Research Reports - Missed diagnosis of traumatic brain injury in patients with traumatic spinal cord injury

J Rehabil Med. 2014 Mar 31;46(4):370-3

Sharma B(1), Bradbury C, Mikulis D, Green R

Objective: To determine the frequency of missed acute care traumatic brain injury
diagnoses in patients with traumatic spinal cord injury, and to examine risk
factors for missed traumatic brain injury diagnosis. Design: Prospective magnetic
resonance imaging and neuro-psychological assessment plus retrospective medical
record review, including computed tomography. Subjects: Ninety-two adults with
traumatic spinal cord injury recruited from a large, tertiary spinal cord injury
program, initially referred from urban teaching hospitals with neurotrauma
facilities. Methods: Diagnosis of traumatic brain injury made with clinical
neurological indices (i.e., Glasgow Coma Scale, post-traumatic amnesia, and loss
of consciousness), neuroimaging (computed tomography and structural magnetic
resonance imaging), and neuropsychological tests of attention and speed of
processing, memory, and executive function; all measures were validated on a
case-by-case basis to rule out confounds. Missed traumatic brain injury diagnoses
were made via acute care medical record review and were corroborated by
patient/family report where possible. Results: The frequency of missed traumatic
brain injury diagnoses in our sample was 58.5%. Missed traumatic brain injury
diagnoses were more frequent in injuries sustained outside of a motor vehicle
collision (MVC), with 75.0% of acute care traumatic brain injury diagnoses missed
in non-MVC patients vs. 42.9% missed in MVC patients. Among patients with non-MVC
injuries, a comparable percentage of missed traumatic brain injury diagnoses were
observed in patients with cervical (79%) and sub-cervical injuries (80%).
Conclusion: In more than half of the traumatic spinal cord injury patients
referred for in-patient rehabilitation, acute care diagnoses of traumatic brain
injury were missed. A risk factor for missed diagnosis was an injury caused by a
mechanism other than an MVC (e.g., falls, assaults), perhaps due to reduced
expectations of traumatic brain injury in non-MVC patients. In our research
study, we employed multiple assessments to aid diagnosis, which is particularly
important for detecting the milder traumatic brain injuries often associated with
spinal cord injury; unfortunately, limited resources may preclude a comprehensive
diagnostic approach in clinical settings. Our findings point to the need to
examine current acute care diagnostic protocols, and to increase vigilance in
patients with traumatic injuries sustained outside of an MVC setting.

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