured his shoulder. He seemed to have some difficulty and pain with walking. The parents could not calm him down so they presented to the ED.
The emergency physician noted that the child fell off the couch (jumped) and was "limp" when picked up, according to mom. On the extremity exam, the child "withdraws all, but somewhat flaccid. Won't reach for mom. Cries as if in pain when moves. Arouses to mom's voice." The physician testified that the neck was not tender. Examination did not elicit a pain response. No indication of stiffness or spasm. The emergency physician testified regarding his neurologic examination: "I checked sensation grossly with my car keys but did not record the result. Checked cranial nerves grossly." Again, he did not document the result. The emergency physician's documented impression was "Traumatic injury, s/p fall."
The emergency physician never ordered cervical spine immobilization, even later during the ED visit when he began to consider a C-spine injury. The EP testified that he did not want the child moving around, but did not consider immobilization at that time.
At one point during the ED visit, the child began to develop progressive paralysis and had difficulty clearing his airway secretions. At that point the spinal cord injury was apparent, and the emergency physician called anesthesia to intubate the child. The anesthesiologist initially attempted intubation without a muscle relaxant but this was not successful since the child was able to bite just enough to make it impossible. The child was then intubated following the administration of 1 mg of norcuron.
The initial C-spine trauma screening portable film visualized only the upper six cervical vertebrae. No gross abnormalities detected. AP and lateral study of the spine showed normal alignment. Disk spaces well preserved. No soft tissue swelling seen. No fractures. CT of the C spine showed no bony abnormality. No narrowing of the spinal canal seen. No fractures. Nl C-spine AP and lateral, and normal CT cervical spine.
The patient was transferred to a nearby referral center for neurosurgical evaluation. The child's neck was immobilized prior to transfer. The neurosurgeon at the referral center told the family that if they had gotten him to surgery earlier it might have been an entirely different situation. The child is currently quadriplegic and is totally dependent for all activities of daily living.
During the physician's deposition he was asked: "Why didn't you immediately immobilize the c-spine? Answer: "He was laying down supine, not moving. Nothing to be gained."
When the physician was asked: "Did you consider giving steroids," the physician responded, "No, I would not do it without a neurosurgical consult."
The family sued and alleged failure to immobilize and failure to administer steroid treatment. The parties settled for an undisclosed amount.63
In Case # 3, there was sufficient information from the EMTs to warrant immobilization. In Case # 4, there were clues available from both the family and the physical examination to suggest a possible spinal injury. That's all it takes. At that point, immobilization is warranted. Also, in both cases, the administration of methylprednisolone was delayed.
In one series of children with SCIWORA, 13 of 24 children had a delay in onset of neurologic symptoms from 30 minutes to four days. In all cases, there were transient symptoms of numbness, paresthesia, or subjective paralysis immediately after the injury, and the patients were neurologically intact on examination in the ED.64 The EP should recognize this common pattern in patients with this type of injury.
As mentioned above, steroid therapy is indicated when spinal cord injury is suspected. The risk of administration is low, and the potential benefit is high. This is one of those treatment issues where the clock is ticking. Research has demonstrated a benefit from early administration. In recent years, this has clearly become a standard of care issue. There is no need to wait for neurosurgical confirmation.
Alcohol and drug impairment is another common denominator in missed spinal injury litigation. The following three cases demonstrate some of the problems seen in this area.
Case # 5
The patient presented to the ED of the McGuire Veterans Administration Medical Center requiring assistance to walk and under the influence of alcohol. He complained of tingling in his arms and weakness in his legs. He also complained of severe pain in his neck and shoulders. He was initially combative and verbally abusive but calmed down later. The patient cooperated with the medical examination in the ED by allowing his blood to be taken and his upper motor strength to be tested.
When asked to move his legs, however, he indicated that they were sluggish to move. The patient had a history of a C-spine injury sixteen years earlier in a helicopter crash. The diagnosis was possible cervical spine injury, but the physician felt that a repeat exam would be necessary when the plaintiff was sober.
The patient/plaintiff claimed that no cervical MRI or x-ray studies were performed for sixteen hours. The MRI studies revealed an acute herniated disc at the C6-7 level causing his neurologic symptoms. The plaintiff claimed that surgery was performed nineteen hours after admission, which resulted in his becoming a C-7 quadriplegic.
According to accounts, a settlement with a present cash value of $1 million was reached.65
Once again, the clinical clues were overlooked. The patient complained of tingling in his arms and weakness in his legs. That should result in immobilization and aggressive evaluation for spinal injury.
Case # 6
The patient was a 33-year-old male, taken to the defendant, Northwest Community Hospital, following a motorcycle accident. The physicians and the ED did not diagnose the fractured cervical spine and did not immediately put a cervical collar on him. The collar was eventually placed, but the patient was able to remove it. The plaintiff became a quadriplegic.
The defendants maintain that the plaintiff was on drugs and belligerent at the time he arrived at the hospital.
According to accounts, a settlement was reached with the physicians for $2.42 million. A $4.5 million settlement was then reached with the hospital and its nurse.66
Case # 7
A 33-year-old South Carolina machine operator suffered multiple injures in an auto accident. He was immobilized and taken to the defendant hospital, where his cervical collar and head blocks were removed. One defendant emergency physician interpreted the c-spine x-rays as normal, but ordered consultation with a second defendant physician, who ordered repeat x-rays and replacement of the cervical collar. The x-rays showed moderate anterior subluxation of the vertebral body of C5 consistent with locked facets at C6-C7. The plaintiff was transferred to a regional medical center, and was found to be quadriplegic upon arrival. The defendant claimed the plaintiff refused to allow a cervical collar to remain in place, and was intoxicated, abusive, and difficult to manage, resulting in unreadable x-rays.
According to published accounts, the jury returned a $1 million verdict for the plaintiffs injuries, and a $500,000 verdict for his wife's loss of consortium.67
There seems to be a natural human tendency to minimize the severity of patient injury or suffering. This tendency is exacerbated in the alcohol-impaired patient, probably related to another natural human tendency: to avoid obnoxious or difficult patients. The alcohol-impaired patient is the prototypical `difficult-to-manage' patient. As a result, the diagnosis of spinal injury is often delayed or missed. Emergency physicians must aggressively work-up all potential life or limb threats in the patient `under the influence.'
The inebriated patient with neck pain has an unstable cervical fracture until proven otherwise. This patient should be completely immobilized and a hard collar and backboard applied pending further diagnostic evaluation. If the physician feels the need to repeat the exam prior to diagnostic evaluation, complete immobilization in the interim may avoid a lawsuit.
The emergency physician faces a very difficult moment when she recognizes a `soft' or questionable clinical indication of possible spinal injury, and the patient is acting out, belligerent, and unmanageable even with typical restraint measures. At the point that the EP seriously considers a spinal injury, immobilization must be accomplished. Risk is related to the measures necessary to accomplish the immobilization, which may entail use of a paralyzing agent and intubation. The threshold for making this decision must be low, and then management must be aggressive.
In case # 5, the defendants maintain that the plaintiff was on drugs and belligerent at the time he arrived at the hospital. In case # 6, the defendant claimed the plaintiff refused to allow a cervical collar to remain in place and was intoxicated, abusive, and difficult to manage, resulting in unreadable x-rays. These are not winning arguments in a court of law. The jury may be mildly sympathetic to these arguments, but in balance is likely to want to compensate the paralyzed plaintiff, who needs total life care.
Case # 8
The plaintiff, Mr. Ellis, was severely injured in a car accident. The paramedics who arrived at the scene of the accident administered first aid and immobilized Ellis by placing him in a cervical collar and securing him to a rigid board. The paramedics then transported Ellis to Richland Memorial Hospital's trauma center. The initial examination at the hospital revealed Ellis had suffered, among other things, closed head trauma, a fractured scapula, a torn right brachial plexus, and a cervical spine injury. Although Ellis could no longer move his right arm because of the torn brachial plexus, Ellis had some voluntary movement of the left arm, pain reflexes in his legs, and rectal tone, an indication that he was not paralyzed below the waist.
Because of Ellis' closed head injury, the chief surgical resident called for an anesthesiologist to establish an airway in order to reduce the swelling of Ellis' brain by means of hyperventilation. The anesthesiologist responded and was informed of Ellis's condition by the chief resident. Thereafter, the anesthesiologist made five attempts to establish an airway by inserting a tube through Ellis' nasal passage. When these attempts failed, the anesthesiologist made five unsuccessful attempt to orally intubate using a laryngoscope.
The first attempt at oral intubation was made while Ellis remained in the cervical collar. The second attempt was made after appellant loosened the front of the collar so he could move Ellis' jaw. The third attempt was made after appellant removed the front of the collar and administered a paralyzing agent. For the fourth and fifth attempts, the defendant anesthesiologist used different size blades on the laryngoscope.
Following these attempts, and one further unsuccessful attempt by the chief resident, the chief resident established a surgical airway. The following day it was discovered that Ellis had suffered a spinal cord injury rendering him quadriplegic.
Mr. Ellis brought a medical malpractice action against the anesthesiologist. Shortly thereafter, he died from sepsis allegedly related to his quadriplegia. The trial resulted in a jury verdict for the plaintiff for $700,000.
The anesthesiologist appealed the case. One issue on appeal was whether the plaintiff presented sufficient evidence to establish the requisite causal connection between appellant's acts and Mr. Ellis' injuries.68
This `causation' issue is worth discussion because it is a critical factor in many spinal injury malpractice cases. Once the plaintiff establishes the fact of negligent conduct (duty of care plus breach of duty), then he must establish that the negligent conduct caused the patient's injury. In many of these cases, it is not at all clear that the injury had anything to do with the ED care, and thus causation does not exist, and the case should fail as a matter of law. That is, no harm, no foul. However, if the plaintiff can show a breach in a standard of care and get the case to the jury, a good plaintiff's attorney may get sympathetic jurors to minimize the causation issue and award damages. There is always a plaintiff's expert around who will testify that the breach caused an injury.
The court in this case pointed out that negligent conduct is not actionable unless it is a proximate cause of the injury complained of, and "negligence may be deemed a proximate cause only when without such negligence the injury would not have occurred or could not have been avoided."
One expert testified that the defendant violated the standard of care by inappropriately and excessively attempting to intubate Ellis orally. He stated that one attempt at oral intubation without moving the patient would have been acceptable, but multiple attempts using a laryngoscope was a violation of the standard of care because such a procedure inevitably causes movement of the patient's head and neck. This expert also testified that the patient did not become quadriplegic because of the motor vehicle accident. It was his opinion the injury to Ellis' spinal cord occurred during the oral intubation attempts, and this injury resulted in quadriplegia and eventual death. He further testified that if the defendant had not multiple attempts at oral intubation, that Ellis would have walked out of the hospital within two or three weeks.
Another plaintiff's expert testified that the defendant was negligent for allowing a resident to attempt oral intubation following the first five unsuccessful attempts by the plaintiff and because the defendant used in-line traction during the attempts. The expert defined traction as "pulling on the head." However, the defendant maintained the term "traction" was used in the report synonymously with the term "stabilization" or immobilization, and that no "pulling on the head" occurred. This expert also testified that the quadriplegia did not result from the accident, but was the direct result of the "unacceptable manipulation" of Ellis' airway following the accident.
The court felt that there was expert testimony sufficient to show that Ellis' injuries most probably resulted from the alleged negligence of the defendant and that the lower court did not err in denying motions for a directed verdict for the defense.
The defendant also made an interesting standard-of-care argument. Apparently, the plaintiff's experts made several references to the 1988 Advance Trauma Life Support Manual and the ATLS course. In his brief, the defendant argued that the trial court erred in allowing the experts to testify that the ATLS Manual "constituted the applicable standard of care" because the manual does not specifically limit the number of attempts at oral intubation for a patient with a cervical spine injury. A review of the record, however, indicated that the plaintiff's experts did not testify that the ATLS Manual "constituted the applicable standard of care." Rather, the experts specifically stated the they did not base their opinion about the standard of care solely on the ATLS Manual itself because the manual was merely a guide to the logical approach a physician should take when faced with a patient requiring intubation.
This case demonstrates several critical issues for the emergency physician. The airway should always be in the most capable hands in the ED. Excessive manipulation of the head and neck seems obvious from the number of attempts at intubation. It seems apparent that the number of attempts should be limited, followed by obtaining a surgical airway.
The case also demonstrates several aspects of the plaintiff's case, the proximate cause hurdle, and the testimony of plaintiff's experts. Understand the critical importance of documentation. When the spine case hits the door, get the pens moving. Document the patient's initial condition, and any change in condition over time. Lack of documentation in these cases definitely weighs in favor of the plaintiff.
Conclusion
A review of the legal and medical literature demonstrates several opportunities for the emergency physician to avoid the nightmare of missing or exacerbating a spinal injury and related litigation. As in most areas of EM malpractice, there is a wide range of cases. Sometimes there are obvious blunders, and the injured individual may be justly compensated. However, in most cases, the issues of duty, breach, and causation are not obvious, and the emergency physician will have the opportunity to aggressively support the care provided. The emergency physician should be clear on the several standards of care discussed above, periodically review the approach to the spine x-ray with colleagues, demand the highest quality x-ray films, aggressively manage the alcohol-impaired patient, and carefully document the patient's condition initially, and as it changes over time. These efforts will be effective in protecting the patient, and reducing the incidence of spine injury malpractice litigation.
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