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Correlation of clinical and radiographic findings with outcomes in acute cervical discoligamentous trauma manifesting as persistent midline cervical tenderness.
thesisposted on 06.02.2017, 02:26 by Ackland, Helen Margaret
According to current international practice, the presence of midline cervical tenderness following trauma mandates cervical spine imaging. Whilst this aspect of trauma management is unambiguous, difficulties arise when midline tenderness is persistent, and computed tomography (CT) imaging is negative for acute injury. The extent to which this clinical sign is an indication of occult discoligamentous injury, undetectable on CT imaging, is unclear. The identification of such injury and the determination of clinical significance are essential in the avoidance of missed injury, the assignment of an appropriate management strategy and the mitigation of post-acute morbidity. Magnetic resonance imaging (MRI) is the optimal radiographic modality for the identification of injuries to the cervical soft tissue structures. As a result, this project sought to ascertain the prevalence of acute occult cervical discoligamentous injury in alert, sober and neurologically intact patients with persistent midline cervical tenderness, and without painful distracting injury. Additionally, with the hypothesis that acute findings would correlate with post-acute outcomes, the project aimed to assess the associations of demographic, injury mechanism, clinical and radiographic factors with acute injury, post-acute morbidity and the costs of investigation and symptom management. In a Level 1 trauma centre with approximately 15,000 trauma presentations per year, the integrity of the cervical discs, ligaments and spinal cord were assessed using early MRI in alert patients (Glasgow Coma Scale = 15) with persistent midline cervical tenderness following negative CT imaging in a prospective cohort study. Exclusion criteria comprised (i) base of skull or upper thoracic fractures (ii) painful distracting injury, intoxication or persistent focal neurologic deficit according to the criteria of the National Emergency X‐Radiography Utilisation Study (NEXUS)(iii) history of cervical spine injury or surgery and (iv) MRI conducted > 96 hours post presentation. Patients with minor, isolated low thoracic or lumbar fracture were included, as were patients with transient neurologic deficit fully resolving shortly after presentation to the emergency department. De-identified MR images were reviewed by two independent senior trauma radiologists, and injuries were identified and graded. Patients were reviewed in the outpatient clinic following discharge, and were subsequently reassessed at 6 and 12 months. Ordinal logistic regression was used to determine the associations of demographic, injury mechanism, clinical and radiographic factors with acute injury and post-acute neck pain and disability, while survival analysis was used to analyse the rate of return to normal daily activities. Health service utilisation cost data for the 12 month period for the subset of patients involved in road trauma, who had not sustained additional injuries, were collated and assessed for factors associated with higher acute and post-acute costs, using multivariate linear regression analysis. There were 178 patients recruited to the study over a 2 year period. Of these, 78 patients (44%) were found to have acute injuries detected on MRI. There were 48 single column injuries, 15 two- column injuries and 5 three-column injuries. The remaining abnormalities included posterior muscle oedema, alar ligamentous oedema, epidural haematoma or atlanto‐occipital oedema. In 38 cases (21%), injuries were clinically managed: 5 patients underwent surgical stabilisation for cord oedema and/or contusion and 33 patients were treated in cervical collars for 2‐12 weeks. Factors associated with more extensive injury, according to the number of spinal columns involved, included advanced CT‐detected cervical spondylosis, minor, isolated thoracolumbar fractures and multidirectional cervical spine forces during the trauma incident. There were 162 patients (91%) available for assessment at 12 months, of whom 43% reported neck pain and neck-related disability. Neck disability was associated with pre-morbid depressive symptoms, workers’ compensation and low annual income level, while delay in return to work was associated with pre-morbid depressive symptoms and the presence of minor additional injury. Patients on high annual incomes returned to work significantly more quickly than those on low or medium income levels. Neither mechanism of injury nor MRI findings were associated with post-acute outcomes. There were 64 patients included in the health resource utilisation cost analysis, and transient neurologic deficit was associated with higher mean acute and post‐acute costs in these patients. Low education standard and the presence of neck pain at 6 months were also associated with higher costs in the post-acute period. Non‐osseous cervical spine injury requiring clinical management can remain undetected on high quality CT imaging. However, MRI is not necessary in all cases of acute persistent midline tenderness when CT findings are negative following trauma. Instead, this resource can be rationalised for use in patients with advanced cervical spondylosis, and consideration of MRI should be made when thoracolumbar fractures are present, or when multidirectional spine forces had occurred during the trauma. The presence of transient neurologic deficit may be indicative of the presence of subclinical injury, and as such, may require greater intervention in the acute and post-acute settings in order to mitigate costs. Regardless of radiographic imaging findings, patients with post-acute neck pain following trauma may benefit from an individual, targeted care plan involving general practice and allied health collaboration, in order to expedite the early return to normal activities and to mitigate chronic morbidity.