What defines a distracting injury in cervical spine assessment?

Background: The National Emergency X-Radiography Utilization Study defined five criteria for obtaining cervical spine radiographic investigations in blunt trauma patients. Distracting injury was given as the indication for more than 30% of all x-ray studies ordered. The hypothesis of this study was that upper and lower torso injuries would have different effects on clinical cervical spine assessment.

Methods: This is a single-center, prospective, observational study of admitted, alert, adult blunt-trauma patients. All patients underwent cervical spine plain-film radiography. Data were collected on all injuries, physical examination findings, narcotic administration, and radiograph results. Patients with upper and lower torso injuries were compared in their ability complain of pain or midline tenderness relative to a cervical spine fracture.

Results: In all, 406 patients participated. All patients received narcotic analgesics before examination. Forty patients (9.9%) had cervical spine fractures, of whom seven had a nontender neck examination. All seven patients with a nontender cervical spine and a neck fracture had at least one upper torso injury. None of the 99 patients with injuries isolated to the lower torso and a nontender neck had a cervical spine fracture (p < 0.05). The frequency of cervical spine fracture among patients with cervical spine tenderness was 19.8% (n = 33).

Conclusions: The National Emergency X-Radiography Utilization Study definition of a distracting injury may be narrowed. Upper torso injuries may be sufficiently painful to distract from a reliable cervical spine examination. Patients may detect spine tenderness in the presence of isolated painful lower torso injuries. Patients with spine tenderness warrant imaging.