The Journal of TRAUMA௡ Injury, Infection, and Critical Care Missed and Mismanaged Injuries of the Spinal Cord Pradeep Matthew Poonnoose, MS(Orth), Ganapathiraju Ravichandran, FRCS, and Martin Raymond McClelland, FRCS Objective: The purpose of this study tients with no neurologic deficits were ex- associated injuries, and radiographic was to determine the incidence of missed cluded from the study. errors. and mismanaged injuries of the spinal Results: Of the 569 patients, the di- Conclusion: Despite a greater aware- cord, to identify factors contributing to a agnosis of spinal cord injury was missed in ness of the potential for spinal injury after failure to recognize such injuries, and to 52 instances (9.1%). The patients were road traffic accidents, failure to recognize assess the consequences of such failures. mismanaged in 34 instances, and the a spinal cord injury in the acute care set- Methods: Missed and mismanaged treatment offered to 30 was considered ting appears to be increasing. Injuries are injuries were defined using previously val- negligent. In 26 of 52 (50%), mismanage- seldom missed because of an isolated idated statements. All medical records ment resulted in neurologic deterioration. cause, but rather because of a combina- and radiographs of patients with acute The study identified several factors that tion of several factors. Increased vigilance traumatic spinal cord injury admitted to contributed to a failure to recognize a spi- on the part of the primary care physicians the Regional Spinal Cord Injury Unit in nal cord injury. These include ambience and careful documentation may reduce al- Sheffield, United Kingdom, over a period and circumstances surrounding the in- legations of medical negligence. of 10 years from 1989 were evaluated. Pa- jury, inadequate neurologic assessment, J Trauma. 2002;53:314–320. ailure to recognize evidence of spinal column injuries ognized by the original hospital were retrieved. All available because of radiographic or radiodiagnostic errors has radiographs, including the earliest radiographs from referring Fbeen highlighted in several recent articles.1–9 These re- hospitals, were reviewed systematically to identify all diag- ports included patients with and without associated neuro- nostic features of bony and soft tissue injury. logic injuries. The present study was undertaken to identify For the purposes of this study, the following definitions the causes of failure to recognize vertebral column injuries in were used to quantify the extent of “missed” injury to the patients with coexisting significant neurologic deficit. Our spinal cord. In some instances, failure to recognize SCI re- study also addresses the clinical consequences of such failure sulted in “mismanagement.” The authors felt that a certain to recognize spinal cord injury (SCI). proportion of them were managed “negligently.” Missed in- jury was defined as failure to recognize conditions that are PATIENTS AND METHODS likely to cause or contribute to neurologic deterioration. Mis- A retrospective analysis of case records of all 569 SCI management was defined as execution of a “therapeutic” patients admitted for comprehensive management to the Re- maneuver likely to cause deterioration of the condition. To gional Spinal Cord Injury Unit in Sheffield during the period confirm that the management given in a particular case was April 1989 to April 1999 was conducted. Patients were ad- negligent, two senior clinicians should be satisfied that there mitted either directly from the accident and emergency de- is an established usual and normal practice for the manage- partment or after acute management at another referring hos- ment of the condition suffered by the patient; the person pital. Patients who had vertebral column injuries, without (doctor) must be shown not to have adopted that practice; and neurologic deficits, were excluded from this study. the course adopted by that person (doctor) was one that no The extent of primary neurologic deficit was assessed by professional person of ordinary skill would have taken if he 10 close scrutiny of the medical and nursing records of all or she had acted with ordinary care. patients where an injury to the spinal column was not recog- nized initially. From the records, the level of vertebral col- RESULTS umn injury, the cause of the injury, associated injuries, and Medical records of 569 patients with neurologic deficits the extent of neurologic deficit when it was eventually rec- secondary to traumatic spinal cord injury were evaluated. In 52 instances (9.1%), the diagnosis was initially missed for a Submitted for publication June 22, 2001. varying period of time. The records confirmed that 34 of the Accepted for publication December 21, 2001. patients in whom the diagnosis was missed underwent a Copyright © 2002 by Lippincott Williams & Wilkins, Inc. therapeutic intervention that was inappropriate to their con- From the Princess Royal Spinal Injury Unit, Sheffield, United Kingdom. dition and were therefore mismanaged by the referring hos- Address for reprints: G. Ravichandran, FRCS, Princess Royal Spinal pital. After detailed discussions between two senior authors, Injury Unit, Northern General Hospital, Sheffield S5 7AU, United Kingdom. the treatment offered to 30 patients was considered negligent 314 August 2002 Missed and Mismanaged Injuries of the Spinal Cord In 26 of 52 patients (50%), mismanagement of SCI Table 1 Vertebral Level of the Missed Injury resulted in neurologic deterioration. In seven of these pa- Population Studied tients, the neurologic deficit at the time of initial presentation Vertebral Level No. of Lesions to the accident and emergency unit was minimal. The remain- C1/2 1 ing 19 had significant neurologic deficit, which deteriorated C3–C6 28 after mismanagement. In nine patients, mismanagement C7/D1 4 caused the neurology to deteriorate to complete paralysis. Six T14 L5patients died as a direct result of the delay in diagnosis. Eight patients had more than one vertebral fracture. Even though one of the vertebral column injuries was initially recognized, and inappropriate. There were 40 men with a mean age of the second injury remained unrecognized in these patients, 43.2 years (range, 17–81 years) in whom the spinal cord resulting in additional neurologic disability. injury was initially missed. The average age of the 12 women Thirty-six (36 of 52) patients (69%) had multisystem was 59 years (range, 25–92 years). The vertebral level of injuries, and nearly a third had significant head injury. Six- these missed lesions is shown in Table 1. The distribution of teen were admitted to the accident and emergency unit with the incidence of missed lesions during the last 10 years is an altered Glasgow Coma Scale score (Ͻ13–15). Thirteen of shown in Figure 1. them required ventilation soon after admission, and this re- Of the 52 patients in whom SCI was initially missed, 30 suffered the injury after road traffic (car/motorcycle) acci- stricted an opportunity for a secondary survey. Nine of the dents. Minor falls (n ϭ 7), falls down a flight of stairs (n ϭ patients were under the influence of alcohol when first seen. 7), and falls from a significant height (n ϭ 6) were other Seven patients were labeled hysterical at the time of initial important causes of paralysis in this group. One patient suf- examination. fered tetraplegia after a diving injury. A heavy beam fell on A major cause for the delay in diagnosis seems to be the back of one patient, resulting in paralysis. Dislocation of related to a failure to appreciate radiologic signs. Initial the cervical spine resulting in tetraplegia occurred in one radiographs were of poor quality in 18 of the 52 cases. The individual whose head and neck were forcefully restrained entire region was not visualized adequately in 11 of 52 (head lock) by the police during a struggle. instances. In four cases, radiographs of uninjured regions The paralysis caused by spinal cord injury was unrecog- were requested. Surprisingly, in 10 of 52 of the radiographs, nized even after referral to specialists such as neurosurgeons an obvious fracture was missed. Another 11 of 52 lesions and orthopedic surgeons in 33 of 52 (63%) instances. Spinal were missed because of failure to interpret facet joint mal- column injury and/or SCI was unrecognized by accident and alignment. Initial radiographs of 10 (10 of 52) patients who emergency units in 17 patients. Failure to recognize SCI developed tetraplegia showed evidence of increased prever- occurred both in district general hospitals (n ϭ 28) and tebral soft tissue space, suggestive of hematoma. In these teaching hospitals (n ϭ 19). The paralysis was unrecognized patients, a spinal column lesion could have been suspected if by general practitioners in two instances. In this study, pa- closer attention was given to the presence of increased pre- ralysis was not recognized by a medical team abroad on two vertebral soft tissue shadow. Six of the patients in whom the occasions. One individual who suffered an injury in a com- paralysis was missed had no obvious vertebral injury on the munity hospital developed paralysis gradually over several routine radiographs, and magnetic resonance imaging (MRI) days. The median time to recognition of SCI was 4 days scans were required to confirm cord damage. Spondylitic (range, 10 hours to 6 weeks). changes on the cervical spine contributed to the difficulty in Fig. 1. Annual incidence of missed injuries of the spinal cord during the period of study. Volume 53 • Number 2 315 The Journal of TRAUMA௡ Injury, Infection, and Critical Care the diagnosis in 14 patients. Five of the patients had anky- riorated after their admission to a trauma center.9 The need to losing spondylitis, and this probably led to a difficulty in minimize the secondary damage to the spinal cord occurring obtaining and assessing the radiograph. In eight patients, no in the trauma centers/accident and emergency departments radiograph was taken when the patient presented with the cannot be overstated in this group of patients.