The initial assessment of patients in the emergency room is essential to detect life-threatening injuries or injuries that can lead to permanent disabilities 20–22, 25. Most maxillofacial injuries can easily be diagnosed, as the symptoms are relatively easy to assess. Nevertheless, severe injuries of the cervical spine can occur without alarming signs. Especially in unconscious patients, a possible injury to the cervical spine must always be considered both at the scene of the accident and in the emergency room. Many authors point out that injuries of the CS are often misdiagnosed 16,23.
The highest incidence of concomitant MSI-CSI was detected in older patients than center average of maxillofacial trauma patients. In our study, 2.47% of all MFI patients were diagnosed with a concomitant CSI. This is comparable with the literature but is lower than the international average (0.8%3 to 12%5). This result is less than reported from the German registry study by Pietzka et al. (11.3%) or single-center studies from the UK or USA 1,2,11, but more than 0.8% reported by Roccia et al from Italy3. All these studies analyze a similarly long period of time, Färkkilä et al. from the same years1,2.
Our study presents a clear demographic trend. In female patients with MFI, there is an increasing risk with increasing age to suffer a concomitant CSI.
We found that injuries located near to the cranial base (most common fracture sites were the forehead, nose, LeFort I and II level, zygomatic bone, orbital floor or mandibular condyle) both in central and in lateral areas of the facial skull are significantly more often presented with CSI than other areas of the face (87.7% of cases with CSI). This level represents approximately the plane of the Frankfurt horizontal. Fractures in this area may point to a far more dangerous injury of the spine, thus from our data we suggest this region can be referred to as the “Cervical Spine Injury Alert Bend” of the face. To us, it is an important finding that soft tissue injuries of the face even without jaw fractures are associated with CSI as high as 5.25% range of all soft tissue injuries (p = 0.162). The soft tissue injury sites were often less precisely documented; thus, a mapping was not possible. Based on the findings in the fracture group, we suppose that the same distribution will apply for patients that suffered soft tissue injuries only. In contradiction to our study, Färkkilä et al. report in total higher MFI-CSI rates in patients with mandibular fractures than in those with midface fractures 1,2. After a detailed analysis of these papers, a higher incidence of CSI is reported in more cranial fractures of the lower jaw, like fractures of the mandibular collum2. Their analysis of concomitant midfacial fractures and CSI provided a very similar result1 than our study.
The above findings provide important guidance for the initial assessment in the emergency room, too. We suggest considering a high-resolution CT-scan of both the cervical spine (C1-C7) and the complete facial skeleton, if
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there is an injury in the above-described zone, and
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the patient is a male 35–65 years old or a female above 60 years of age, and
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the injury mechanism suggests a middle to the high-energy impact of the head with fronto-posterior hyperextension of cervical spine 12 or high shear forces in the lateral midface.
These clinical findings reflect the statements of Tuchtan et al. resulting from the finite element analysis of the projection of von Mises-forces after facial blunt trauma27. This paper reports that high antero-posterior forces can result in injuries to the ligaments, blood vessels, spinal cord or brain stem. Živković et al. report the same injuries in autopsy reports 12. To the best of our knowledge, this is the first report that correlates MFI to CSI based on a large clinical data analysis. Our findings correlate to both virtual modeling and postmortem studies.
From our data, we strongly suggest that a thorough patient examination should be conducted by both, experienced maxillofacial surgeons and neurosurgeons, in critically injured patients presenting with the “Facial Alert Band” (FAB). This may help to avoid diagnostic failures or delayed diagnosis, especially in unconscious patients23.
In conclusion, injuries to the cervical spine in patients with maxillofacial injuries can be life-threatening or can cause severe life-long disability. The findings and the heat map presented in this paper can be a useful clinical tool even for an experienced team. It can reduce missing or delayed diagnosis of CSI, thus it helping to reduce possible complications, improve treatment outcome and quality and avoid legal consequences.