Correspondence

Traumatic Cervical-Spine Disruption

N Engl J Med 2001; 345:1134-1135October 11, 2001

Article

To the Editor:

We describe the clinical course of a patient who sustained a traumatic cervical cord injury while driving under the influence of alcohol. His care emphasizes the importance of following strict guidelines in declaring a patient brain-dead.

A 22-year-old man was ejected from his car after a high-speed chase by police. Paramedics found the patient pulseless and initiated cardiopulmonary resuscitation.

On his arrival at the emergency department, the patient regained a spontaneous pulse but had profound hypotension. His score on the Glasgow Coma Scale was 3 (i.e., no eye opening, no verbal output, and no motor activity). Radiographs of the cervical spine revealed a distraction injury. Pulseless electrical activity subsequently developed, and cardiopulmonary resuscitation was performed for 22 minutes, without success. The patient was declared dead. While the transfer to the morgue was being arranged, the patient was found to have a pulse with spontaneous respirations. Laboratory studies revealed a blood alcohol level of 279 mg per deciliter.

The patient was subsequently transferred to a level 1 trauma center, where he continued to have a score of 3 on the Glasgow Coma Scale. Neurologic examination revealed an intact corneal response, nasal tickle, and oculocephalic reflexes with flaccid tetraplegia. A computed tomographic scan of the cervical spine showed a distraction injury between C2 and C3 (Figure 1Figure 1Reconstructed Computed Tomographic Scan of the Neck Showing Complete Distraction of the Cervical Spine at C2–C3.), and magnetic resonance imaging confirmed the disruption of the cervical spinal cord (Figure 2Figure 2Sagittal T₂-Weighted Magnetic Resonance Imaging Scan of the Neck Revealing Disruption of the Cervical Spinal Cord at the Level of the Distraction Injury.). The patient was placed in a halo, with conservative management until his cervical spine had been stabilized surgically. After surgery, he required ventilatory support, but higher cortical functioning, including language, was intact.

This case highlights the importance of following practice guidelines established by the American Academy of Neurology for determining brain death in adults.1 Prerequisites include clinical or neuroradiographic evidence of an acute central nervous system injury compatible with brain death and the absence of drug intoxication. Requisite clinical findings include unresponsiveness, the absence of brain-stem reflexes, and apnea. Patients with traumatic cervical injuries often meet only two of these criteria (i.e., unresponsiveness and apnea).

Scott R. Plotkin, M.D., Ph.D.
Ming-Ming Ning, M.D.
Harvard Medical School, Boston, MA 02115
splotkin@partners.org

1 References

1
The Quality Standards Subcommittee of the American Academy of Neurology. Practice parameters for determining brain death in adults (summary statement). Neurology 1995;45:1012-1014
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