832 ACADEMIC EMERGENCY MEDICINE SEP 1996 VOL 3/NO 9 Delayed Diagnosis of Thoracolumbar Fractures in Mult iple-t rauma Patients Stephen Anderson, MD, Michelle H. Biros, MD, MS, Robert E Reardon, MD I ABSTRACT Objectives: To determine the frequency of delayed diagnosis of major thoracolumbar vertebral fractures (T-L Fxs) in ED multiple-trauma patients, and to determine the differences between cases of delayed and nondelayed diagnoses of T-L Fx. Methods: A retrospective chart review was conducted of 181 trauma patients with 310 major T-L Fxs (com- pression, burst, or chance Fxs or dislocations). Data collected included the time of the diagnosis of T-L Fx, the patient’s clinical presentation in the ED, the mechanism of injury, and the outcome. Results: Of the 181 patients with major T-L Fxs, 138 were diagnosed in the ED (nondelayed group), and 43 were diagnosed after the patient left the ED (delayed group). Of these, 33 cases occurred in unstable patients requiring emergent medical imaging and/or operation, 7 occurred when emergency physicians failed to detect subtle compression Fxs on ED radiographs, and 3 occurred in stable patients who were not radiographed in the ED. The delayed group were more often critical, and hypotensive, and had lower Glasgow Coma Scale (GCS) scores than did the nondelayed group. The delayed group patients also had more cervical spine injuries, multiple noncontiguous spinal Fxs, high-energy mechanisms of injury, and direct blunt assaults to the back than did the nondelayed group patients. There were 13 patients with T-L Fxs, GCS scores = 15, and normal back examinations. There were 43 patients who had neurologic deficits associated with their injuries; 11 patients with incomplete cord lesions progressed, including 3 in the delayed group. Conclusions: A delay in the diagnosis of T-L Fx in hospitalized trauma patients is frequently associated with an unstable patient condition that necessitates higher-priority procedures than ED T-L spine radiographs. Such patients should receive spinal precautions until more complete evaluation can be performed. The decision to selectively radiograph T-L spines in multiple-trauma patients should consider the mechanism of injury, the presence of possible confounders to physical examination, and clinical signs and symptoms of back injury. Key words: multiple trauma; thoracolumbar spine; spine fractures; injury Acad. Emerg. Med. 1996; 3:832-839. ..................................................................................................................................................... I More than 160,000 vertebral fractures (Fxs) occur in the United States each year, resulting in >40,000 serious Fxs and >10,000 spinal cord injuries.’ In most circum- stances, radiographic examination of the cervical spine is a standard ED practice during the evaluation of the ................................................................................ From Hennepin CounIy Medical Center, Minneapolis, MN, Depart- ment of Emergency Medicine (SA. MHB); and SUNY- Buffalo, Buf- falo, NI: Department of Emergency Medicine (RFR) Received: December 12, 1995: revision received: April 3, 1996; ac- cepted: April 7, 1996; updated: April 23, 1996. Prior presentation: 3rd International Neurotrauma Symposium, To- ronto, Onrario, Canada, July 1995. Address for correspondence and reprints: Stephen Anderson, MD, De- parrment of Emergency Medicine. Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415. Fax #: 612-337-7447: e-mail: [email protected]multiple-trauma patient. For the patient with distracting painful injuries or an altered sensorium, this practice is generally followed, even if the trauma patient has no clinical sign or symptom suggesting cervical spine in- jury. Currently there is no consensus regarding similar routine radiographic screening of the thoracolumbar (T-L) spine, even though approximately half of the ver- tebral Fxs and neurologic injuries sustained by multiple- trauma patients occur in the T-L spine. Recognizing the potential serious consequences of a delay in the diagnosis of a T-L Fx, the 1993 Advanced Trauma Life Support (ATLS) guidelines recommend the addition of an anteroposterior T-L radiograph in the emergent screening of all multiple-trauma patients, with the remainder of the T-L radiographic series to be ob- tained later.’ Some investigators have challenged tnis recommendation, and suggest that routine T-L spine ra- diographic evaluation of multiple-trauma patients is not
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832 ACADEMIC EMERGENCY MEDICINE SEP 1996 VOL 3/NO 9
Delayed Diagnosis of Thoracolumbar Fractures in Mult iple-t rauma Patients Stephen Anderson, MD, Michelle H. Biros, MD, MS, Robert E Reardon, M D
I ABSTRACT
Objectives: To determine the frequency of delayed diagnosis of major thoracolumbar vertebral fractures (T-L Fxs) in ED multiple-trauma patients, and to determine the differences between cases of delayed and nondelayed diagnoses of T-L Fx.
Methods: A retrospective chart review was conducted of 181 trauma patients with 310 major T-L Fxs (com- pression, burst, or chance Fxs or dislocations). Data collected included the time of the diagnosis of T-L Fx, the patient’s clinical presentation in the ED, the mechanism of injury, and the outcome.
Results: Of the 181 patients with major T-L Fxs, 138 were diagnosed in the ED (nondelayed group), and 43 were diagnosed after the patient left the ED (delayed group). Of these, 33 cases occurred in unstable patients requiring emergent medical imaging and/or operation, 7 occurred when emergency physicians failed to detect subtle compression Fxs on ED radiographs, and 3 occurred in stable patients who were not radiographed in the ED. The delayed group were more often critical, and hypotensive, and had lower Glasgow Coma Scale (GCS) scores than did the nondelayed group. The delayed group patients also had more cervical spine injuries, multiple noncontiguous spinal Fxs, high-energy mechanisms of injury, and direct blunt assaults to the back than did the nondelayed group patients. There were 13 patients with T-L Fxs, GCS scores = 15, and normal back examinations. There were 43 patients who had neurologic deficits associated with their injuries; 11 patients with incomplete cord lesions progressed, including 3 in the delayed group.
Conclusions: A delay in the diagnosis of T-L Fx in hospitalized trauma patients is frequently associated with an unstable patient condition that necessitates higher-priority procedures than ED T-L spine radiographs. Such patients should receive spinal precautions until more complete evaluation can be performed. The decision to selectively radiograph T-L spines in multiple-trauma patients should consider the mechanism of injury, the presence of possible confounders to physical examination, and clinical signs and symptoms of back injury.
I More than 160,000 vertebral fractures (Fxs) occur in the United States each year, resulting in >40,000 serious Fxs and >10,000 spinal cord injuries.’ In most circum- stances, radiographic examination of the cervical spine is a standard ED practice during the evaluation of the
From Hennepin CounIy Medical Center, Minneapolis, MN, Depart- ment of Emergency Medicine (SA. MHB); and SUNY- Buffalo, Buf- falo, NI: Department of Emergency Medicine (RFR)
Received: December 12, 1995: revision received: April 3, 1996; ac- cepted: April 7, 1996; updated: April 23, 1996.
Prior presentation: 3rd International Neurotrauma Symposium, To- ronto, Onrario, Canada, July 1995.
Address for correspondence and reprints: Stephen Anderson, MD, De- parrment of Emergency Medicine. Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415. Fax #: 612-337-7447: e-mail: [email protected]
multiple-trauma patient. For the patient with distracting painful injuries or an altered sensorium, this practice is generally followed, even if the trauma patient has no clinical sign or symptom suggesting cervical spine in- jury. Currently there is no consensus regarding similar routine radiographic screening of the thoracolumbar (T-L) spine, even though approximately half of the ver- tebral Fxs and neurologic injuries sustained by multiple- trauma patients occur in the T-L spine.
Recognizing the potential serious consequences of a delay in the diagnosis of a T-L Fx, the 1993 Advanced Trauma Life Support (ATLS) guidelines recommend the addition of an anteroposterior T-L radiograph in the emergent screening of all multiple-trauma patients, with the remainder of the T-L radiographic series to be ob- tained later.’ Some investigators have challenged tnis recommendation, and suggest that routine T-L spine ra- diographic evaluation of multiple-trauma patients is not
Delayed Diagnosis of T-L Fractures, Anderson et al. 833
necessary in the presence of a negative back examination and the absence of confounders to adequate evaluation [a Glasgow Coma Scale (GCS) score 2 13; no spinal neurologic deficit; no advanced airway adjunct; an eth- anol level of <22 mmoVL (<lo0 mg/dL); and no pain, tenderness, or distracting injury).]’“
We conducted a retrospective review of the Hennepin County Medical Center (HCMC) experience with T-L Fxs in order to determine their frequency, the historical and clinical factors associated with T-L Fxs in our hospitalized patient population, the number of cases in which the di- agnosis was not made in the ED, and the reasons for the delay in diagnosis. We also wanted to determine whether the delayed diagnosis of T-L Fx resulted in any clinically significant consequences to the patient.
A retrospective analysis of hospitalized trauma pa- tients with diagnosed T-L Fxs presenting to a county teaching hospital ED was performed to characterize this population and address the frequency of delayed diag- nosis (i.e., after the patient leaves the ED). This archival data review was approved with expedited review by the Human Subjects Research Committee of HCMC.
Study Setting and Participants
Hennepin County Medical Center is a level- 1 trauma center with approximately 100,000 ED visits each year. All patients admitted to HCMC with a diagnosis consis- tent with trauma (single or multiple-system) are enrolled into the Institutional Trauma Data Registry. Enrollment is based on discharge diagnosis ICD codes and is not dependent on the admitting service or the severity of injury. The HCMC Institutional Trauma Data Registry of 15,200 trauma patients admitted to HCMC through the ED between July 1987 and July 1993 was used to generate a list of 283 patients with discharge diagnoses including T-L Fx. Major T-L Fxs were defined as com- pression, burst, or chance Fxs or dislocations. Patients with minor T-L Fxs (n = 51), defined as isolated trans- verse process and spinous process Fxs, were not in- cluded in this study. The charts of 51 additional patients were incomplete or unavailable for review, despite 3 sep- arate attempts to locate the completed medical record. The final study group included 18 1 patients discharged from the hospital with diagnoses of major T-L Fx.
Measurements
All data were extracted from the medical record by 2 of the authors (SA and RFR), and entered onto a stan-
dardized data form. Whether the patient was diagnosed as having the T-L Fx in the ED or subsequently was determined by the dating of the first medical record note indicating a Fx was present. This information was used (described below) to group the patients for analysis. The mechanism of injury and the type, number, and location of spinal Fxs were noted. Clinical signs and symptoms of injury noted in the ED, the neurologic examination, the physical examination of the back, and the GCS score also were reviewed. The incidence of other major inju- ries was recorded. Associated major trauma included moderate to severe head injury (i.e., GCS score 5 12), chest injury (rib fractures, pneumothorax, hemothorax, widened mediastinum), significant blunt or penetrating abdominal injury, or pelvic or long-bone Fxs. The initial condition of the patient on arrival to the ED was deter- mined. A patient was considered critical if hemody- namic and/or cardiopulmonary instability was present and the patient required acute ED stabilization and re- suscitation, such as fluid and blood administration a n d or airway intervention. Noncritical patients may have had serious injuries but did not require acute stabiliza- tion.
All ED physical assessments were performed and documented in the ED record by the primary physician involved with the patient’s emergency care. In critical cases, evaluation was done by second- or third-year emergency medicine (EM) residents or third-year sur- gery residents under the direct supervision of the EM attending physician. Noncritical cases were evaluated by first- or second-year rotating residents, and a senior (third-year) EM or surgery resident or an EM attending physician.
Radiographs
All T-L radiographs for ED patients were performed in the ED by ED medical imaging technicians. All ra- diographs were read in the ED by third-year EM resi- dents, third-year surgery residents, andor the EM at- tending staff physician while the patient was in the ED. The ED interpretation was immediately entered into a designated area of the ED record, and the interpretation also was recorded on a “wet reading” form that sub- sequently was returned to the department of radiology with the films. Documentation of the ED interpretation was required for all films before they could be delivered to the department of radiology for review. Radiographs were overread by staff radiologists within 24 hours of patient presentation. The radiologists were not blinded to the ED interpretation of the initial films, and also were aware of subsequent radiographic evaluation that may have occurred during the continued management of the patient. The radiologists were, however, blinded to the patient’s ED presentation and assessment. If a discrep-
834 ACADEMIC EMERGENCY MEDICINE SEP 1996 VOL 3/NO 9
I TABLE 1 Subgroup Analysis of Delayed Diagnosis of Thor- acolumbar Fractures . . . . , . . . . _ .
Subgroup n (% Total) Status Comments*
1 33 (77%) Unstablet 25 to medical imaging 8 to OR directly
2 7 (16%) Stable$ All had subtle compres- sion fractures (~30% vertebral height), ini- tially missed on ED readings
3 3 (7%) Stable No radiograph obtained in the ED
Case 1) Ped vs MV EtOH = 33 mmoln (150
mg/dL); tib-fib Fx Case 2) 10-foot fall EtOH on breath, CHI Case 3) Ped vs MV EtOH = 54 mrnol/L (250
mg/dL); CHF
*OR = operating room; Ped = pedestrian; MV = motor vehicle; tib-fib Fx = tibia-fibula fracture; CHI = closed head injury; EtOH = ethanol; CHF = congestive heart failure.
tunstable patients required acute ED resuscitation and remained cardiopufmonary/hemodynamically unstable despite fluid resuscitation and/or airway intervention.
$ Stable patients were cardiopulmonary/hemodynamically stable or stabilized in the ED.
ancy existed between the ED and radiologist interpre- tations of the film, the ED was contacted within 24 hours of patient evaluation.
Definitions
For analysis, the patients were assigned to a nonde- luyed group if the diagnosis of T-L Fx occurred before the patient left the ED. If the diagnosis of T-L Fx was made after ED evaluation and disposition, the patient was assigned to the delayed group. The delayed group was further subdivided based on pattern of delayed di- agnoses.
Subgroup-] included critical patients who were sent from the ED directly to the operating room or medical imaging for higher-priority imaging procedures than T- L radiographs. These patients were hemodynamically unstable and/or required acute airway intervention; their injuries were immediately life-threatening and necessi- tated continuous resuscitation, emergency diagnostic testing, and/or emergent surgical intervention. Once these patients had been stabilized (i.e., after surgery) and were admitted to the surgical intensive care unit (SICU), T-L radiographs were obtained. These radiographs were evaluated by the trauma team in consultation with the radiologist on call.
Subgroup-2 included patients who were hemody-
namically stable or stabilized in the ED. These patients received T-L radiographs during the course of the ED workup, which were interpreted by a third-year EM or surgery resident and/or an EM attending physician, while the patient was still in the ED. In all subgroup-2 cases, the initial interpretation of the T-L radiographs obtained and read in the ED differed from the subsequent reading of the radiologist. The latter readings were obtained after the patient had been admitted to the SICU.
Subgroup-3 included stable, noncritical patients who were admitted for observation after significant trauma. In subgroup 3, no T-L radiograph was obtained while the patient was in the ED.
Fractures were grouped into spine regions defined by biomechanical studies reported in the l i t e r a t~ re .~ .~ Con- tiguous Fxs in the same spinal region were counted as 1 Fx for descriptive analysis of the spinal region distri- bution of injury. Multiple noncontiguous Fxs were counted once for each spinal region in which they oc- curred; each noncontiguous Fx occurring within the same spinal region was counted as a separate Fx.
Injury mechanisms with high or low likelihood of T-L Fx were identified in the medical literature and these definitions were used to describe high- or low-risk mech- anism of injury in this study group. High-risk mecha- nisms of injury were therefore defined as high-speed mo- tor vehicle crashes (MVCs), motorcycle crashes (MCCs), falls from elevated heights (>6 feet), direct trauma to the back, or recreational vehicle crashes ( RVCS).’.~
Data Analysis
Collected demographic, clinical, and radiographic findings were analyzed using descriptive statistics. Con- tinuous and interval data are reported as mean 5 SD. Comparisons between the delayed and nondelayed groups were made using chi-square analysis. Signifi- cance was set at p c 0.05, as obtained from analytical chi tables.
The 181 study patients included in this protocol repre- sented 1.2% of the trauma population of 15,200 admitted during the time under review. A total of 310 major T-L Fxs occurred in the study group. The average age of the study population was 35 (+ 16.4) years, with a range of 5-85 years (the second youngest patient was 16). The male/female ratio was 2.5 to 1. Most (97%) diagnoses of major T-L Fx were made by 36 hours after presen- tation. The diagnosis of major T-L Fx was made in the ED for 138 patients (nondelayed group). There was a delay in diagnosis of major T-L Fx for 43 patients (de- layed group), representing 24% of all the cases of T-L
Delayed Diagnosis of T-L Fractures, Anderson et al. 835
* p < 0.05 when compared with the nondelayed group, xz analysis. t p c 0.001 when compared with the nondelayed group, x 2 analysis.
Fx. None of the patients in the study group was trans- ferred from another institution while he or she had a known diagnosis of T-L Fx. Table 1 describes the sub- group analysis of the 43 delayed-group cases.
Clinical characteristics of the patients in each cate- gory are listed in Table 2. The 2 groups had the same frequency of associated major injuries. However, the de- layed group had significantly more episodes of hypoten- sion (p < 0.05), more cases with a GCS score <15 (p < 0.05), and more with critical conditions (i.e., necessitat- ing ongoing fluid/blood resuscitation andor emergent airway intervention) (p < 0.05) than did the nondelayed group. There were 5 patients with multiple contiguous Fxs within the same spinal region, which were counted as a single Fx. There were 22 patients (12% of total) with multiple noncontiguous Fxs involving > 1 spinal re- gion. Significantly more multiple noncontiguous Fxs oc- curred in the delayed group than in the nondelayed group (p < 0.01). In addition to the T-L Fx, there were 14 cases of cervical-spine Fxs. The delayed group had a signifi- cantly higher proportion of cervical Fxs than did the nondelayed group (p < 0.001).
Physical examinations of the back were documented by the primary care provider in all cases of the nonde- layed group. Most (90%) of the patients in the nonde- layed group had clinical signs and symptoms suggesting backhpine injury. These included abrasions, contusions, neurologic deficit, pain on palpation of the back, and complaints of back pain. Most (84%) of the 43 delayed- group patients had back examinations documented in the medical record of the ED evaluation. Of these, only 32% had clinical evidence of back injury as described above. When all the patients who had documented back ex- aminations were compared, there were significantly more patients with clinical evidence of injury in the non- delayed group than in the delayed group (p < 0.005). The most frequently occurring clinical sign of T-L Fx was pain on palpation of the T-L spine, elicited in 60%
of all the patients who had clinical evidence of back injury.
Of cases with a GCS score = 15, documented back examination, and no obvious clinical clue of injury (i.e., no physical evidence of back trauma or pain on palpation of the back), there were 16 T-L Fxs in 13 patients. Of these 16 asymptomatic Fxs, there were 6 noncontiguous Fxs in different spinal regions and 4 contiguous Fxs in the same spinal region. These Fxs represented 8.3% of the total Fxs in the study patients. Details of their pre- sentations are listed in Table 3.
More than half (n = 28; 65%) of the delayed diagnoses were made within 12 hours after hospital admission. An additional 14 (33%) of the delayed diagnoses were made 12-36 hours after admission. Most (n = 24; 54%) of the delayed diagnoses occurred when the trauma team or- dered T-L spine radiographs subsequent to the patient’s admission from the ED. However, 10 (23%) Fxs were eventually discovered on radiographs initially obtained in the ED. These included 7 T-L Fxs detected in radio- graphs specifically ordered in the ED to assess the back (subgroup 2) and incidental findings of T-L Fxs on 3 chest radiographs obtained in the ED. Another 9 Fxs (2 1 %) were discovered incidentally with abdominaVpe1- vic CT (n = 3) or at autopsy (n = 6).
Table 4 illustrates the distribution of T-L Fxs and neu- rologic injuries in the study group. The nondelayed group had 36 (26%) cases of neurologic deficits asso- ciated with their T-L Fxs compared with 8 (19%) in the delayed group (p = NS). Progression of neurologic def- icit occurred in 8 of 20 (40%) cases of incomplete le- sions in the nondelayed group and 3 of 3 (100%) in the delayed group.
In 3 cases, the mechanism of injury was unknown. Table 5 describes the mechanisms of injury sustained by the rest of the study group. High-energy MVCs and di- rect blunt assaults to the back were more frequent in the delayed group than in the nondelayed group (p < 0.05).
836 ACADEMIC EMERGENCY MEDICINE SEP 1996 VOL 3/NO 9
1 TABLE 3 Fracture
Characteristics of the Patients Presenting with Glasgow Coma Scale Scores = 15 and without Clinical Clues of Thoracolumbar
Complete Incomplete Progression Resolution Time to NO. T-L* Fxst No. NIs Fracture level Diagnosis (% Total Fxs) (% Total Fxs) (CCL) ( I W (% Total ICL) (% Total ICL.)
TI -TI" Delayed 18 5 4 1 1 0 Not delayed 45 14 8 6 4 1 Total 63 (33%) 19 (43%) 12 . I 5 (71%) 1(14%)
* T-L = thoracolumbar. t Fxs = fractures. $Total includes multiple noncontiguous fractures counted in >1 spinal region.
Delayed Diagnosis of T-L Fractures, Anderson et al. 837
I DISCUSSION
The occurrenck of delays in the diagnosis of T-L Fx among multiple-trauma patients has been described in the literature.lO.ll In general, these delays have been con- sidered unacceptable, and have prompted ATLS recom- mendations for radiographic screening of the T-L spine, as well as the cervical spine, of all multiple-trauma pa- tients.’ While this approach is undoubtedly the best way to avoid delays in the diagnosis of T-L Fx, it seems ex- treme given the critical nature of many multiple-trauma patients, for whom higher priority interventions seem more prudent.
This study was aimed at addressing the following questions: How often does the ED evaluation fail to make the diagnosis of T-L Fx, thus contributing to the overall delay in diagnosis? What elements in the ED presentation and evaluation of these patients contribute to failure to make the diagnosis? Is failure to diagnose T-L Fx in the ED detrimental to the ultimate outcome of the patient?
The frequency of delayed diagnosis of T-L Fx in our series was 24%. This is much higher than that reported by other investigators, where the occurrence of delayed diagnosis of spinal Fxs ranged from 4% to 14%.”,” Re- garding the study by Reid and coworkers, which re- ported a delay in T-L Fx diagnosis of 4.9% in 253 trauma patients,” ‘‘delayed diagnosis” was defined as failure to detect the Fx by 24 hours after trauma. We defined de- layed diagnosis as failure to make the diagnosis of T-L Fx while the patient was in the ED. In our study group, 65% of the delayed-group Fxs were discovered by 12 hours and 97% by 36 hours after admission to the hos- pital. Hence, our rate of early detection is actually com- parable to that of prior studies.
The Fx profile of our study group was similar to that of prior series. In our study group, the majority of Fxs occurred at the T-L junction. This is the most common site of T-L Fx because of its increased mobility com- pared with the remainder of the T-L pine.'^-'^ Fractures in the thoracic spine were associated with a high degree of neurologic injury and complete cord lesions. This also is consistent with the literature, and may be due to the narrow canal vs cord diameter in this spinal region.” We determined a 75% overall incidence of significant other major injuries in our patients, similar to that reported by other investigator~.~.’~ Overall, the most frequent mech- anism of injury we observed was falls, which subject the patient to axial loading and hyperflexion and are asso- ciated with a high likelihood of T-L Fx.”.I6 Thirty per- cent of our patients had injuries due to MVCs, in which many patients may be subjected to hyperflexion and shearing forces due to rapid deceleration. These forces have been associated with compression and chance Fxs.’~ Since our population appears similar to trauma
Direct penetrating 13 (9%) 4 (9%) 17 (9%) trauma to the back
* p < 0.05, x 2 analysis. ?In some cases the medical record did not comment on the use of
seat belts.
patients described by other investigators, we attribute the greater frequency of delay in diagnosis of T-L Fxs to our definition of delay rather than differences in injury pat- terns.
Despite equal frequencies of associated major injuries in the delayed and nondelayed groups, the delayed-group patients were more frequently hypotensive, had an in- creased frequency of GCS scores < 15, and were more frequently critical than the nondelayed-group patients. All the delayed patients in the subgroup 1 required on- going resuscitation because of life-threatening cardio- pulmonary and/or hemodynamic instability, and required diagnostic and/or therapeutic intervention that was con- sidered to have higher priority than obtaining T-L radi- ographs in the ED. We believe the delay in diagnosis for the subgroup-I patients was due to the critical clinical condition of this group.
There were 7 Fxs in subgroup 2 that were initially missed on readings of T-L radiographs obtained in the ED. One case involved a poorly penetrated radiograph; another radiograph was obtained later in the patient’s hospitalization and showed a Fx. In all other cases where Fxs were missed on radiographs obtained and interpreted in the ED, the Fxs that were later seen by radiologists were considered subtle compression Fxs. None of the patients in subgroup 2 had neurologic deficits from their
838 ACADEMIC EMERGENCY MEDICINE SEP 1996 VOL 3/NO 9
injuries. The 7 subgroup-2 patients were admitted to the hospital because of other injuries, and the diagnosis of T-L Fx was made before hospital discharge.
In the subgroup-3 cases of delayed diagnosis, T-L ra- diographs were not obtained in the ED. Review of these 3 cases suggests that the possibility of T-L Fx should have been considered. All 3 patients had significant mechanisms of injury, painful distracting associated in- juries, and evidence of alcohol ingestion. which may have obscured the clinical examination.
The most devastating clinical consequences of a delay in diagnosis of T-L Fx is progression of neurologic def- icits, and an early diagnosis of T-L Fx seems intuitively better for patient outcome and management than does a later diagnosis. If a spinal Fx is detected,. extra caution in the patient’s movement and positioning would be in- itiated and continued throughout his or her hospitaliza- tion. Those patients who have Fxs with associated neu- rologic deficits detected in the ED might receive high-dose steroids, while those not diagnosed in the ED would not be treated until the lesion was noted. Only a small number of deficits occurred in our study group. Forty-five percent (23 of 51) of the neurologic deficits were incomplete spinal cord lesions, with the potential for progression. Of incomplete lesions, 48% (1 1 of 23) progressed. One of these cases (patient 3, Table 3) was in subgroup 3; T-L radiographs were not obtained during the ED evaluation but were done later when the patient complained of paresthesias. Although attributing this neurologic progression to the delay in T-L Fx diagnosis is speculative, this case does point out the need to con- sider T-L injury when a high-risk mechanism has oc- curred and other injuries are present (e.g., closed head injury) that may distract attention from the back exam- ination.
The incidence of multiple noncontiguous Fxs in our study group was 12% overall. We also found a large number of cervical Fxs in association with T-L Fxs, es- pecially in the delayed group. Several investigators have commented on the frequent finding of a second spinal Fx in multiple-trauma patients,”,”*’* and many have sug- gested screening the entire spine if 1 Fx is f o ~ n d . ” ~ ” ~ Our findings also suggest that the presence of 1 Fx should prompt consideration of screening for another Fx.
Almost all the patients in the nondelayed group had clinical suggestions of back injury, compared with ap- proximately 30% of the patients in the delayed group. The most common sign of Fx was back pain, which may not have been elicited during the examination of criti- cally injured delayed-group patients, many of whom were unconscious. Our data agree with previous studies showing that physical examination may be inadequate in detecting T-L Fxs when there are confounders to ex- amination such as a GCS score < 15, the presence of intoxicants, a history of head trauma, or other painful
distracting i n j ~ r y . ~ . ~ The retrospective nature of this study does not permit an absolute conclusion; however, we speculate that subgroup-3 cases may have occurred because of a failure to appreciate the significance of the mechanism of injury and the presence of confounders to examination. Our study indicated that if T-L radiographs were not obtained in the ED, they were not obtained for up to 36 hours after the patient’s admission. If radio- graphs are indicated, emergency physicians should de- termine whether the patient is stable enough to allow the few minutes needed for the study. The films can be viewed shortly after ED disposition if necessary, with the results reported to the admitting physician.
I LIMITATIONS AND FUTURE QUESTIONS ............................................................................
This study is limited by the problems that are inherent with retrospective chart review. Since multiple clinicians were involved in the care of these patients, the infor- mation collected as part of the standard medical record was not entered in a standard fashion for all cases. Dif- ferences may exist in descriptions, definitions, and ter- minology used by the clinicians.
For the purposes of analysis, we established our own definitions of ‘‘critical” and ‘‘noncritical’ ’ patients, and did not compare injury severity scores. We also relied on literature definitions of high- and low-risk injury mechanisms. Some data pieces were missing and there- fore could not be retrieved or recalled. Some charts were lost or incomplete and therefore could not be retrieved for review; this may have introduced selection bias in data collection.
This study reviewed only those T-L Fx patients who were admitted to the hospital and therefore were prob- ably the most severely injured patients evaluated in the ED. Patients evaluated but then sent home with T-L Fx either diagnosed or missed in the ED were not included. It is likely this selection bias results in an underrepre- sentation of the frequency of missed T-L Fx and inac- curacies with clinical characteristics of this group. This, along with the retrospective nature of the study, pre- cludes the establishment of clinical criteria that would predict the need for T-L radiographs. A future prospec- tive study, including patients released home, might pro- vide more complete information and would be especially useful in determining when radiographs should be ob- tained.
m CONCLUSION ................................................................
A delay in the diagnosis of T-L Fx is not uncommon during the ED evaluation of trauma patients. Most com- monly, delayed diagnosis of T-L Fx occurs in severely injured multiple-trauma patients who require immediate
Delayed Diagnosis of T-L Fractures, Anderson et al. 839
resuscitation and high-priority diagnostic or management procedums for stabilization. Most Fxs are discovered within 36 hours of admission to the hospital. Progression of incomplete neurologic deficits occurred more fre- quently for the patients who had delayed diagnosis, but it is unclear whether these delays contributed to these adverse clinical outcomes.
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