Is CT cervical spine necessary in elderly patients with a blunt head injury and ambiguous clinical findings?

A 92-year-old man presented to ED with a fall the day before, he hit the back of his head and had retrograde amnesia. Fully mobile after fall. Not on any anticoagulants. On examination, he looked comfortable with a GCS of 15; pupils were equal and reactive and no focal weakness was identified. Palpation revealed minimal midline cervical spine tenderness.

Given the history and clinical findings, a CT scan was performed of the head and cervical spine by immobilising the patient as per the National Institute of Health and Care Excellence(NICE) guidelines[1]. CT scan revealed a mild-moderate posteriorly shifted C2 odontoid base fracture. It also showed a background of periodontoid chronic calcific degenerative changes, along with mild-moderate posterior shifting of the odontoid peg, abutting anteriorly the distal medulla oblongata and proximal cervical spinal cord. (Fig. 2

Cervical spine injuries can occur in the elderly with relatively minor trauma, due to osteoarthritis of the cervical spine, limited movement at the atlanto-odontoid joint and trabecular structure of the dens. Low energy trauma can induce forced atlanto-axial rotation, and the torque force at the base of the odontoid process can lead to a fracture [2]. Potential subsequent neurological injury and morbidity make these important injuries to identify in the emergency department.

The Trauma Audit and Research Network aim to study and identify the extent and impact trauma has on the British healthcare system. They aim to use the Injury Severity Score, a standardised tool to score the extent of injury based on the anatomical injuries.[3] Their most recent report shows that for patients >65 years of age, the commonest mechanism of injury for an injury severity score (ISS) of >15 was a fall from standing height [4]. Often these injuries occurring in elderly frail patients, also known as “silver trauma”, are under-triaged in the pre-hospital setting and do not get a trauma team activation. They are more likely to be assessed outside the resuscitation room by more junior clinicians and are often more difficult to assess due to underlying co-morbidities. We have highlighted a case of an elderly patient who fell from standing height and sustained an odontoid peg fracture who presented with minimal neck pain. Such cases emphasise the importance of a lower threshold for cervical spine imaging in elderly patients with silver trauma, who report minimal pain and have no focal neurology.

Using Canadian C-spine Rules, all patients >65 years of age with silver trauma should get cervical spine imaging [5]. NEXUS does not incorporate age criteria, and there is evidence to suggest that NEXUS criteria are insufficient to exclude cervical spine fractures in this patient group. The cervical spine injury should always be suspected in elderly patients who present with a fall and head injury [6].

This case was discussed with the Neurosurgical team as a matter of urgency but conservative management was recommended, keeping in mind the age and clinical presentation of the patient, and the gentleman was admitted under the medical team for further neurological observations and neurological review.