Authors: Eric Kamenetsky Thomas J Esposito Carol R Schermer
Publish Date: 2012/09/29
Volume: 37, Issue: 1, Pages: 127-135
Abstract
The concept of distracting pain DP is a controversial subjective confounder that often impedes the efficient and timely clearance of the cervical spine Cspine This study attempted to define DP more objectively and assess its true potential to mask the presence of Cspine injury It also evaluated reliability and safety of clinical judgment in discounting the significance of pain peripheral to the neck PPThis prospective study included patients with a Glasgow Coma Score ≥14 at a level I trauma center presenting in a Cspine collar Demographics mechanism of injury severity and location of all pain and Cspine imaging data were obtained Patient and examiner perception of DP were ascertained using the Verbal Numerical Rating Scale VNRS along with the examiner’s clinical opinion as to the presence of a fractureA total of 160 patients were studied 65 male mean age 39 years and 44 presenting after a motor vehicle crash In all 16 complained of neck pain NP and 82 of PP There were 134 patients without NP 110 of whom 82 had PP The mean VNRS in patients with no NP was 42 in patients with NP it was 48 When examined 14 patients without NP exhibited posterior cervical tenderness one of whom had a fracture 7 Of the patients with PP 10 stated it was DP The mean VNRS described as DP by all patients was 75 but by clinician 65 VNRS described as not DP was 48 for both patients and clinicians Overall 8 of the 160 patients 5 had confirmed Cspine injuries Regardless of NP or PP and its potentially distracting nature clinicians believed no fracture was present in 95 of all cases Clinical impression was 98 accurate For patients with NP clinical impression had a 91 negative predictive value NPV and a 100 a positive predictive value PPV In those without NP the NPV was 99 and the PPV 25 The concept of DP is subjective and unreliable as a method to mitigate missed Cspine injuries If it is to be considered for use DP should be defined as VNRS ≥5 Reliance on clinical impressions regardless of the presence or absence of NP or PP distracting or otherwise is accurate and safe
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