Post-traumatic neck pain: A prospective and follow-up study

ORIGINAL CONTRIBUTION trauma, neck, pain

Post.Traumatic Neck Pain: A Prospective and Follow.up Study Three hundred fifty-one alert emergency department patients with posttraumatic neck pain were evaluated prospectively. Seven (2%) had proven fractures or ligament disruptions. The immediate onset of neck pain and the presence of posterior midline cervical tenderness each had 100% sensitivity, with specificity of 65% and 48%, respectively. Discharged patients were followed up by telephone or letter at a mean of 25 +_ 20 weeks. Of this group, 63% saw another physician, and 43% had persistent moderate-to-severe neck pain or neurologic symptoms at a mean follow-up time of 24 weeks after injury. Of those who had not had a cervical radiograph while in the ED, 52% later obtained one. In addition, 66% of the discharged patients were pursuing litigation. The results suggest that it m a y be possible to identify alert patients with cervical spine injury by means of history and examination only; however, a larger study confirming these results is required. The high frequency of post-ED radiography, the high prevalence of persistent symptoms after injury, and frequent involvement in litigation are factors to be considered when evaluating ED patients with post-traumatic neck pain. These factors m a y support the validity of obtaining cervical spine radiographs on m a n y more of these patients than high-yield criteria would dictate. [McNamara RM, O'Brien MC, Davidheiser S: Post-traumatic neck pain: A prospective and follow-up study. Ann Emerg M e d September 1988;17:906-911.]

Robert M McNamara, MD Mary C O'Brien, MD Sharon Davidheiser, RN Philadelphia, Pennsylvania From the Department of Emergency Medicine, The Medical College of Pennsylvania, Philadelphia, Pennsylvania. Presented at the University Association for Emergency Medicine Annual Meeting in Philadelphia, May 1987. Received for publication November 30, 1987. Revision received April 8, 1988. Accepted for publication May 10, 1988. Address for reprints: Robert M McNamara, MD, Department of Emergency Medicine, The Medical College of Pennsylvania, 3300 Henry Avenue, Philadelphia, Pennsylvania 19129.

INTRODUCTION Recent economic forces affecting medicine have encouraged the development of selective criteria for ordering diagnostic studies. When considering radiographic examination, physicians must consider not only cost but also the small but real risk of radiation exposure to the patient. 1 In the emergency department, cervical spine radiographs are those most frequently ordered. 2 The total yearly cost of cervical spine radiographs may be as high as $140,000,000. 3 When attempting to eliminate unnecessary cervical spine radiographs, the cost of a missed cervical spine injury (CSI) with possible resultant permanent neurologic damage must be considered. Spinal cord injury is a financially, socially, physically, and psychologically devastating catastrophe. 4 Thus, any attempt to develop selective criteria in this area must strive for absolute sensitivity, Most of the literature on the evaluation of CSI is retrospective, and there are no clear guidelines for when to order cervical radiographs, s In addition, these studies rarely conduct outpatient follow-up on their patients. We, therefore, sought to prospectively evaluate ED patients presenting with posttraumatic neck pain to identify historical and physical examination findings predictive of CSI. We also attempted short-term outpatient follow-up in those patients discharged without such a diagnosis. This follow-up was conducted to detect any missed diagnosis and to evaluate persistence of symptoms, subsequent medical care needed, and involvement in litigation. METHODS Over a 15-month period (from September 1985 to November 1986), patients presenting to the ED of one of three urban hospitals were enrolled in the study. These hospitals were the Medical College of Pennsylvania and the 17:9 September 1988

Annals of Emergency Medicine

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POST-TRAUMATIC NECK PAIN McNamara, O'Brien & Davidheiser

TABLE 1. Patients with fracture or ligament disruption

Age/Sex 62/M

Type of Neck Injury

Inciting Event

Head Injury/Loss Cross-Table Full Cervical Confirmatory Study of Consciousness Intoxication Lateral View Services

C1 lateral mass MVA* fracture C3 lamina fracture; MVA C3, C4, C5 ligamentous C1 burst fracture Blow to head

+/+

No

+/+

+/

MVA

+/+

35/M

C5 body and pedicle fracture C4-5 subluxation

Fall on steps

-/-

Mild

29/M

C2 teardrop fracture MVA

+/+

No

80/F

Odontoid fracture

+/+

No

35/M

75/M 29/M

MVA

Treatment

No

Possible C5 fracture Negative

PossibleC5 fracture C3-4 subluxation

Computed tomography Computed tomography

No

Not done

C1 b u r s t fracture Not done

Tomography

Collar

Tomography

ORIF

Severe

C5 fracture C4-5 subluxation C2 teardrop fracture Negative

Halo Collar

C4-5 sublux- Flexion-exten- Neck cast ation sion views Not done Computed toCollar mography N e g a t i v e Computed toCollar mography

*MVA, motor vehicle accident.

FIGURE 1. Prospective ED question-

naire. Frankford and Torresdale divisions of Frankford Hospital, a c o m m u n i t y affiliate. All three EDs are staffed full time by the faculty and residents of the Medical College of Pennsylvania R e s i d e n c y P r o g r a m in E m e r g e n c y Medicine. The e n t r y criteria for this study were quite simple. Patients had to experience some degree of neck pain resulting f r o m t r a u m a and had to be alert enough to give an accurate history. Age, associated injury, and alcohol and drug use were not exclusion criteria, provided that a satisfactory history and physical examination were possible. It was also required that a prospective questionnaire, described below, be completed at the time of ED evaluation. This requirement was the most significant l i m i t i n g f a c t o r on h o w m a n y patients were recruited because physician participation was voluntary, Therefore, the patients were not consecutive. Subjects also were excluded if there was insufficient initial data c o l l e c t i o n or if the official radiographic interpretation or inpatient records were unavailable. The prospective questionnaire solicited information on seven historical and five physical examination points (Figure 1). The historical data collected included the type of traumatic event and w h e n the n e c k pain started. A 70/907

Historical Points

Physical Examination

Type of traumatic event

Level of consciousness (Glasgow Coma Scale)

Onset of neck pain

Degree of intoxication

Head injury

Midline cervical tenderness

Loss of consciousness

Unassisted range of motion

Use of drugs or alcohol

Neurologic findings

Neurologic symptoms

1

Previous neck problem

history of head injury or loss of consciousness was sought, and patients were asked about their use of drugs or alcohol. T h e y were also questioned about neurologic symptoms (ie, weakness or paresthesias) and the existence of a previous neck problem. Specific i t e m s addressed on the physical examination included an assessment of the patient's level of cons c i o u s n e s s w i t h c a l c u l a t i o n of the Glasgow Coma Scale. It was believed that a Glasgow Coma Scale score of less than 14 may be associated with i m p a i r e d pain perception, but the scale was not used as an exclusion criterion for this study. The physician caring for the patient was asked to rate the degree of i n t o x i c a t i o n by clinical assessment and to record this as none, mild, moderate, or severe. Ethanol levels were obtained only at the discretion of the treating physician. Midline cervical tenderness was defined as posterior tenderness from the occipital notch to the spinous proAnnals of Emergency Medicine

cess of T1, extending 1 inch to either side of the spinous processes. Also noted was the unassisted range of motion and w h e t h e r this was painful. The range of m o t i o n generally followed radiographic examination and was not performed if fracture or ligam e n t disruption was proven or suspected. Last, neurologic findings were recorded. The e m e r g e n c y physician's radiographic interpretation was obtained, but that of the radiologist was considered final. Inpatient records were reviewed on all hospitalized patients to c o n f i r m diagnosis. A t t e m p t s were m a d e to c o n t a c t all p a t i e n t s discharged directly from the ED by telephone and, if unsuccessful, by letter. Before leaving the ED, patients were informed that a follow-up telephone call would be placed. In the follow-up phase (Figure 2), subjects were questioned about the persistence of neck pain and their rating of the pain as mild, moderate, or severe. Neurologic 17:9 September 1988

TABLE 2. Variable

Immediate onset of pain Head injury Loss of consciousness Neurologic symptoms Midline cervical tenderness Impaired range of motion Neurologic findings

Fracture-ligament disruption

Yes (n = 7)

No (n = 344)

%Sensitivity

%Specificity

7/7 6/7 5/7 0/7 5/5 2/2 1/7

119/344 102/341 21/339 36/341 176/340 137/341 7/326

100 86 71 0 100 100 14

65 70 94 89 48 60 98

FIGURE 2. Presence and rating of neck pain Neurologic symptoms Physician contact Diagnostics performed Treatment prescribed Diagnosis rendered Litigation (second half of study) 2 s y m p t o m s (ie, w e a k n e s s or paresthesias) were also sought. The patients were asked if they saw another physician regarding their neck pain and, if so, what additional diagnostic studies were performed, what treatment was prescribed, and the diagnosis rendered. During the initial follow-up period, it was noted that m a n y patients were skeptical of our intentions or refused follow-up, often referring us to their lawyer. We began to passively note this involvement in litigation and decided to actively question this during the second half of the follow-up phase. Only those involved as plaintiffs were considered to be in this group. Statistical analysis was conducted with an u n p a i r e d t test or X2 test when appropriate. Sensitivity was determined by dividing the true positives by t h e s u m of t h e t r u e positives and the false negatives. Specificity was obtained by dividing the true negatives by the sum of the true negatives and the false positives.

RESULTS A total of 446 p a t i e n t s m e t the entry criteria for the study. Of these, 95 did not have a cervical radiograph while in the ED, were not reachable by telephone and letter, or refused to answer any questions at the time of follow-up. Of this group, 33 patients refused follow-up but indicated their 17:9 September 1988

Follow-up questions.

i n v o l v e m e n t in l i t i g a t i o n and are therefore included in the litigation data. Otherwise, these 95 were excluded from further analysis. Of the remaining 351 patients, 211 had ED cervical radiographs, and 123 (58%)of this group had adequate outpatient follow-up. The other 140 patients who were included did not have an ED radiograph but were adequately followed (Figure 3). Motor vehicle accidents accounted for 80% of the traumatic events, with falls (11%) being the next most comm o n cause. Most of the subjects (94%) were judged clinically to be nonintoxicated, and only nine (3%) were believed to be moderately to severely intoxicated. For the p u r p o s e of this study, a clinical rating of intoxication was thought to be adequate because only those patients having neck pain were included in the study. No effort was made to seek out "occult" injuries where impaired pain perception attributable to alcohol or drugs would need to be more clearly documented. Of the study group, only seven (2%) had a proven fracture or ligament disruption of the cervical spine. These were identified acutely and are detailed (Table 1). All injuries were confirmed by either computed tomography, plain tomography, or flexionextension views. No patient contacted in follow-up was found to have a fracture or ligament disruption that was not detected in the ED. A listing of the sensitivities and specificities of various historical and physical e x a m i n a t i o n points is presented (Table 2). All seven patients with proven CSI had immediate onsets of neck pain; all five patients in w h o m it was tested had cervical spine tenderness. The two patients who did Annals of Emergency Medicine

not have assessed cervical tenderness had their injuries identified while immobilized in a hard cervical collar, and this collar was not removed to determine cervical tenderness on the order of the treating physician. Unassisted range of m o t i o n was i n a d v e r t e n t l y tested in two patients and was impaired in both. In this group of patients with CSI, loss of consciousness (71%) and head injury (86%) were frequent, but only one patient (14%) had neurologic findings. In the follow-up phase, data collection was at times difficult because of patient suspicions, lack of sophistication regarding medical care, and partially completed letter responses. Att e m p t s at p a t i e n t c o n t a c t w e r e initiated by telephone approximately four weeks after the ED presentation, and, if u n s u c c e s s f u l , r e p e a t e d attempts were undertaken at intervals of three to four weeks. If repeated attempts at telephone contact were unsuccessful or refused by the patient, a letter was sent containing the followup questions. During the initial phase of the study, follow-up was difficult b e c a u s e calls were p l a c e d d u r i n g weekday working hours. As the study progressed, calls were also placed during evenings and weekends. Therefore, the range of contact time was wide, with a mean of 25 + 20 weeks after ED presentation. Follow-up was considered a d e q u a t e if the p a t i e n t responded to the questions regarding persistent pain and s y m p t o m s and, when these answers were positive, if there was reasonable certainty of the outpatient diagnosis. A total of 263 patients cooperated in an adequate fashion in this phase, but information regarding outpatient treatment and diagnostic testing was incomplete because of the above-mentioned problems. 908/71

POST-TRAUMATIC NECK PAIN McNamara, O'Brien & Davidheiser

FIGURE 3. Study group.

By the time of contact, 167 of the 263 patients (63%) had sought treatment from another physician. Further treatment and testing in this group follows with the denominator being the number of patients who responded adequately to these questions. A total of 138 of 157 (87%) were prescribed physical therapy; 24 of 142 (17%) underwent cervical computed tomography scanning; and 19 of 141 (13%) had an electromyogram. When a cervical radiograph had not been obtained in the ED, 60 of 115 (52%) later obtained one. Significant s y m p t o m s at follow-up were defined as the presence of moderate-to-severe neck pain and/or the report of n e u r o l o g i c s y m p t o m s t h a t were possibly related to a cervical injury. Of the 263 patients followed, 110 (43%) reported such symptoms. A majority of the patients were women, had been rear-ended in a motor vehicle accident, and were pursuing litigation (Table 3). During the second half of the follow-up phase, patients were actively questioned as to their involvement in litigation. Of the 109 questioned, 72 (66%) gave an affirmative response. Overall, it was determined that 110 patients were definitely pursuing litigation, while 44 definitely were not. These groups are compared {Table 4). The litigation group patients were significantly more likely to have been involved in a motor vehicle accident, to have seen another physician, or to still be experiencing moderate-to-severe neck pain.

DISCUSSION The e m e r g e n c y physician plays a critical role in evaluating the patient with a potential CSI because the vast majority of these victims will initially present to the ED. Recommendations on when to order cervical radiographs vary widely from a liberal policy6, z to one with more restrictive criteria.S, 9 In the traumatized patient with a depressed level of consciousness, it is generally agreed that CSI should be suspected until proven otherwise.m, u Considerable controversy exists, however, in the role of cervical radiography in the alert trauma victim. Some believe that all patients with a mechanism of injury that could possibly lead to CSI should undergo radiography re72/909

Cervical radiograph ~ . _ obtained in ED (211) ~~lncluded in study (351)

Presenting patients (446)

3

Patients /followed up No cervical r a d i o g r a p h ~ ( 1 4 0 ) obtained in ED (235) Patients not followed up (95)

gardless of the physical examination results or patient complaints. 1I Others believe the a b s e n c e of clinical signs or s y m p t o m s allows CSI to be effectively ruled out in the alert, nonintoxicated trauma victim.7,9,t2A 3 The actual n u m b e r of fractures or ligament disruptions detected in our s t u d y (2.0%) and in p r e v i o u s reports7,9,14, is by cervical radiography is quite small. When prospectively asked to give a reason for ordering cervical radiographs, Eliastam et al 2 found that 78% of the time ED housestaff obtained this study for medicolegal reasons. This type of approach not only increases costs and unnecessary radiation exposure but also slows up the ED flow, increasing the inconvenience for all patients. 2 The development of s e l e c t i v e c r i t e r i a to d e c r e a s e the amount of unnecessary cervical radiographs is desirable, but the high cost of a missed CSI demands virtually absolute sensitivity. The monetary cost of a cervical radiograph is negligible compared with that of a spinal cord injury, which may be $400,000 over the victim's lifetime, m However, no price tag can be affixed to the disastrous physical and psychological consequences of permanent paralysis. In the current study, we found that in the alert patient, the i m m e d i a t e onset of neck pain and the presence of posterior cervical midline tenderness had 100% sensitivity for CSI. Unfortunately, as in m a n y other studies, the actual number of proven fractures or ligament disruptions is quite small, limiting the usefulness of this data. It has been previously estimated 3 that it may require a study of up to 10,000 patients to define acceptable highyield criteria for CSI. It is our impression t h a t the i m m e d i a t e or fairly abrupt onset of neck pain should ocAnnals of Emergency Medicine

Excludedfrom study (95)

cur with CSI in the alert trauma victim. Conversely, we feel the presence of posterior cervical midline tenderness should not be expected to be universal because certain injuries (ie, anterior a v u l s i o n fracture) m a y not incite this finding. Unassisted range of motion was inadvertently tested in two of our patients with proven CSI. This occurred in one patient who had normal plain radiographs but was admitted because of the severity of neck pain and in ano t h e r p a t i e n t by the n e u r o s u r g i c a ] consultant w h o disagreed with the e m e r g e n c y physician's radiographic interpretation. Neither patient developed neurologic signs or symptoms as a result o f this manipulation. While both of these patients had impaired range of motion and 60% of the noninjured group had normal range of motion, this finding may be useless because it was previously reported that 16% of patients with acute CSI had normal range of motion. 16 In the follow-up phase of our study, the primary focus was to identify any missed diagnoses of CSI in those patients discharged from the ED. The mean follow-up period was nearly six months, and no missed injuries were d i s c o v e r e d . H o w e v e r , s e v e r a l uncovered facts are of note to emergency physicians. Foremost, a large percentage (52%) of patients not filmed during their ED evaluation subsequently obtained cervical radiography. These patients most likely had what was assessed to be a minor injury because it is general practice among the physicians in our program to obtain cervical radiography if any chance of fracture or dislocation exists, given the high cost of misdiagnosis. In one previous report of outpatient follow-up of ED patients with back and neck prob17:9 September 1988

TABLE 3. Significant symptoms at follow-up Variable

Yes(n

= 110)

No(n

= 153)

P

Test

Mean age (yr)

37 _+ 16

31 + 15

< .05

Unpaired t

Mean contact time (wk)

24 _+ 18

22 _+ 19

Unpaired t

Women Race (white/black)

72/109 (67%) 62/34

62/153 (40%) 77/51

NS < .001 NS

In motor vehicle accident

98/110 (89%) 54/87 (62%)

119/153 (78%) 48/103 (46%)

"( .05

X2

26/107 (24%) 51/108 (47%)

50/149 (33%) 60/152 (39%)

< .05 NS

X2 X2

106/151 (70%)

NS NS

X2

65/107 (61%)

×2 X2

Rear-ended in motor vehicle accident Immediate onset of pain Midline cervical tenderness Full range of motion

X2

X2

Saw another physician

82/90

(91%)

65/136 (48%)

< .001

In litigation

44/53

(83%)

33/68

< .001

(48%)

X2

TABLE 4. Pursuing Etigation Variable

Yes (n = 1 1 0 )

No (n = 44)

P

Test

Mean age (yr) Mean contact time (wk)

36 _+ 16 28 _+ 20 64/110 (58%) 67/35 105/110 (95%)

34 _+ 18 26 _+ 18

NS NS

Unpaired t Unpaired t

20/44 (45%) 21/18

NS NS

X2

Women Race (white/black) In motor vehicle accident Rear-ended in motor vehicle accident

×2

29/44

(66%)

< .001

X2

57/96 (59%) 37/109 (34%)

11/27 15/44

(41%) (34%)

NS NS

X2

Midline cervical tenderness Saw another physician Having moderate to severe pain

48/107 (45%) 77/78 (99%)

23/44 16/44 5/43

(52%) (36%) (12%)

NS < .001 < .001

x2 ×2

lems, Kaplan17 found that 37% of patients contacted at two m o n t h s subsequently obtained radiographs that had not been ordered initially. A s i g n i f i c a n t p e r c e n t a g e (63%) of our p a t i e n t s c o n t a c t e d o t h e r p h y s i cians a f t e r ED d i s c h a r g e , a n d t h i s group f r e q u e n t l y u n d e r w e n t o t h e r noninvasive testing. The majority (87%) of t h e s e p a t i e n t s w e r e prescribed p h y s i c a l therapy, a f o r m of treatment emergency physicians m a y need to c o n s i d e r for p a t i e n t s w i t h neck injuries. As mentioned, our estimates of the above figures are approximations because many patients would give only l i m i t e d i n f o r m a t i o n or were not sure exactly w h a t testing had occurred. It was clear, despite a long interval between i n j u r y and follow-up, t h a t many patients (43%) were still experi-

encing significant s y m p t o m s . These patients were more likely to be pursuing l i t i g a t i o n , b u t no a t t e m p t was m a d e to c o r r e l a t e s y m p t o m a t o l o g y with settlement. Previous reports have indicated a link between symptomatology and legal involvem e n t , 18-~o b u t o t h e r s have d o u b t e d that this connection is significant. 21,22 Our data seem to support the former view. We also f o u n d a s i g n i f i c a n t l y higher incidence of persistent serious s y m p t o m a t o l o g y i n w o m e n . A previous report documented an incidence of neck injury in w o m e n in a metrop o l i t a n area to be nearly five t i m e s higher than that of men, 22 perhaps indicating a true intersex difference in the susceptibility to more severe injury. We p o s t u l a t e t h a t the r e l a t i v e l y smaller mass of cervical musculature in w o m e n m a y contribute to this dif-

Immediate onset of pain

17:9 September 1988

41/80

(51%)

Annals of Emergency Medicine

X2

X2

ference. Probably the m o s t disturbing finding in our study is the very high percentage (66%) of patients involved in l i t i g a t i o n . T h e o n l y factor f o u n d to identify these patients in the ED was involvement in a m o t o r vehicle accident. In 95% of our litigation group, m o t o r vehicle accidents were the inciting events. Certainly this adds the specter of a malpractice action if a CSI were to be m i s s e d in this group of patients. Some deficiencies in our study need to be a d d r e s s e d . P r i m a r i l y , as discussed, the s m a l l a m o u n t of defined injuries uncovered m a k e s a decision s t r a t e g y based on our r e s u l t s risky. The finding of 100% sensitivity of the i m m e d i a t e onset of neck pain for CSI, however, appears to have promise as a useful clinical tool for assessing the 910/73

POST-TRAUMATIC NECK PAIN McNamara, O'Brien & Davidheiser

alert, n o n i n t o x i c a t e d patient. A larger study t h a t w o u l d l o o k at t h e v a l u e of t h e abrupt o n s e t of pain and perhaps use a cutoff of five m i n u t e s or m o r e to a l l o y ; for t h e p a t i e n t ' s i n i t i a l e m o t i o n a l d a z e t o d i s s i p a t e w o u l d be useful. N e c k pain as an e n t r y r e q u i r e m e n t m a y be too l i m i t i n g for t h o s e w h o ascribe to t h e belief of t h e painless cervical fracture.7, 23 T h e r e is little supp o r t in t h e l i t e r a t u r e r e g a r d i n g t h e actual e x i s t e n c e of this p h e n o m e n o n , and its e x i s t e n c e has b e e n s e r i o u s l y questioned32,13 O u r study did n o t att e m p t to u n c o v e r o c c u l t injury, and, therefore, no c o n c l u s i o n can be d r a w n r e g a r d i n g CSI i n a s y m p t o m a t i c pat i e n t s r e g a r d l e s s of i n t o x i c a t i o n . A m o r e practical c o n s i d e r a t i o n is for the e m e r g e n c y p h y s i c i a n to be aware that spinal cord injury m a y o c c u r w i t h o u t CSI in t h e case of c e n t r a l cord synd r o m e a t t r i b u t e d to h y p e r e x t e n s i o n injury. 24 A p r o s p e c t i v e q u e s t i o n n a i r e was c o m p l e t e d on o n e s u c h p a t i e n t d u r i n g t h i s study, b u t this case was n o t i n c l u d e d b e c a u s e n e c k p a i n was absent. F u r t h e r i n v e s t i g a t i o n revealed t h a t n o f r a c t u r e or l i g a m e n t disrupt i o n was u n c o v e r e d in t h i s p a t i e n t . T h i s injury is n o t occult in the alert patient, however, because a proper neurological examination will uncover it. A t o t a l of 88 p a t i e n t s w e r e discharged after ED cervical radiography and were n o t followed up. T h e r e exists a slight c h a n c e that a significant CSI w a s m i s s e d in t h i s g r o u p b e c a u s e plain radiographs are n o t 100% sensitive. ~s In addition, in t h e follow-up phase, we w e r e dealing w i t h a group of suspicious patients, and this affected the c o m p l e t e n e s s and, possibly, t h e accuracy of our results. T h e original a i m of this s t u d y was to i d e n t i f y historical and physical examination factors that would allow the e m e r g e n c y p h y s i c i a n to l i m i t t h e n u m b e r of n e g a t i v e c e r v i c a l r a d i o graphs obtained. T h i s is a reasonable goal, b u t t h e discovery of t h e frequency w i t h w h i c h our p a t i e n t s p u r s u e d litigation and underwent outpatient t e s t i n g h a s c a s t d o u b t o n t h e prac-

74/911

t i c a l i t y of l i m i t a t i o n on a cost-effective basis. T h e l o w cost of cervical radiography and the h i g h cost of spinal cord injury or litigation arising f r o m a m i s s e d CSI c o m b i n e d w i t h t h e fact t h a t m o r e t h a n h a l f of n o n r a d i o graphed p a t i e n t s r e c e i v e d t h e m l a t e r are factors e m e r g e n c y p h y s i c i a n s and researchers n e e d to c o n s i d e r in treatm e n t of p a t i e n t s w i t h n e c k injuries. Also, it has been p r e v i o u s l y reported that p a t i e n t s are m o r e l i k e l y to be satisfied w i t h their care w h e n subjected to radiography despite its lack of influe n c e on therapy. 26

SUMMARY The immediate onset of neck pain and the presence of posterior midline cervical tenderness were found to be helpful predictors of cervical fracture or l i g a m e n t disruption in p a t i e n t s pres e n t i n g to t h e ED w i t h p o s t - t r a u m a t i c n e c k pain. It h a s b e e n s h o w n t h a t m a n y of t h o s e d i s c h a r g e d w i t h o u t s u c h a diagnosis w i l l r e m a i n s y m p tomatic. Many patients will receive e x t e n s i v e o u t p a t i e n t d i a g n o s t i c testing and t r e a t m e n t , and a s i g n i f i c a n t percentage w i l l be i n v o l v e d in litigation. The authors thank William H Spivey, MD, for his advice and assistance with statistical analysis and Stella Melissen for her assistance in the preparation of this manuscript.

REFERENCES 1. Evans JS, Wennberg JE, McNeil BJ: The influence of diagnostic radiography on the incidence of breast cancer and leukemia. N Engl J Med 1986;315:810-815. 2. Eliastam M, Rose E, Jones H, et al: Utilization of diagnostic radiologic examinations in the emergency department of a teaching hospital. J Trauma 1980;20:61-66. 3. Cadoux CG, White JD: High-yield radiographic considerations for cervical spine injuries. Ann Emerg Med 1986;15:236-239. 4. Meyer PR, Sullivan DE: Injuries to the spine. Emerg Med Clin North A m 1984;2:313-329. 5. Knopp RK: Evah~ation of the cervical spine: Unresolved issues (editoriall. Ann Emerg Med 1987;16:819-820. 6. McCabe JB, Angetos MG: Injury to the head and face in patients with cervical spine injury. Am J Emerg Med 1984;2:333-335.

Annals of Emergency Medicine

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