Spinal cord injury resulting from injury missed on CT scan: the danger of relying on CT alone for collar removal.

BACKGROUND: Strict criteria have been used before removing cervical collars in patients with injuries who have midline pain or are unable to be reliably examined. This sometimes leads to prolonged immobilization in cervical collars or use of MRI to rule out injury. Several studies suggest a collar may be removed in the absence of fractures, dislocation, or pathologic subluxation on a cervical CT scan. This may avoid the morbidity of prolonged cervical immobilization or cost of advanced imaging study but risks devastating consequences from missing injuries. CASE DESCRIPTION: We report a patient with a cervical spinal cord injury after removal of a collar after a CT scan was misinterpreted as normal. Retrospective review of the CT showed subtle signs of widening between the spinous processes of the injured level, a finding easily missed without the use of further imaging studies. LITERATURE REVIEW: Several articles suggest cervical collars may be safely removed from awake and alert patients and in patients who cannot be reliably examined after a negative CT scan without the need for further imaging. PURPOSES AND CLINICAL RELEVANCE: CT scans are excellent at detecting bony injuries but not ligamentous injuries. Removing cervical collars based on CT scans alone may be expeditious, but some injuries may be missed without further imaging. Our case demonstrates the catastrophic consequences of missing a cervical spine injury and emphasizes the need for maintaining the cervical collar in high-risk patients until proper imaging can be obtained.