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A retrospective study was undertaken that evaluated the medical records and imaging studies of a subset of patients with spinal injury from large level I trauma centers.To characterize patients with spinal injuries who had neurologic deterioration due to unrecognized instability.Controversy exists regarding the most appropriate imaging studies required to “clear” the spine in patients suspected of having a spinal column injury. Although most bony and/or ligamentous spine injuries are detected early, an occasional patient has an occult injury, which is not detected, and a potentially straightforward problem becomes a neurologic catastrophe.The study was designed as a retrospective review of patients who had neurologic deterioration as a direct result of an unrecognized fracture, subluxation, or soft tissue injury of the cervical, thoracic, or lumbar spine from 8 level I trauma centers. Demographics, injury information, and neurologic outcome were collected. The etiology and incidence of the missed injury were determined.A total of 24 patients were identified who were treated or referred to 1 of the participating trauma centers and had an adverse neurologic outcome as a result of the missed injury. The average age of the patientswas 50 years (range 18–92), and average delay in diagnosis was 19.8 days. Radiculopathy developed in 5 patients, 16 had spinal cord injuries, and 3 patients died as a result oftheir neurologic injury. The most common reason for the missed injury was insufficient imaging studies (58.3%), while only 33.3% were a result of misread radiographs or 8.3% poor quality radiographs. The incidence of missed injuries resulting in neurologic injury in patients with spine fractures or strains was 0.21%, and the incidence as a percentage of all trauma patients evaluated was 0.025%.This multicenter study establishes that missed spinal injuries resulting in a neurologic deficit continue to occur in major trauma centers despite the presence of experienced personnel and sophisticated imaging techniques. Older age, high impact accidents, and patients with insufficient imaging are at highest risk.