Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Nov 26, 2021; 9(33): 10369-10373
Published online Nov 26, 2021. doi: 10.12998/wjcc.v9.i33.10369
Clinical algorithm for preventing missed diagnoses of occult cervical spine instability after acute trauma: A case report
Ce Zhu, Hui-Liang Yang, Gi Hye Im, Li-Min Liu, Chun-Guang Zhou, Yue-Ming Song
Ce Zhu, Hui-Liang Yang, Li-Min Liu, Chun-Guang Zhou, Yue-Ming Song, Department of Orthopedic Surgery and Orthopedics Research Institute, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
Gi Hye Im, Department of Emergency Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI 02903, United States
Author contributions: Zhu C and Yang HL conceived the study design, carried out the study, and drafted the manuscript; Im GH and Liu LM carried out the initial analyses and reviewed and revised the manuscript; Zhou CG and Song YM coordinated and supervised data collection and critically reviewed and revised the manuscript for important intellectual content; all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work; Im GH is a native English speaker and refined the language of the manuscript; Zhu C and Yang HL contributed equally to this work.
Supported by grants from China Postdoctoral Science Foundation General Program No. 2019M653417; Sichuan Science and Technology Program, No. 2020YJ0025, No. 2017SZ0046, and No. 2017SZDZX0021; Post-Doctor Research Project, Sichuan University, No. 2019SCU12043; and International Postdoctoral Exchange Fellowship Program, No. PC2019060.
Informed consent statement: Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
Conflict-of-interest statement: The authors declare they have no conflicts of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Chun-Guang Zhou, MD, PhD, Assistant Professor, Department of Orthopedic Surgery and Orthopedics Research Institute, West China Hospital of Sichuan University, No. 37 Guoxue Road, Chengdu 610041, Sichuan Province, China. zcg_spine@163.com
Received: July 9, 2021
Peer-review started: July 9, 2021
First decision: July 26, 2021
Revised: July 29, 2021
Accepted: September 10, 2021
Article in press: September 10, 2021
Published online: November 26, 2021
Abstract
BACKGROUND

Missed or delayed diagnosis of cervical spine instability after acute trauma can have catastrophic consequences for the patient, resulting in severe neurological impairment. Currently, however, there is no consensus on the optimal strategy for diagnosing occult cervical spine instability. Thus, we present a case of occult cervical spine instability and provide a clinical algorithm to aid physicians in diagnosing occult instability of the cervical spine.

CASE SUMMARY

A 57-year-old man presented with cervical spine pain and inability to stand following a serious fall from a height of 2 m. No obvious vertebral fracture or dislocation was found at the time on standard lateral X-ray, computed tomography, and magnetic resonance imaging (MRI). Subsequently, the initial surgical plan was unilateral open-door laminoplasty (C3-7) with alternative levels of centerpiece mini-plate fixation (C3, 5, and 7). However, the intraoperative C-arm fluoroscopic X-rays revealed significantly increased intervertebral space at C5-6, indicating instability at this level that was previously unrecognized on preoperative imaging. We finally performed lateral mass fixation and fusion at the C5-6 level. Looking back at the preoperative images, we found that the preoperative T2 MRI showed non-obvious high signal intensity at the C5-6 intervertebral disc and posterior interspinous ligament.

CONCLUSION

MRI of cervical spine trauma patients should be carefully reviewed to detect disco-ligamentous injury, which will lead to further cervical spine instability. In patients with highly suspected cervical spine instability indicated on MRI, lateral X-ray under traction or after anesthesia and muscle relaxation needs to be performed to avoid missed diagnoses of occult cervical instability.

Keywords: Clinical algorithm, Missed diagnoses, Occult cervical spine instability, Case report

Core Tip: Currently, there is no consensus on the optimal strategy for diagnosing occult cervical spine instability. We present a case of occult cervical spine instability and provide a clinical algorithm for diagnosing occult instability of the cervical spine. In this clinical algorithm, we recommend bedside lateral X-ray under traction or lateral X-ray after anesthesia and muscle relaxation prior to surgery as an effective, safe, and efficient method for detecting highly suspected instability of the cervical spine. We believe that this clinical algorithm will aid physicians in preventing missed diagnoses of occult instability of the cervical spine.