Traumatic cervico-thoracic spondylolisthesis is a crucial orthopaedics emergency. Significant spondylolisthesis may alter cervical mechanics. Up to 30% of these patients may suffer permanent neurological complications [1]. A cervical spine injury can go undiagnosed or missed diagnosed if complete history is not taken from the patient, inadequate physical examination done by the doctor, patient under alcohol influence or if a radiograph failed to demonstrate a lesion properly. According to Davis JN, the rate of missed diagnosis of cervical spine injuries in Emergency Department (ED) due to various reasons ranges from 5% to 20% which is potentially disastrous [2]. The following case report describes the missed diagnosis for an alcohol intoxicated patient with a neglected cervical spine injury followed by a dislocated lower cervical spine which has progressed to the unusual secondary deficits.

Forty three year old man, a chronic alcoholic presented to our ED with a complaint of unable to walk. The patient stated that he had already visited ED twice for his neck pain following a fall from a tree at a height of 10 feet. He was treated conservatively with analgesics; however the pain led to bilateral lower limb weakness. The first and second visits were made on day two and day five of trauma respectively. During his both visits, patient walked into ED and complained of neck pain. He was noted to be intoxicated with alcohol during both his visits. His Glasgow Coma Scale was 15. However, he was not cooperative and the medical officers who examined him had difficulty in performing a complete clinical assessment. Physical examination revealed mild tenderness over the lower cervical region but no neurological impairment during both the visits. The radiograph images of the cervical spine were poorly visualized in AP view and they did not include the vertebral spine below C6 in lateral view.

Radiographic findings were interpreted as negative for fracture or dislocation, therefore the patient was discharged with analgesics (Figure 1).

Figure 1:(a) Plain x-ray film image not included the vertebral spine below C6.
(b) CT cervical spine sagittal images showing anterolisthesis of C7-T1 vertebrae.
(c) Sagittal T2 weighted MRI showing anterior angulation and narrowing of the spinal canal at C7-T1 level.
(d) Axial T2-weighted MRI showing the existence of spinal cord compression.

On musculoskeletal examination by the orthopaedic medical officer, the grip power of the patient was 1/5 and 2/5 on the right and left upper limb respectively whereas all lower limb muscle groups showed power 1/5. Computed tomography (CT) scan and Magnetic Resonance Imaging (MRI) of the cervical were performed. CT scan showed grade II C7-T1 anterolisthesis with bilateral C7/T1 facet joint dislocation and minimal spinal stenosis. Following review of all films and musculoskeletal examination, the patient was recommended for stabilisation surgery of the cervical spine and was transferred to the orthopaedic ward. Surgery was delayed because of financial constraints the patient subsequently developed severe lung infection and died at the intensive care unit.

A thorough neurological examination is mandatory for patients who sustained neck pain following fall from a height and suspected of alcohol intoxication as in this case. Even though cervical spine radiographs have limitations, it is still warranted for all trauma patients with neck pain. If x-rays are not satisfactory, a CT scan of the area in question should be obtained. A study conducted by Platzer has shown incidence of missed diagnosis of cervical spine fracture is 4.9% where the three main reasons are: lack of experience in evaluation of radiographs leading to misinterpretations, inadequate radiographs and incomplete sets of radiographs [3]. If the mechanism of injury suggests potential cervical spine injury, we must assume that the cervical spine injury exists until proven otherwise. Patients who are under the influence of alcohol and are not cooperative for clinical examination, x-rays and CT scan must be adequately protected with a cervical collar and spine board. Patients with alcohol intoxication may become combative when tied to the board. Attempts to manually restrain the patient’s head against his will significantly increase the stress upon the patient’s cervical spine. Pharmacological control of the patient may be required until the cervical injury can be reliably demonstrated or excluded.

An accurate and detailed history, physical examination and diagnostic imaging of the cervical spine are essential for the diagnosis of cervical spine fracture in an alcohol intoxicated patient with symptomatic cervical injury is not to be missed. This case will not be missed if the fundamental rules of assessing a cervical lateral x-ray are followed. We are presenting this case to illustrate the importance of timely recognition of the cervical injury in alcohol intoxicated patient in order to rule out medico legal issues in the future.