SPINE Volume 31, Number 4, pp 451– 458 ©2006, Lippincott Williams & Wilkins, Inc. Neurologic Deterioration Secondary to Unrecognized Spinal Instability Following Trauma–A Multicenter Study Allan D. Levi, MD, PhD,* R. John Hurlbert, MD, PhD,† Paul Anderson, MD,‡ Michael Fehlings, MD, PhD,§ Raj Rampersaud, MD,§ Eric M. Massicotte, MD,§ John C. France, MD, Jean Charles Le Huec, MD, PhD,¶ Rune Hedlund, MD,** and Paul Arnold, MD†† Study Design. A retrospective study was undertaken that evaluated the medical records and imaging studies of a subset of patients with spinal injury from large level I trauma centers. Objective. To characterize patients with spinal injuries who had neurologic deterioration due to unrecognized instability. Summary of Background Data. Controversy exists re- garding the most appropriate imaging studies required to “clear” the spine in patients suspected of having a spinal column injury. Although most bony and/or ligamentous spine injuries are detected early, an occasional patient has an occult injury, which is not detected, and a poten- tially straightforward problem becomes a neurologic ca- tastrophe. Methods. The study was designed as a retrospective review of patients who had neurologic deterioration as a direct result of an unrecognized fracture, subluxation, or soft tissue injury of the cervical, thoracic, or lumbar spine from 8 level I trauma centers. Demographics, injury information, and neurologic outcome were collected. The etiology and incidence of the missed injury were determined. Results. A total of 24 patients were identified who were treated or referred to 1 of the participating trauma centers and had an adverse neurologic outcome as a result of the missed injury. The average age of the patientswas 50 years (range 18 –92), and average delay in diagnosis was 19.8 days. Radiculopathy developed in 5 patients, 16 had spinal cord injuries, and 3 patients died as a result of their neurologic injury. The most common reason for the missed injury was insufficient imaging studies (58.3%), while only 33.3% were a result of misread radiographs or 8.3% poor quality radiographs. The incidence of missed injuries resulting in neurologic injury in patients with spine fractures or strains was 0.21%, and the incidence as a percentage of all trauma patients evaluated was 0.025%. Conclusions. This multicenter study establishes that missed spinal injuries resulting in a neurologic deficit continue to occur in major trauma centers despite the presence of experienced personnel and sophisticated im- aging techniques. Older age, high impact accidents, and patients with insufficient imaging are at highest risk. Key words: spinal instability, trauma, spinal clearance, spinal cord injury, radiculopathy. Spine 2006;31:451– 458 One of the major goals of caring for the trauma patient is the early detection and treatment of acute spinal injuries, thereby preventing delayed neurologic deterioration from a missed spinal injury. Although extensive re- sources are used to screen patients, the success of trauma teams at attaining this goal is unclear. Several studies have reviewed the issue of missed injuries in the trauma population, and the reported incidence of significant missed spinal injuries is low, with an exact figure depen- dent on the study population. 1–5 However, most of these studies are authored by general trauma surgeons and/or radiologists, with many of the recent reports lacking suf- ficient follow-up. Spine surgeons in academic centers who specialize in trauma have a unique perspective on the issue of clearing the spine because they are often the last treating physi- cian in cases in which instability or neurologic deficits from spinal injuries go undetected. There are certain spi- nal fractures that if left undetected, will have only rela- tively minor consequences to the patient. Although this may be recorded as a missed injury in some studies, par- ticularly studies that use spinal computerized tomogra- phy (CT) as an end point, the significance of such minor fractures is probably limited. 6–9 Of major interest is the detection and treatment of an injury that if missed, may result in neurologic compromise. Because caring for a patient who has an adverse event from a missed spinal injury is unlikely to be forgotten by the attending spine surgeon, a retrospective review, even many years after the event, will still likely accurately reflect the trauma center’s experience. From the *Department of Neurosurgery and the Miami Project to Cure Paralysis, University of Miami, Miami, FL; †Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada; ‡Department of Orthopedic and Neurological Surgery & Re- habilitation, University of Wisconsin–Madison, Madison, WI; §Divi- sions of Orthopaedic and Neurosurgery, Toronto Western Hospital, Krembil Neuroscience Center, University of Toronto, Toronto, Ontario, Canada; Department of Orthopedics, Robert C. Byrd Health Sciences Center, West Virginia University, WV; ¶Department of Ortho- Trauma, Hopital Tripode Pellegrin; **Department of Orthopedic Sur- gery, Karolinska Institute, Huddinge University Hospital; and ††De- partment of Neurosurgery, University of Kansas, Kansas City, KS. Acknowledgment date: December 7, 2004. First revision date: January 11, 2005. Second revision date: February 22, 2005. Acceptance date: February 23, 2005. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Allan D. Levi, MD, PhD, The Miami Project to Cure Paralysis, University of Miami School of Medicine, Department of Neurological Surgery, 2nd Floor, D4-6, 1095 NW 14th Terrace, Miami, FL 33136; E-mail: alevi@med. miami.edu 451