Health resource utilisation costs in acute patients with persistent midline cervical tenderness following road trauma☆
Introduction
The assessment of the cervical spine and the exclusion of cervical spine injury are among the most common issues in trauma management following road crashes. The prevalence of cervical spine injury in all cases of trauma is 3.7%, including 2.8% in alert patients and 7.7% in obtunded patients.1 Whilst exclusion of acute injury removes the threat of cervical instability, neck pain and associated disability may persist regardless of radiographic findings. In fact, the severity of initial neck pain intensity appears to be a predictor of long term pain severity.2, 3, 4, 5 This may be a reflection of the variability of success in the wide variety of health resource measures and combinations of therapy used to manage post-traumatic neck pain, including physiotherapy, exercises, early mobilisation, analgesics, psychology and rest.
Much of the evidence related to acute cervical spine trauma focuses on the detection and management of injury and the measurement of clinical outcomes, whereas evidence related to long term demographic and cost outcomes is limited. Health resource costs can vary considerably over seemingly homogeneous patient groups. In a group of alert road trauma patients who had acute midline cervical tenderness on palpation and negative computed tomography (CT) findings, we aimed to quantify and categorise the costs associated with injury and symptom management over the 12-month post-trauma period. We also aimed to determine whether factors associated with these expenses may explain the variability in costs. As acute emergency department and hospital costs were likely to be a reflection of length of stay and services aimed at injury detection and management, we hypothesised that the presence and severity of cervical spine injury would determine inpatient costs. Conversely, we suspected that costs attributed to the post-acute period would be associated with psychological and socioeconomic factors, rather than injury morphology or mechanism. We have previously reported the acute clinical and post-acute outcome findings from a larger study from which this subset of patients was derived.6, 7
Section snippets
Methods
There are approximately 15,000 trauma presentations to the emergency department of our Level 1 trauma centre per year, and major trauma constitutes 10% of these presentations. In a prospective cohort study, alert trauma patients presenting over a 2 year period to January, 2009, with midline cervical tenderness and negative acute computed tomography (CT) findings were screened for inclusion. Those in whom midline tenderness was persistent, who were investigated further with cervical magnetic
Results
There were 741 acute trauma patients with persistent midline cervical tenderness and negative CT findings, who were investigated with MRI during the recruitment period. Of these, there were 554 excluded for the presence of skull base, cervical spine or upper thoracic spine fractures (n = 338), painful distracting injury (n = 113), persistent neurologic deficit (n = 17), history of cervical spine surgery or injury (n = 20) or MRI >96 h post-admission.6 Nine patients refused consent. Of the 178 remaining
Discussion
Cervical spine injuries are most commonly associated with hyperflexion, hyperextension, lateral flexion, rotational forces and axial loading, and most often result from motor vehicle accidents.22, 23 Fracture or malalignment evident on CT or MR imaging allows for decisive management decisions to be made, but soft tissue cervical injuries of less certain clinical significance can remain untreated and may result in enduring symptoms. Additionally, although the presence of acute and persistent
Conclusion
The relationship between costs and acute clinical, radiographic, injury mechanism and post-acute outcome characteristics in patients with persistent midline cervical tenderness and negative CT imaging has not been reported previously. In our study, mechanism of injury, radiographic findings and psychological outcomes were not found to influence the costs of health resource utilisation. A history of resolved neurologic deficit in these patients may signal the presence of subclinical injury and
Conflicts of interest
There are no conflicts of interest to declare.
Acknowledgements
The authors are indebted to the Transport Accident Commission for project funding support, and we gratefully acknowledge the assistance of David Attwood and Simone Boer of the Claims Research Department of the Transport Accident Commission for assistance with patient cost data retrieval. The Transport Accident Commission had no other involvement in the study.
References (44)
- et al.
Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results
Annals of Emergency Medicine
(2011) - et al.
Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS)
Annals of Emergency Medicine
(1998) - et al.
Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury
Annals of Emergency Medicine
(2001) The Neck Disability Index: state-of-the-art, 1991–2008
Journal of Manipulative and Physiological Therapeutics
(2008)- et al.
Clearance of the cervical spine in multitrauma patients: the role of advanced imaging
Seminars in Ultrasound, CT and MR
(2001) - et al.
Whiplash injury
Pain
(1994) - et al.
Prevalence of cervical spinal injury in trauma
Neurosurgical Focus
(2008) - et al.
The prognosis of neck injuries resulting from rear-end vehicle collisions
Journal of Bone and Joint Surgery – British Volume
(1983) - et al.
Factors associated with recovery expectations following vehicle collision: a population-based study
Journal of Rehabilitation Medicine
(2010) - et al.
What influences positive return to work expectation? Examining associated factors in a population-based cohort of whiplash-associated disorders
Spine
(2010)