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The fast-track PA approaches you about a case. “I just want to run something by you. I have this guy who fell a week ago and he wants some pain meds.  Sounds like he might be a drug seeker because he is refusing to be X-rayed.” 

Great, you think, just what I need today. “Lets go talk to him,” you say. 

On your way to Fast Track you spot the gentleman in question. He is walking around near the nurses station, holding the left side of his neck and nagging the nurses for service. “Look, I just need a shot for pain,” he tells you. “I can’t afford to pay for any X-rays”. His story is that he fell backwards off a ladder about 10 days ago and his neck has been hurting ever since. He keeps rubbing the back of his neck and you notice that he turns his entire body rather than his neck to look around when his name is called.

“We can give you some pain meds, Sir”, you say sympathetically, “but you really need the X-rays”.  You make your case with the usual arguments – might have a broken neck, might be paralyzed forever, etc... No luck. The PA then chimes in brilliantly, in a quiet voice, “Sir, you know, if you get paralyzed from a broken neck, you might not be able to have...you know...sex again.”

That argument wins the day.  He heads off to X-ray, still refusing to wear a C-collar. Oh well, you think, I’ll get over it. The X-rays will probably be negative anyway. 

A few minutes later, the X-ray tech calls you STAT. 
“You better come look at this lateral C-spine that Fast Track just ordered”. 
What does it show?
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See next page for diagnosis and discussion
{mospagebreak title=Diagnosis}
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Kudos to the PA for picking up on this fellow’s problem. A certain percentage of C-spine fractures and injuries, albeit small, will present with minimal to no symptoms, especially in the setting of distracting injury, alcohol or extreme age. Other patients will present some time after the injury with nothing more than persistent pain, often without neurologic deficit.

Several clues were present in this case to suspect a delayed presentation. First was the mechanism of injury – falling backwards off a ladder has always been a good way to break your neck.  The second was the exam finding of diminished range of motion – this patient, due to pain and overlying muscle spasm, was guarding his injury and would not rotate his neck voluntarily.  Effectively, that means that he could not have his C-spine cleared clinically in the setting of trauma. It is also notable that this fellow remained completely without neurologic deficit during his ED stay – the same as during the last 10 days.

The X-rays show widening of the posterior elements (circled) at the C6-C7 level, along with loss of the normal ligamentous curvature at this same level. This implies ligamentous injury and instability of the posterior longitudinal ligament and other (e.g. spino-laminar) posterior supporting elements. The “perching” of the C6-C7 facet can also be seen on the oblique views (left images), especially on the left side.  There is loss of the usual “roof shingle” juxtaposition of the facets as you move downward. Of note, this C-spine problem is a hyperflexion injury, which tends to be unstable even in the absence of major fracture (there was NO significant fracture present on CT scanning in this case).

After further threats and cajoling, the patient agreed to lie (mostly) flat and accept a C-collar. Then its off to neurosurgery and then a date with Mr. Halo at the trauma center. Oh, and by the way, Sir....don’t do it again.

John Dallara, MD, directs the Emergency Medicine PREP Course
www.emprepcourse.com
 

Comments   

# Kudos to the PAMark Levine, D.C. 2008-12-03 12:22
How condescending! even my Aunt Minnie could see the problem.
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# C-spine fracture triage to FTJohn Dallara 2008-12-04 19:55
I like this case for several reasons. It beautifully illustrates how easy it is for fairly serious stuff to get triaged to FT.

In addition, the x-ray is a classic. It shows not only the mal-alignment at the posterior longitudinal ligament, but the posterior element splaying. As a teaching case, I think it is useful to emphasize looking for this "widening out" of the posterior elements. Sometimes, that will be the only clue to ligamentous instability.

JD
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