Prehospital stabilization of the cervical spine for penetrating injuries of the neck - is it necessary?

Lack of Association between Cervical Spine Injuries and Prehospital Immobilization: From Tradition to Evidence

Background: Cervical spine (C-spine) trauma usually results from blunt injuries and is traditionally managed by prehospital spinal immobilization using a cervical collar. We sought to examine if prehospital C-spine immobilization is associated with actual C-spine injuries and what factors are associated with the decision to immobilize the C-spine. Methods: We retrospectively analyzed blunt trauma patients treated by Israeli Defense Force (IDF) medical teams from 2015 to 2020. Children, penetrating injuries, and non-threatening injuries were excluded. Demographic data, injury characteristics, and prehospital information were collected from the IDF Trauma Registry's electronic medical records and merged with corresponding hospital data from the Israeli National Trauma Registry. Results: Overall, 220 patients were included, with a mean age of 32 and a predominance of male patients (78%). Most injuries were due to motor vehicle collisions (77%). In total, 40% of the patients received a cervical collar. C-spine injuries were present in 8%, of which 50% were immobilized with a cervical collar. There were no significant differences in the incidences of C-spine injuries or disability outcomes with or without collar immobilization. The use of a collar was significantly associated with backboard immobilization (OR = 14.5, p < 0.001) and oxygen use (OR = 2.5, p = 0.032). Conclusions: Prehospital C-spine immobilization was not associated with C-spine injury or neurological disability incidences. C-spine immobilization by medical providers may be influenced by factors other than the suspected presence of a C-spine injury, such as the use of a backboard. Clear clinical guidelines for inexperienced medical providers are called for.

The top-cited military relevant spine articles

Introduction

Historically musculoskeletal injury has substantially affected United States (US) service members. Lumbosacral spine injuries are among the most common sites of injury for service members across all US military branches and usually presents with pain in the lower back and extremities. The aim of this study is to identify and describe the 50 most-cited articles relevant to military medicine on the subject of the spine.

Methods

In April 2020 Web of Science was used to search the key words: spinal cord injury, spine, thoracic spine, lumbar spine, cervical spine, sacrum, sacral, cervical fusion, lumbar fusion, sacral fracture, combat, back pain, neck pain, and military. Articles published from 1900 to 2020 were evaluated for relevance to military spine orthopaedics and ranked based on citation number. The 50 most-cited articles were characterized based on country of origin, journal of publication, affiliated institution, topic, military branch, and conflict.

Results

1900 articles met search criteria. The 50 most-cited articles were cited 24 to 119 times and published between 1993 and 2017. 30 articles (60%) originated in the United States. Aviation, Space, and Environmental Medicine accounted for the most frequent (n = 10) destination journal followed by Spine (n = 8). 37 institutions contributed to the top 50 most-cited articles. The most common article type was clinically focused retrospective analysis 36% (n = 18), clinically focused cohort study 10% (n = 5), and clinically focused cohort questionnaire, cross-sectional analysis, and randomized study 8% each (n = 4). 90% of articles were non-surgical (n = 45). The US Army had the greatest number of associated articles. Operation Iraqi Freedom and Operation Enduring Freedom were the most-cited conflicts.

Conclusion

The 50 most-cited articles relevant to military spine orthopaedics are predominantly clinically focused, arising from the US, and published in Aviation, Space, and Environmental Medicine, Spine, and The Spine Journal.

Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update

The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2023, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to American College of Chest Physicians methodology. Key recommendations include the concept that interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique-oriented (immobilization). An evidence-based, goal-oriented approach excludes the immobilization of suspected spinal injuries via rigid collars or backboards.

Spine Bracing: When to Utilize-A Narrative Review

Spinal bracing is a common non-surgical technique that allows clinicians to prevent and correct malformations or injuries of a patient's spinal column. This review will explore the current standards of practice on spinal brace utilization. Specifically, it will highlight bracing usage in traumatic injuries, pregnancy, pediatrics, osteoporosis, and hyperkyphosis; address radiological findings concurrent with brace usage; and provide an overview of the braces currently available and advancements in the field. In doing so, we aim to improve clinicians' understanding and knowledge of bracing in common spinal pathologies to promote their appropriate use and improve patient outcomes.

Practice patterns after implementation of a selective spinal immobilization protocol in a regional trauma system

BACKGROUND

Universal spinal immobilization has been the standard of prehospital trauma care since the 1960s. Selective immobilization has been shown to be safe and effective for emergency medical services use, but it is unclear whether such protocols reduce unnecessary and potentially harmful immobilization practices. This study evaluated the impact of a selective spinal immobilization protocol on practice patterns in a regional trauma system.

METHODS

All encounters for traumatic injury in the Tidewater Emergency Medical Services region from 2010 to 2016 were extracted from the Virginia Pre-Hospital Information Bridge. An interrupted time series analysis was used to assess practice change after system-wide protocol implementation in 2013. Intravenous access was used as a nonequivalent outcome measure in the absence of an appropriate control group.

RESULTS

A total of 63,981 encounters were analyzed. At baseline, 16.7% of patients underwent full immobilization. The preprotocol slope was slightly positive (0.2% per month; 95% confidence interval, 0.1-0.2%). Slope and level changes after protocol implementation did not differ from those observed for intravenous access (-0.4% vs. -0.4% per month [ p = 0.4917] and -1.6% vs. -1.1% [ p = 0.1202], respectively). Cervical spinal immobilization became more common over the postimplementation period (0.1% per month; 95% confidence interval, 0.1-0.1%). Rates of immobilization for isolated penetrating trauma remained unchanged.

CONCLUSION

Implementation of a selective spinal immobilization protocol did not reduce prehospital immobilization rates in a regional trauma system. Given the entrenched nature of immobilization practices, more intensive education and training strategies are needed. Efforts should prioritize eliminating immobilization for isolated penetrating trauma given its association with increased mortality.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Cervical immobilization in trauma patients: soft collars better than rigid collars? A systematic review and meta-analysis

INTRODUCTION

Rigid cervical spine following trauma immobilization is recommended to reduce neurological disability and provide spinal stability. Soft collars have been proposed as a good alternative because of the complications related to rigid collars. The purpose of this study was to perform a systematic review on soft and rigid collars in the prehospital management of cervical trauma.

METHOD

A systematic review was performed following the PRISMA guidelines. Search terms were (immobilization) AND (collar) AND ((neck) OR (cervical)) to evaluate the range of motion (ROM) and evidence of clinical outcome for soft and rigid collars.

RESULTS

A total of 18 studies met eligibility criteria including 2 clinical studies and 16 articles investigating the range of motion (ROM). Four hundred and ninety-six patients at a mean age of 32.5 years (SD 16.8) were included. Measurements were performed in a seated position in twelve studies. Eight articles reported the ROM without a collar, 7 with a soft collar, and 15 with a rigid collar. There was no significant difference in flexion/extension, bending and rotation following immobilization with soft collars compared to no collar. Rigid collars provided significantly higher stability compared to no collar (p < 0.005) and to soft collars in flexion/extension and rotation movements (p < 0.05). The retrospective clinical studies showed no significant differences in secondary spinal cord injuries for soft collar (0.5%) and for rigid collar (1.1%). One study, comparing immobilization without a collar compared to that with a rigid collar, found a significant difference in neurologic deficiency and supraclavicular nerve lesion.

CONCLUSION

Although rigid collars provide significant higher stability to no collar and to soft collars in flexion/ extension and rotation movements, clinical studies could not confirm a difference in neurological outcome.

LEVEL OF EVIDENCE

II, Systematic Review.

Spontaneous Recovery of Penetrating Cervical Spinal Cord Injury with Physiotherapeutic Treatment: Case Report and Review of the Literature

Stab wounds to the cervical spine are less common than injuries from road accidents, sports injuries, and falls. The presence of vital, vascular, neural, respiratory, and digestive structures in the neck region mean that this kind of spinal injury is generally critical, and its management is a challenge. We report a unique case of a previously healthy 17-year-old adolescent admitted for quadriplegia secondary to a stab wound to the cervical spine at the C4C5 level. There was no surgical indication. The patient underwent physiotherapy. He showed spontaneous neurological improvement two weeks later and was able to sit on his own and to walk about three months of physical rehabilitation.

Isolated traumatic occipital condyle fractures: Is external cervical orthosis even necessary?

Background:

Occipital condyle fractures (OCFs) have been reported in up to 4–16% of individuals suffering cervical spine trauma. The current management of OCF fractures relies on a rigid cervical collar for 6 weeks or longer. Here, we calculated the rate of acute and delayed surgical intervention (occipitocervical fusion) for patients with isolated OCF who were managed with a cervical collar over a 10-year period at a single institution.

Methods:

This was a retrospective analysis performed on all patients admitted to a Level 1 Trauma Center between 2008 and 2018 who suffered traumatic isolated OCF managed with an external rigid cervical orthosis. Radiographic imaging was reviewed by several board-certified neuroradiologists. Demographic and clinical data were collected including need for occipitocervical fusion within 12 months after trauma.

Results:

The incidence of isolated OCF was 4% (60/1536) for those patients admitted with cervical spine fractures. They averaged 49 years of age, and 58% were male falls accounted for the mechanism of injury in 47% of patients. Classification of OCF was most commonly classified in 47% as type I Anderson and Montesano fractures. Of the 60 patients who suffered isolated OCF that was managed with external cervical orthosis, 0% required occipitocervical fusion within 12 months posttrauma. About 90% were discharged, while the remaining 10% sustained traumatic brain/orthopedic injury that limited an accurate neurological assessment.

Conclusion:

Here, we documented a 4% incidence of isolated OCF in our cervical trauma population, a rate which is comparable to that found in the literature year. Most notably, we documented a 0% incidence for requiring delayed occipital-cervical fusions.

Pre-hospital management of penetrating neck injuries: a scoping review of current evidence and guidance

Penetrating injuries to the neck pose a unique challenge to clinicians due to the proximity of multiple significant anatomical structures with little protective soft tissue coverage. Injuries to this area, whilst low in incidence, are potentially devastating. Respiratory, vascular, gastro-oesophageal and neurological structures may all be involved, either in isolation or combination. These injuries are particularly difficult to manage in the resource poor, often austere and/or remote, pre-hospital environment. A systematic scoping review of the literature was conducted to evaluate the current available research pertaining to managing this injury profile, prior to the patient arriving in the emergency department. The available research is discussed in sections based on the commonly used trauma management acronym ‘cABCD’ (catastrophic haemorrhage, Airway, Breathing, Circulation, Disability) to facilitate a systematic approach and clinical evaluation familiar to clinicians. Based on the available reviewed evidence, we have proposed a management algorithm for this cohort of patients. From this we plan to instigate a Delphi process to develop a consensus statement on the pre-hospital management of this challenging presentation.

Evidence for the use of spinal collars in stabilising spinal injuries in the pre-hospital setting in trauma patients: a systematic review

Purpose

Spinal collars were introduced in 1967 into the management of spinal trauma care as it was thought that this technique of immobilisation would prevent any further neurological or spinal damage in high-risk patients. The aim of this systematic review was to determine whether the use of spinal collars in the pre-hospital trauma patient was recommended by published literature.

Methods

A systematic search of the literature was conducted between 1990 and 2020, screening PubMed, Medline, Science Direct and Google Scholar. The consequent findings were then qualitatively synthesised with the aim of effectively evaluating the evidence to resolve the discrepancy between current practice and literature.

Results

Of the nine eligible studies, six deemed that spinal collars should not be used in pre-hospital trauma patients with the remaining three reporting uncertainty if spinal collars were best practice. Our results suggest that there is a discrepancy between current guidance and practice in that although the guidelines recommend the use of spinal collars in the pre-hospital setting the majority of the studies were against the use of spinal collars. Importantly, none of the studies reported any benefits of spinal collars.

Conclusion

Our study shows a disparity between current guidelines and the published literature and warrants further direct research to obtain a more comprehensive view of the use of spinal collars in a pre-hospital setting.

Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel

Background

Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments.

Objective

To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments.

Eligibility criteria

All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms.

Sources of evidence

PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles.

Charting methods

Evidence was searched according to clinically relevant topics and PICO questions.

Results

Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland.

Conclusions

Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.

Penetrating neck injuries

Penetrating neck injuries are becoming more common because of the increasing prevalence of knife and gun crimes. The immediate and long-term consequences of injury to the neck can be significant because of the close relationship of important anatomical structures in a confined space. Delayed recognition of major injury and inadequate treatment results in high morbidity and mortality. Developing a clear understanding of the underlying anatomy, common mechanisms of injury and principles of management will provide first responders, emergency doctors and trauma surgeons with confidence in appropriate evidence-based management. Early involvement of otolaryngologists or head and neck surgeons is advisable. Two cases of penetrating neck injury from the June 2017 London Bridge terror attack are discussed.

Prehospital care of spinal injuries: a historical quest for reasoning and evidence

PURPOSE

The practice of prehospital immobilization is coming under increasing scrutiny. Unravelling the historical sequence of prehospital immobilization might shed more light on this matter and help resolve the situation. Main purpose of this review is to provide an overview of the development and reasoning behind the implementation of prehospital spine immobilization.

METHODS

An extensive search throughout historical literature and recent evidence based studies was conducted.

RESULTS

The history of treating spinal injuries dates back to prehistoric times. Descriptions of prehospital spinal immobilization are more recent and span two distinct periods. First documentation of its use comes from the early 19th century, when prehospital trauma care was introduced on the battlefields of the Napoleonic wars. The advent of radiology gradually helped to clarify the underlying pathology. In recent decades, adoption of advanced trauma life support has elevated in-hospital trauma-care to an high standard. Practice of in-hospital spine immobilization in case of suspected injury has also been implemented as standard-care in prehospital setting. Evidence for and against prehospital immobilization is equally divided in recent evidence-based studies. In addition, recent studies have shown negative side-effects of immobilisation in penetrating injuries.

CONCLUSION

Although widely implementation of spinal immobilization to prevent spinal cord injury in both penetrating and blunt injury, it cannot be explained historically. Furthermore, there is no high-level scientific evidence to support or reject immobilisation in blunt injury. Since evidence in favour and against prehospital immobilization is equally divided, the present situation appears to have reached something of a deadlock. These slides can be retrieved under Electronic Supplementary Material.

Marauding terrorist attack (MTA): prehospital considerations

Terrorist attacks are increasing each year as are the number of deaths associated with them. Recent incidents have seen a shift in tactics with the use of multiple terrorists across multiple locations with firearms or knives, referred to as the marauding terrorist attack. These methods are becoming more prevalent alongside the use of vehicles deliberately aimed at pedestrians. Management of these incidents can be challenging. Not only it involves a large number of casualties but also the management of a dynamic scene in terms of both location and threat from attack. In order to improve response, and potentially outcomes, a system or response needs to have preplanned and practised procedures in place. This article reviews major incident management for those unfamiliar with current prehospital practice and details some of the findings from recent marauding terrorist firearm attacks, in particular the evolution of newer scene management tools such as 3 Echo and THREAT. It highlights the importance of haemorrhage control and the public initiatives focusing on actions during a terrorist incident.

Cervical spine injuries in civilian victims of explosions: Should cervical collars be used?

BACKGROUND

Semirigid cervical collars (SRCCs) are routinely applied to victims of explosions as part of the prehospital trauma protocols. Previous studies have shown that the use of SRCC in penetrating injuries is not justified because of the scarcity of unstable cervical spine injuries and the risk of obscuring other neck injuries. Explosion can inflict injuries by fragments penetration, blast injury, blunt force, and burns. The purpose of the study was to determine the occurrence of cervical spine instability without irreversible neurologic deficit and other potentially life-threatening nonskeletal neck injuries among victims of explosions. The potential benefits and risks of SRCC application in explosion-related injuries were evaluated.

METHODS

This is a retrospective cohort study of all explosion civilian victims admitted to Israeli hospitals during the years 1998 to 2010. Data collection was based on the Israeli national trauma registry and the hospital records and included demographic, clinical, and radiologic details of all patients with documented cervical spine injuries.

RESULTS

The cohort included 2,267 patients. All of them were secondary to terrorist attacks. SRCC was applied to all the patients at the scene. Nineteen patients (0.83%) had cervical spine fractures. Nine patients (0.088%) had unstable cervical spine injury. All but one had irreversible neurologic deficit on admission. A total of 151 patients (6.6%) had potentially life-threatening penetrating nonskeletal neck injuries.

CONCLUSION

Unstable cervical spine injuries secondary to explosion are extremely rare. The majority of unstable cervical spine fractures were secondary to penetrating injuries, with irreversible neurologic deficits on admission. The application of SRCC did not seem to be of any benefit in these patients and might pose a risk of obscuring other neck injuries. We recommend that SRCC will not be used in the prehospital management of victims of explosions.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Cervical collars and immobilisation: A South African best practice recommendation

INTRODUCTION

The consequences of spinal injury as a result of trauma can be devastating. Spinal immobilisation using hard trauma boards and rigid cervical collars has traditionally been the standard response to suspected spinal injury patients even though the risk may be extremely low. Recently, adverse events due to the method of immobilisation have challenged the need for motion restriction in all trauma patients. International guidelines have been published for protection of the spine during transport and this article brings those guidelines into the South African context.

RECOMMENDATIONS

Trauma patients need to be properly assessed using both an approved list of high and low risk factors, as well as a thorough examination. They should then be managed accordingly. Internationally validated assessment strategies have been developed, and should be used as part of the patient assessment. The method of motion restriction should be selected to suit the situation. The use of a vacuum mattress is the preferable technique, with the use of a trauma board being the least desirable.

CONCLUSION

The need for motion restriction in suspected spinal injury should be properly evaluated and appropriate action taken. Not all trauma patients require spinal motion restriction.

On-scene treatment of spinal injuries in motor sports

Because spinal cord injuries can have fatal consequences for injured race car drivers, prehospital treatment of spinal injuries is a major concern in motor sports. A structured procedure for assessing trauma patients and their treatment should follow established ABCDE principles. Only then, a stable patient could be further examined and appropriate measures can be undertaken. For patients in an acute life-threatening condition, rapid transport must be initiated and should not be delayed by measures that are not indicated. If a competitor must first be extricated from the racing vehicle, the correct method of extrication must be chosen. To avoid secondary injury to the spine after a racing accident, in-line extrication from the vehicle and immobilization of the patient are standard procedures in motor sports and have been used for decades. Since immobilization can be associated with disadvantages and complications, the need for immobilization of trauma patients outside of motor sports medicine has become the subject of an increasing number of reports in the scientific literature. Even in motor sports, where specific safety systems that offer spinal protection are present, the indications for spinal immobilization need to be carefully considered rather than being blindly adopted as a matter of course. The aim of this article is to use recent literature to present an overview about the treatment of spinal injuries in motor sports. Further, we present a new protocol for indications for immobilizing the spine in motor sports that is based on the ABCDE principles and takes into account the condition of the patient.

Development of a new Emergency Medicine Spinal Immobilization Protocol for trauma patients and a test of applicability by German emergency care providers

Background

In order to match the challenges of quickly recognizing and treating any life-threatening injuries, the ABCDE principles were established for the assessment and treatment of trauma patients. The high priority of spine protection is emphasized by the fact that immobilization of the cervical spine is performed at the very first step in the ABCDE principles. Immobilization is typically performed to prevent or minimize secondary damage to the spinal cord if instability of the spinal column is suspected. Due to increasing reports about disadvantages of spinal immobilization, the indications for performing spinal immobilization must be refined.

The aim of this study was (i) to develop a protocol that supports decision-making for spinal immobilization in adult trauma patients and (ii) to carry out the first applicability test by emergency medical personnel.

Methods

A structured literature search considering the literature from 1980 to 2014 was performed. Based on this literature and on the current guidelines, a new protocol that supports on scene decision-making for spinal immobilization has been developed. Parameters found in the literature concerning mechanisms and factors increasing the likelihood of spinal injury have been included in the new protocol. In order to test the applicability of the new protocol two surveys were performed on German emergency care providers by means of a questionnaire focused on correct decision-making if applying the protocol.

Results

Based on the current literature and guidelines, the Emergency Medicine Spinal Immobilization Protocol (E.M.S. IMMO Protocol) for adult trauma patients was developed. Following a fist applicability test involving 21 participants, the first version of the E.M.S. IMMO Protocol has to be graphically re-organized. A second applicability test comprised 50 participants with the current version of the protocol confirmed good applicability. Questions regarding immobilization of trauma patients could be answered properly using the E.M.S. IMMO Protocol.

Discussion

Current literature increasingly reports of disadvantages that may be associated with immobilization. Based on the requirements of the current guidelines, a new protocol that supports decision-making for indications for out-of-hospital spinal immobilization has been developed in this study. In contrast to established protocols, the new protocol offers different options for immobilization as well as a decicion-support.

Conclusions

The E.M.S. IMMO protocol provides a decision-support tool for indications for spinal immobilization in adult trauma patients that permits variable decision-making depending on the current condition of the trauma patient and the pattern of injuries for immobilization in general and for immobilization method in particular.

Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature

OBJECTIVES

The objectives were to review published reports of secondary neurologic deterioration in the early stages of care after blunt spinal trauma and describe its nature, context, and associated risk factors.

METHODS

The authors searched the MEDLINE, EMBASE, and CINAHL databases for English-language studies. Cases were included meeting the criteria age 16 years or older, nonpenetrating trauma, and experiencing neurologic deterioration during prehospital or emergency department (ED) care prior to definitive management (e.g., discharge, spinal clearance by computed tomography, admission to an inpatient service, or surgical intervention). Results were qualitatively analyzed for characteristics and themes.

RESULTS

Forty-one qualifying cases were identified from 12 papers. In 30 cases, the new deficits were apparently spontaneous and were not detected until routine reassessment. In 12 cases the authors did attribute deterioration to temporally associated precipitants, seven of which were possibly iatrogenic; these included removal of a cervical collar, placement of a halo device, patient agitation, performance of flexion/extension films, "unintentional manipulation," falling in or near the ED, and forced collar application in patients with ankylosing spondylitis. Thirteen cases occurred during prehospital care, none of them sudden and movement-provoked, and all reported by a single study.

CONCLUSIONS

Published reports of early secondary neurologic deterioration after blunt spinal trauma are exceptionally rare and generally poorly documented. High-risk features may include altered mental status and ankylosing spondylitis. It is unclear how often events are linked with spontaneous patient movement and whether such events are preventable.

Should suspected cervical spinal cord injury be immobilised?: a systematic review

BACKGROUND

Spinal cord injuries occur worldwide; often being life-threatening with devastating long term impacts on functioning, independence, health, and quality of life.

OBJECTIVES

Systematic review of the literature to determine the efficacy of cervical spinal immobilisation (vs no immobilisation) in patients with suspected cervical spinal cord injury (CSCI); and to provide recommendations for prehospital spinal immobilisation.

METHODS

Searches were conducted of the Cochrane library, CINAHL, EMBASE, Pubmed, Scopus, Web of science, Google scholar, and OvidSP (MEDLINE, PsycINFO, and DARE) databases. Studies were included if they were relevant to the research question, published in English, based in the prehospital setting, and included adult patients with traumatic injury.

RESULTS

The search identified 1471 citations, of which eight observational studies of variable quality were included. Four studies were retrospective cohorts, three were case series and one a case report. Cervical collar application was reported in penetrating trauma to be associated with unadjusted increased risk of mortality in two studies [(OR, 8.82; 95% CI, 1.09-194; p=0.038) & (OR, 2.06; 95% CI, 1.35-3.13)], concealment of neck injuries in one study and increased scene time in another study. While, in blunt trauma, one study indicated that immobilisation might be associated with worsened neurological outcome (OR, 2.03; 95% CI, 1.03-3.99; p=0.04, unadjusted). We did not attempt to combine study results due to significant heterogeneity of study design and outcome measures.

CONCLUSION

There is a lack of high-level evidence on the effect of prehospital cervical spine immobilisation on patient outcomes. There is a clear need for large prospective studies to determine the clinical benefit of prehospital spinal immobilisation as well as to identify the subgroup of patients most likely to benefit.

The prehospital management of suspected spinal cord injury: an update

INTRODUCTION

Spinal cord injury (SCI) is a serious condition that may lead to long-term disabilities placing financial and social burden on patients and their families, as well as their communities. Spinal immobilization has been considered the standard prehospital care for suspected SCI patients. However, there is a lack of consensus on its beneficial impact on patients' outcome.

OBJECTIVE

This paper reviews the current literature on the epidemiology of traumatic SCI and the practice of prehospital spinal immobilization.

DESIGN

A search of literature was undertaken utilizing the online databases Ovid Medline, PubMed, CINAHL, and the Cochrane Library. The search included English language publications from January 2000 through November 2012.

RESULTS

The reported annual incidence of SCI ranges from 12.7 to 52.2 per 1 million and occurs more commonly among males than females. Motor vehicle collisions (MVCs) are the major reported causes of traumatic SCI among young and middle-aged patients, and falls are the major reported causes among patients older than 55. There is little evidence regarding the relationship between prehospital spinal immobilization and patient neurological outcomes. However, early patient transfer (8-24 hours) to spinal care units and effective resuscitation have been demonstrated to lead to better neurological outcomes.

CONCLUSION

This review reaffirms the need for further research to validate the advantages, disadvantages, and the effects of spinal immobilization on patients' neurological outcomes.

Prehospital use of cervical collars in trauma patients: a critical review

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

Care related and transit neuronal injuries after cervical spine trauma: state of care and practice in Nigeria

Suboptimal care during extraction and transfer after spinal trauma predisposes patients to additional spinal cord injury. This study examines the factors that contribute to care related and transit injuries and suggests steps to improve standard of care in spinal trauma patients in Nigeria. It is a questionnaire-based prospective study of patients admitted with cervical cord injury to two neurosurgical centers in Enugu, Nigeria, between March 2008 and October 2010. Demography, mechanism of injury, mode of extraction from the scene and transportation to first visited hospital, precautions taken during transportation, and treatment received before arriving at the neurosurgical unit were analyzed. There were 53 (77.9%) males, the mean age was 33.9 years, and 23.5% had concomitant head injury. Average delay was 3.5 h between trauma and presentation to initial care and 10.4 days before presentation to definitive care. Only 26.5% presented primarily to tertiary centers with trauma services. About 94.1% were extracted by passersby. None of the patients received cervical spine protection either during extrication or in the course of transportation to initial care, and 35.3% were sitting in a motor vehicle or supported on a motorbike during transport. Of the 43 patients transported lying down, 41.9% were in the back seat of a sedan, and only 11.8% were transported in an ambulance. Neurological dysfunction was first noticed after removal from the scene by 41.2% of patients, while 7.4% noticed it on the way to or during initial care. During subsequent transfer to definitive centers, only 36% had cervical support, although 78% were transported in ambulances. Ignorance of pre-hospital management of cervically injured patients exists in the general population and even among medical personnel and results in preventable injuries. There is need for urgent training, provision of paramedical services, and public enlightenment.

Spinal injuries after improvised explosive device incidents: implications for Tactical Combat Casualty Care

BACKGROUND

Tactical Combat Casualty Care aims to treat preventable causes of death on the battlefield but deemphasizes the importance of spinal immobilization in the prehospital tactical setting. However, improvised explosive devices (IEDs) now cause the majority of injuries to Canadian Forces (CF) members serving in Afghanistan. We hypothesize that IEDs are more frequently associated with spinal injuries than non-IED injuries and that spinal precautions are not being routinely employed on the battlefield.

METHODS

We examined retrospectively a database of all CF soldiers who were wounded and arrived alive at the Role 3 Multinational Medical Unit in Kandahar, Afghanistan, from February 7, 2006, to October 14, 2009. We collected data on demographics, injury mechanism, anatomic injury descriptions, physiologic data on presentation, and prehospital interventions performed. Outcomes were incidence of any spinal injuries.

RESULTS

Three hundred seventy-two CF soldiers were injured during the study period and met study criteria. Twenty-nine (8%) had spinal fractures identified. Of these, 41% (n = 12) were unstable, 31% (n = 9) stable, and 28% indeterminate. Most patients were injured by IEDs (n = 212, 57%). Patients injured by IEDs were more likely to have spinal injuries than those injured by non-IED-related mechanisms (10.4% vs. 2.3%; p < 0.01). IED victims were even more likely to have spinal injuries than patients suffering blunt trauma (10.4% vs. 6.7%; p = 0.02). Prehospital providers were less likely to immobilize the spine in IED victims compared with blunt trauma patients (10% [22 of 212] vs. 23.0% [17 of 74]; p < 0.05).

CONCLUSIONS

IEDs are a common cause of stable and unstable spinal injuries in the Afghanistan conflict. Spinal immobilization is an underutilized intervention in the battlefield care of casualties in the conflict in Afghanistan. This may be a result of tactical limitations; however, current protocols should continue to emphasize the judicious use of immobilization in these patients.

Unstable cervical spine fracture after penetrating neck injury: a rare entity in an analysis of 1,069 patients

BACKGROUND

The value of cervical spine immobilization after penetrating trauma to the neck is the subject of lively debate. The purpose of this study was to review the epidemiology of unstable cervical spine injuries (CSI) after penetrating neck trauma in a large cohort of patients.

METHODS

This is a retrospective analysis of patients admitted with penetrating neck injuries to a Level I trauma center from January 1996 through December 2008. A penetrating neck injury was defined as a gunshot wound (GSW) or stab wound (SW) between the clavicles and the base of the skull. Univariate and multivariate analyses were performed to investigate associations between injury mechanisms, the presence of CSI instability, and mortality. Risk factors independently associated with the presence of a CSI were identified.

RESULTS

A total of 1,069 patients met inclusion criteria, of which 463 patients (43.3%) and 606 patients (56.7%) were sustaining GSW and SW, respectively. Overall, 65 patients (6.1%) were diagnosed with a CSI with a significantly higher incidence after GSWs compared with SWs (12.1% vs. 1.5%; p < 0.001). In four patients (0.4%), the CSI was considered unstable, all of them following GSW. All patients with unstable CSI had obvious neurologic deficits or altered mental status at the time of admission. Risk factors independently associated with the presence of a CSI were GSW to the neck and a Glasgow Coma Scale score ≤8 on admission (R = 0.16).

CONCLUSION

The overall incidence of unstable CSI after penetrating trauma to the neck is exceedingly low at 0.4%. Following GSW to the neck, an unstable CSI was noted in <1% of patients. After cervical SW, however, no spinal instability was noted precluding the need for spinal precautions in these instances.

Motion within the unstable cervical spine during patient maneuvering: the neck pivot-shift phenomenon

BACKGROUND

Cervical extrication collars are applied to millions of blunt trauma victims despite the lack of any evidence that a collar can protect against secondary injuries to the cervical spine. Cadaver studies support that in the presence of a dissociative injury, substantial motion can occur within the occipitocervical spine with collar application or during patient transfers. Little is known about the biomechanics of cervical stabilization; hence, it is difficult to develop and test improved immobilization strategies.

MATERIALS

Severe unstable injuries were created in seven fresh whole human cadavers. Rigid collars were applied with the body in a neutral position. Computed tomographic examinations were obtained before and after tilting the body or backboard as would be done during patient transport or to inspect the back. Relative displacements between vertebrae at the site of the injury were measured from the Computed tomographic examinations. The overall relative alignment between body and collar was assessed to understand the mechanisms that may facilitate motion at the injury site.

RESULTS

Intervertebral motion averaged 7.7 mm±6.8 mm in the axial plain and 2.9 mm±2.5 mm in the cranial-caudal direction. The rigid collars appeared to create pivot points where the collar contacts the head in the region under the ear and where the collar contacts the shoulders.

DISCUSSION

Rigid cervical collars appear to create pivot points that shift the center of rotation lateral to the spine and contribute to the intervertebral motions that were measured. Immobilization strategies that avoid these neck pivot-shift phenomena may help to reduce secondary injuries to the cervical spine. The whole cadaver model with simulation of patient maneuvers may provide an effective test method for cervical immobilization.

Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso

BACKGROUND

Prehospital spinal immobilization (PHSI) is routinely applied to patients sustaining torso gunshot wounds (GSW). Our objective was to evaluate the potential benefit of PHSI after torso GSW versus the potential to interfere with other critical aspects of care.

METHODS

A retrospective analysis of all patients with torso GSW in the Strong Memorial Hospital (SMH) trauma registry during a 41-month period and all patients with GSW in the National Trauma Data Bank (NTDB) during a 60-month period was conducted. PHSI was considered potentially beneficial in patients with spine fractures requiring surgical stabilization in the absence of spinal cord injury (SCI).

RESULTS

Three hundred fifty-seven subjects from SMH and 75,210 from NTDB were included. A total of 9.2% of SMH subjects and 4.3% of NTDB subjects had spine injury, with 51.5% of SMH subjects and 32.3% of NTDB subjects having SCI. No SMH subject had an unstable spine fracture requiring surgical stabilization without complete neurologic injury. No subjects with SCI improved or worsened, and none developed a new deficit. Twenty-six NTDB subjects (0.03%) had spine fractures requiring stabilization in the absence of SCI. Emergent intubation was required in 40.6% of SMH subjects and 33.8% of NTDB subjects. Emergent surgical intervention was required in 54.5% of SMH subjects and 43% of NTDB subjects.

CONCLUSIONS

Our data suggest that the benefit of PHSI in patients with torso GSW remains unproven, despite a potential to interfere with emergent care in this patient population. Large prospective studies are needed to clarify the role of PHSI after torso GSW.

Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck trauma

BACKGROUND

Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In today's global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties.

METHODS

We retrospectively reviewed the medical records of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention was recorded.

RESULTS

During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 of these (7%) actually survived to reach hospital. Four of this six subsequently died from injuries within 72 h. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury.

CONCLUSIONS

Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life-threatening conditions.

Neurologic sequelae of penetrating cervical trauma

STUDY DESIGN

Multicenter, retrospective chart analysis was performed using data housed in the trauma registries of 2 independent American College of Surgeons verified, Level I Trauma centers. The trauma registries were queried for all cases of penetrating cervical trauma. Abstracted data included age, sex, race, mechanism of injury, Glasgow Coma Scale (GCS) level on arrival, neurologic findings on arrival, zone of injury, associated injuries, imaging studies and results, operations performed, neurologic sequelae, disposition from the hospital and the presence or absence of neurologic injury, cervical spine fracture, and cervical spine immobilization.

OBJECTIVE

The purpose of this study was to determine the relationship between cervical spine immobilization and neurologic sequelae in penetrating cervical trauma.

SUMMARY OF BACKGROUND DATA

Current recommendations for cervical spine immobilization in penetrating cervical trauma developed by empiric extension of blunt trauma protocols without evidentiary support. No evidence exists to support cervical spine immobilization as a means of preventing neurologic injury progression in cases of penetrating cervical injury.

METHODS

Abstracted data were organized, entered into a database, and compared statistically. Significance was accepted for P<0.05.

RESULTS

A total of 196 patient charts formed the study cohort. Neurologic injuries either improved or remained static. No patient could be determined to have benefited from cervical spine immobilization in this study as the only 2 patients presenting with unstable cervical spine fractures were completely neurologically devastated at the time of injury. Prehospital cervical spine immobilization may have negatively affected patients with vascular and airway injuries. Decreased cervical spine immobilization rates at one institution did not affect neurologic outcome.

CONCLUSION

Cervical spine immobilization does not appear to prevent progression of neurologic injury in cases of penetrating cervical trauma. Comorbid penetrating injuries may be negatively impacted by prehospital cervical spine immobilization.

The role of routine spinal imaging and immobilisation in asymptomatic patients after gunshot wounds

BACKGROUND

The role of routine dedicated spinal imaging and immobilisation following gunshot wounds (GSW) to the head, neck or torso has been debated. The purpose of this study was to determine the incidence of spinal column injury requiring stabilisation in evaluable patients following gunshot injury.

METHODS

A retrospective study from of a Level I trauma centre from January 1995 to December 2004. All patients with GSW to the head, neck or torso and bony spinal column injury underwent medical record review to determine injury type, presentation, presence of concomitant spinal cord injury, treatment and outcome.

RESULTS

A total of 4204 patients sustaining GSW to the head, neck or torso were identified. Complete medical records were available for the 327 (7.8%) patients with bony spinal column injury. Among these patients, 173 (52.9%) sustained spinal cord injury. Two patients (0.6%) with GSW to the torso and bony spinal column injury required operative spinal intervention. The indication for operative intervention in both cases was removal of a foreign body or bony fragment for decompression of the spinal canal. None of the 4204 patients sustaining GSW to the head, neck or torso demonstrated spinal instability requiring operative intervention, and only 2/327 (0.6%) required any form of operative intervention for decompression.

CONCLUSION

Spinal instability following GSW with spine injury is very rare. Routine spinal imaging and immobilisation is unwarranted in examinable patients without symptoms consistent with spinal injury following GSW to the head, neck or torso.

Increased risk of death with cervical spine immobilisation in penetrating cervical trauma

The purpose of this study was to determine if cervical spine immobilisation was related to patient mortality in penetrating cervical trauma. One hundred and ninety-nine patient charts from the Louisiana State University Health Sciences Center New Orleans (Charity Hospital, New Orleans) were examined. Charts were identified by searching the Charity Hospital Trauma Registry from 01/01/1994 to 04/17/2003 for all cases of penetrating cervical trauma. Thirty-five patient deaths were identified. Cervical spine immobilisation was associated with an increased risk of death (p<0.02, odds ratio 2.77, 95% CI 1.18-6.49).

Thoracic and neck trauma. Part four

Previous parts to this series on thoracic and neck trauma discussed the anatomy and physiology of the thorax, assessment and initial nursing interventions, imaging and adjuncts to diagnosis. Part 2 described specific chest wall and lung injuries, types of pneumothoraces and their diagnosis and management. Section 3 examined other types of thoracic injuries and their management, such as trauma to the diaphragm and heart. This final part provides a brief but concise overview of neck anatomy, trauma and management.

The identification of criteria to evaluate prehospital trauma care using the Delphi technique

OBJECTIVE

Current trauma system performance improvement emphasizes hospital- and patient-based outcome measures such as mortality and morbidity, with little focus upon the processes of prehospital trauma care. Little data exist to suggest which prehospital criteria should serve as potential filters. This study identifies the most important filters for auditing prehospital trauma care using a Delphi technique to achieve consensus of expert opinion.

METHODS

Experts in trauma care from the United States (n = 81) were asked to generate filters of potential utility in monitoring the prehospital aspect of the trauma system, and were then required to rank these questions in order of importance to identify those of greatest importance.

RESULTS

Twenty-eight filters ranking in the highest tertile are proposed. The majority (54%) pertains to aspects of emergency medical services, which comprise 7 of the top 10 (70%) filters. Triage filters follow in priority ranking, comprising 29% of the final list. Filters concerning interfacility transfers and transportation ranked lowest.

CONCLUSION

This study identifies audit filters representing the most important aspects of prehospital trauma care that merit continued evaluation and monitoring. A subsequent trial addressing the utility of these filters could potentially enhance the sensitivity of identifying deviations in prehospital care, standardize the performance improvement process, and translate into an improvement in patient care and outcome.

Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault

BACKGROUND

The mechanism of injury has not been highly regarded as an important variable when evaluating cervical spine injuries. The aim of this study was to determine the incidence of cervical spine fracture (CSF) and cervical spinal cord injury (CSCI) based on mechanism following blunt and penetrating assault to better aid prioritization of management.

METHODS

Retrospective analysis from two large urban Level I trauma centers over 87 and 144 months caused by gunshot wounds (GSW), stab wounds (SW) or blunt assault (BA).

RESULTS

During the study period, there were 57,532 trauma patients evaluated at the two trauma centers, of which 42.3% were following blunt or penetrating assault. The rates of CSF and CSCI for the various mechanisms were similar between the two centers. The rates for having CSF were significantly different (p < 0.05) for the various mechanisms. GSW (1.35%) was the highest followed by BA (0.41%) and then SW (0.12%). The rates of CSCI for GSW (0.94%) were significantly (p < 0.05) higher than BA (0.14%) and SW (0.11%). For GSW patients, all patients with CSF or CSCI had a point of entry between the ears and the nipple. For SW patients, the wound was directly in the neck below the mandible and above the trapezius muscle. Although many of the SW patients also suffered blunt assault, none of the CSF or CSCI injuries were from blunt forces. In addition, all patients, both blunt and penetrating who had CSCI had neurologic deficit at the time of presentation. Surgical stabilization or tongs were applied in 15.5% (26 of 168) of the GSWs, 27.8% (3 of 11) of the SWs and 31.6% (6 of 19) of the BA patients. There was a BA patient (1 of 4,390) patient with CSF that was neurologically intact that required surgical stabilization and this patient had neck pain on admission. No penetrating injury patients with CSCI regained significant neurologic recovery during the hospitalization.

SUMMARY

The rate of CSF or CSCI is low following assault and dependent on mechanism of injury. Thus the concern and extent of evaluation should also be dependent on the mechanism of injury. Neurologic deficits from penetrating assault were established and final at the time of presentation. Concern for protecting the neck should not hinder the evaluation process or life saving procedures.

Spine Injuries Are Common Among Asymptomatic Patients After Gunshot Wounds

BACKGROUND

Spine injuries after gunshot wounds are thought to be rare among asymptomatic patients. The occurrence of spine injuries among asymptomatic patients with gunshot wounds was studied to determine the necessity for mandatory spine immobilization and radiographic imaging.

METHODS

In this retrospective cohort study, initial physical examination, radiographic findings, and final diagnosis and treatment were reviewed. Patients were included if they were admitted to the authors' level 1 trauma center with gunshot wounds to the head, neck, or trunk during a 10-year period. Spine injuries were considered "significant" if the injury was associated with spinal cord injury or required spine-related surgical procedures or prolonged spine immobilization. Spine injuries were defined as "unsuspected" if there were no neurologic findings at admission.

RESULTS

During the study period, 2,450 patients who survived more than 24 hours were admitted with gunshot wounds to the trunk, neck, or head. Of these patients, 244 (approximately 10%) had spine injuries, and 228 of them had complete records. Two thirds of the spine injuries were found to be significant, requiring surgery or prolonged immobilization, and 13% were unsuspected.

CONCLUSIONS

Spine injuries without neurologic signs are not uncommon among patients with gunshot wounds. Complete radiographic spine imaging is therefore recommended to ensure that spine injuries are not missed in this population.

Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma?

INTRODUCTION

Previous work suggests that patients with isolated penetrating trauma rarely require spinal immobilisation. This study aimed to identify the incidence of mechanically unstable, or potentially mechanically unstable, spinal column injuries in penetrating trauma patients. The study also aimed to identify the incidence of spinal cord injury as a result of penetrating trauma in Scotland.

DESIGN

Retrospective analysis of prospectively collected data from the Scottish Trauma Audit Group (STAG).

METHODS

Study patients were identified from the period 1992-1999. Patients coded for both penetrating trauma and spinal column or spinal cord injury were included. Case records, theatre notes and post mortem information were also examined.

RESULTS

34903 patients were available for study. Twenty-seven patients were coded as having had penetrating trauma and concurrent spinal injury. 15 were excluded as they also had a major blunt mechanism of injury or had no actual injury to the spinal cord or column. In the remaining 12 patients, four cervical, one combined cervical and thoracic and seven thoracic spinal cord injuries were identified. 11 were male and 11 were assaulted. One assault was due to a gunshot wound; 10 resulted from sharp weapons. Four complete cord transections and nine partial cord lesions were identified. All 12 patients with spinal cord injury associated with isolated penetrating trauma either had obvious clinical evidence of a spinal cord injury on initial assessment or were in traumatic cardiac arrest. All had spinal immobilisation.

CONCLUSION

Fully conscious patients (GCS=15) with isolated penetrating trauma and no neurological deficit do not require spinal immobilisation.

The military medical management of missile injury to the spine: a review of the literature and proposal of guidelines

The management of missile injury to the spinal cord is controversial. The literature is reviewed and recommendations made about the management of these injuries. To surgeons in a country that is relatively safe such injuries are rare, this review provides useful information about this condition.