Head trauma and cervical spine injuries

Abstract

The article by Bayless et al in this issue presages revisions.’ The forthcoming new edition of the American College of Surgeons’ book, For the Early Care of Trauma,’ should be brought to the attention of all emergency physicians. In patients who are killed in road traffic accidents, and wherein it appears that brain injury probably contributed to death, the incidence of serious cervical spine injuries jumps to over 20%.’ This is documented in pathologic reports in more than one publication. However, in a minor head injury wherein the patient is able to state that he or she does not have pain in the neck, neurologic problems, etc, there is no necessity to obtain cervical spine x-rays. The incidence of fracture in that group of patients is very low. However, if the patient has complaints of pain in the neck, or a demonstrable neurologic deficit, then cervical spine x-rays obviously are appropriate. In these patients, fractures may be identified. The history and physical examination dictate the necessity of the study, rather than just the event itself. In patients who have serious head injuries and are unable to communicate in a meaningful fashion with the examining physician, cervical spine x-rays are still appropriate if there has been evidence of a significant head injury. In the series by Bayless et al, of 20 patients with skull or intracranial lesions (including brain contusions, subdural and epidural hemorrhaging, etc), one patient (5%) had a documented cervical spine injury.’ In most of our surveys, seriously head-injured patients have approximately a 4% to 5% chance of having a cervical spine injury. It is in this group of patients that we need further evaluations, including cervical spine x-rays. The data of Bayless et al again points out the importance of clinical judgment as opposed to routine performance of any study.’ In the less concussed patient who is neurologically intact and has no neck complaints, a cervical spine x-ray is not useful. In the more seriously head-injured patient, when communication is a problem and there may be neck pain or neurologic deficits, x-ray films still must be obtained.