Cervical spine motion generated with manual versus jackson table turning methods in a cadaveric c1-c2 global instability model

Open Reduction and Decompression of Atlantoaxial Subluxation with Basilar Impression Due to Grisel Syndrome Using the Cervical Management Base Unit

BACKGROUND

Intraoperative manipulation of the craniocervical junction with the Cervical Management Base Unit (CMBU) has been used as an adjunct for achieving optimal anatomic alignment during instrumented fusion procedures in a variety of disease settings. Here, we present our experience using the CMBU as a supplement to achieving a successful reduction and fixation of a reducible craniocervical subluxation with associated basilar impression/medullary compression in the setting of Grisel syndrome.

CASE DESCRIPTION

Under fluoroscopy and neuromonitoring guidance, the elevator and axial translation mechanisms of the CMBU safely allowed for presurgical assessment of reducibility and facilitated complete reduction of the deformity with restitution of a normal atlantodental interval, spinolaminar line, and clivoaxial angle. Magnetic resonance imaging acquired 1 month after surgery and antibiotic therapy showed resolution of a large epidural abscess in the region of the dens and no evidence of residual neural impingement. Upright plain films at 9 months showed maintenance of the desired craniocervical alignment.

CONCLUSIONS

Intraoperative manipulation of the craniocervical junction using the CMBU, when implemented under fluoroscopy and neuromonitoring, can safely facilitate an enduring anatomic correction of craniocervical deformity in the setting of Grisel syndrome. The dynamic utility of the CMBU for translation of the head and neck obviated the need to apply forces directly to hardware-bone interfaces, and its utility may extend to craniocervical disorders of other etiologies, especially those of a reducible nature and in the setting of poor bone quality and joint laxity.

Defining Best Practices for Patient Safety in Positioning and Transferring Patients With the Surgical Spine Table

This quality improvement project's purpose was to define and provide best practices in surgical patient positioning and transfer processes with the surgical spine table to increase patient safety. Using the Define, Measure, Analyze, Improve, and Control quality improvement framework, a multidisciplinary team analyzed surveys, qualitative interviews, ergonomics, near-miss sentinel events and skin integrity data to standardize this process. Results reinforced the need to develop and standardize the process of patient positioning and transfer from cart to table. Findings resulted in practice changes, including a standardized best practice for transfer of patients, educational tools, and checklists for continued monitoring of patient safety issues. Metrics for intervention effectiveness include reduced patient skin integrity, increased staff satisfaction, and improved comfort level with use of spine table accessories and equipment. This practice improvement has a patient safety focus in the perioperative nursing practice.

Comparison of the Vacuum Mattress versus the Spine Board Alone for Immobilization of the Cervical Spine Injured Patient: A Biomechanical Cadaveric Study

STUDY DESIGN

A biomechanical cadaveric study.

OBJECTIVE

We sought to determine the amount of motion generated in an unstable cervical spine fracture with use of the vacuum mattress versus the spine board alone. Our hypothesis is that the vacuum mattress will better immobilize an unstable cervical fracture.

SUMMARY OF BACKGROUND DATA

Trauma patients in the United States are immobilized on a rigid spine board, whereas in many other places, vacuum mattresses are used with the proposed advantages of improved comfort and better immobilization of the spine.

METHODS

Unstable subaxial cervical injuries were surgically created in five fresh whole human cadavers. The amount of motion at the injured motion segment during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc.). The measurements recorded in this investigation included maximum displacements during application and removal of the device, while tilting to 90°, during a bed transfer, and a lift onto a gurney. Linear and angular displacements were compared using the Generalized Linear Model analysis of variance for repeated measures for each of the six dependent variables (three planes of angulations and three axes of displacement).

RESULTS

There was more motion in all six planes of motion during the application process with use of the spine board alone, and this was statistically significant for axial rotation (P = 0.011), axial distraction (P = 0.035), medial-lateral translation (P = 0.027), and anteroposterior translation (P = 0.026). During tilting, there was more motion with just the spine board, but this was only statistically significant for anteroposterior translation (P = 0.033). With lifting onto the gurney, there was more motion with the spine board in all planes with statistical significance, except lateral bending. During the removal process, there was more motion with the spine board alone, and this was statistically significant for axial rotation (P = 0.035), lateral bending (P = 0.044), and axial distraction (P = 0.023).

CONCLUSION

There was more motion when using a spine board alone during typical maneuvers performed during early management of the spine injured patient than the vacuum mattress. There may be benefit of use of the vacuum mattress versus the spine board alone in preventing motion at an unstable, subaxial cervical spine injury.

LEVEL OF EVIDENCE

2.

Controlled Laboratory Comparison Study of Motion With Football Equipment in a Destabilized Cervical Spine: Three Spine-Board Transfer Techniques

Background

Numerous studies have shown that there are better alternatives to log rolling patients with unstable spinal injuries, although this method is still commonly used for placing patients onto a spine board. No previous studies have examined transfer maneuvers involving an injured football player with equipment in place onto a spine board.

Purpose

To test 3 different transfer maneuvers of an injured football player onto a spine board to determine which method most effectively minimizes spinal motion in an injured cervical spine model.

Study Design

Controlled laboratory study.

Methods

Five whole, lightly embalmed cadavers were fitted with shoulder pads and helmets and tested both before and after global instability was surgically created at C5-C6. An electromagnetic motion analysis device was used to assess the amount of angular and linear motion with sensors placed above and below the injured segment during transfer. Spine-boarding techniques evaluated were the log roll, the lift and slide, and the 8-person lift.

Results

The 8-person lift technique resulted in the least amount of angular and linear motion for all planes tested as compared with the lift-and-slide and log-roll techniques. This reached statistical significance for lateral bending (P = .031) and medial-lateral translation (P = .030) when compared with the log-roll maneuver. The lift-and-slide technique was significantly more effective at reducing motion than the log roll for axial rotation (P = .029) and lateral bending (P = .006).

Conclusion

The log roll resulted in the most motion at an unstable cervical injury as compared with the other 2 spine-boarding techniques examined. The 8-person lift and lift-and-slide techniques may both be more effective than the log roll at reducing unwanted cervical spine motion when spine boarding an injured football player. Reduction of such motion is critical in the prevention of iatrogenic injury.

Is it safe to use a kinetic therapy bed for care of patients with cervical spine injuries?

INTRODUCTION

Bedrest is often used for temporary management, as well as definitive treatment, for many spinal injuries. Under such circumstances patients cannot remain flat for extended periods due to possible skin breakdown, blood clots, or pulmonary complications. Kinetic therapy beds are often used in the critical care setting, although this is felt to be unsafe for turning patients with spine fractures. We sought to evaluate whether a kinetic therapy bed would cause as much spinal motion at an unstable cervical injury as occurs during manual log-rolling on a standard intensive care unit bed.

METHODS

Unstable C5-C6 ligamentous injuries were surgically created in 15 fresh, whole cadavers. Sensors were affixed to C5 and C6 posteriorly and electromagnetic motion tracking analysis performed. In all cases a cervical collar was applied by an orthotist after creation of the injury. The amount of angular motion and linear displacement that occurred at this injured level was measured during manual log-rolling and patient turning using a kinetic therapy bed. For statistical analysis, the range of motion for angles about each axis and displacement in each direction was analyzed by multivariate analysis of variance with repeated measures.

RESULTS

When comparing manual log-rolling and kinetic bed therapy, significantly more angular motion was created by the log-roll manoeuvre in flexion-extension (p=0.03) and lateral bending (p=0.01). There was no significant difference in axial rotation between the two methods (p=0.80). There were no significant differences demonstrated in medial-lateral and anterior-posterior translation. There was almost two times the axial displacement between manual log-rolling and the kinetic therapy bed and this reached statistical significance (p=0.05).

CONCLUSION

There is less motion at an unstable cervical injury in flexion-extension, lateral bending, and axial displacement when turning a patient using a kinetic therapy bed as opposed to traditional manual log-rolling. It may be preferable to use a kinetic therapy bed rather than manual log-rolling for patients with cervical spine injuries to decrease unwanted spinal motion. In addition, it may be easier and less physically demanding on nursing staff that must regularly turn the patient if manual log-rolling is implemented.

Motion generated in the unstable upper cervical spine during head tilt-chin lift and jaw thrust maneuvers

BACKGROUND CONTEXT

Although it is essential to maintain a secure airway in a trauma patient, it is also critical to protect the potentially injured cervical spine. It has previously been suggested that the jaw thrust maneuver be used in place of the head tilt-chin lift in the suspected spine-injured patient.

PURPOSE

We sought to examine whether the jaw thrust was in fact safer to use in the setting of an unstable upper cervical spine injury.

METHODS

Unstable, dissociative C1-C2 injuries were surgically created in nine fresh, lightly embalmed human cadaver specimens. An electromagnetic motion analysis device was used to assess the amount of angular and linear motion with sensors placed above and below the injured segment. Measurements were recorded during execution of the two airway maneuvers. Trials were performed both with and without a cervical immobilization collar in place.

RESULTS

There was almost twice as much angular motion in all planes when performing a head tilt-chin lift as compared with the jaw thrust, and this was statistically significant (p<.013). In addition, there was more displacement at the injured level with a head tilt-chin lift as compared with the jaw thrust. This was statistically significant for axial displacement and anteroposterior translation (p=.003 for both), and approached significance for mediolateral translation (p=.056).

CONCLUSIONS

The jaw thrust maneuver results in less motion at an unstable C1-C2 injury as compared with the head tilt-chin lift maneuver. We therefore recommend the use of the jaw thrust to improve airway patency in the trauma patient with suspected cervical spine injury.

Comparison of circumferential pelvic sheeting versus the T-POD on unstable pelvic injuries: A cadaveric study of stability

OBJECTIVES

Commercially available binder devices are commonly used in the acute treatment of pelvic fractures, while many advocate simply placing a circumferential sheet for initial stabilization of such injuries. We sought to determine whether or not the T-POD would provide more stability to an unstable pelvic injury as compared to circumferential pelvic sheeting.

METHODS

Unstable pelvic injuries (OTA type 61-C-1) were surgically created in five fresh, lightly embalmed whole human cadavers. Electromagnetic sensors were placed on each hemi-pelvis. The amount of angular motion during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). Either a T-POD or circumferential sheet was applied in random order for testing. The measurements recorded in this investigation included maximum displacements for sagittal, coronal, and axial rotation during application of the device, bed transfer, log-rolling, and head of bed elevation.

RESULTS

There were no differences in motion of the injured hemi-pelvis during application of either the T-POD or circumferential sheet. During the bed transfer, log-rolling, and head of bed elevation, there were no significant differences in displacements observed when the pelvis was immobilized with either a sheet or pelvic binder (T-POD).

CONCLUSIONS

A circumferential pelvic sheet is more readily available, costs less, is more versatile, and is equally as efficacious at immobilizing the unstable pelvis as compared to the T-POD. We advocate the use of circumferential sheeting for temporary stabilization of unstable pelvic injuries.

Motion in the unstable cervical spine when transferring a patient positioned prone to a spine board

CONTEXT

Two methods have been proposed to transfer an individual in the prone position to a spine board. Researchers do not know which method provides the best immobilization.

OBJECTIVE

To determine if motion produced in the unstable cervical spine differs between 2 prone logrolling techniques and to evaluate the effect of equipment on the motion produced during prone logrolling.

DESIGN

Crossover study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Tests were performed on 5 fresh cadavers (3 men, 2 women; age = 83 ± 8 years, mass = 61.2 ± 14.1 kg).

MAIN OUTCOME MEASURE(S)

Three-dimensional motions were recorded during 2 prone logroll protocols (pull, push) in cadavers with an unstable cervical spine. Three equipment conditions were evaluated: football shoulder pads and helmet, rigid cervical collar, and no equipment. The mean range of motion was calculated for each test condition.

RESULTS

The pull technique produced 16% more motion than the push technique in the lateral-bending angulation direction (F1,4 = 19.922, P = .01, η(2) = 0.833). Whereas the collar-only condition and, to a lesser extent, the football-shoulder-pads-and-helmet condition demonstrated trends toward providing more stability than the no-equipment condition, we found no differences among equipment conditions. We noted an interaction between technique and equipment, with the pull maneuver performed without equipment producing more anteroposterior motion than the push maneuver in any of the equipment conditions.

CONCLUSIONS

We saw a slight difference in the motion measured during the 2 prone logrolling techniques tested, with less lateral-bending and anteroposterior motion produced with the logroll push than the pull technique. Therefore, we recommend adopting the push technique as the preferred spine-boarding maneuver when a patient is found in the prone position. Researchers should continue to seek improved methods for performing prone spine-board transfers to further decrease the motion produced in the unstable spine.

A comparison of 4 airway devices on cervical spine alignment in cadaver models of global ligamentous instability at c1-2

BACKGROUND

The effects of advanced airway management on cervical spine alignment in patients with upper cervical spine instability are uncertain.

METHODS

To examine the potential for mechanical disruption during endotracheal intubation in cadavers with unstable cervical spines, we performed a prospective observational cohort study with 3 cadaver subjects. We created an unstable, type II odontoid fracture with global ligamentous instability at C1-2 in lightly embalmed cadavers, followed by repetitive intubations with 4 different airway devices (Airtraq laryngoscope, Lightwand, intubating laryngeal mask airway [LMA], and Macintosh laryngoscope) while manual in-line stabilization was applied. Motion analysis data were collected using an electromagnetic device to assess the degree of angular movement in 3 axes (flexion-extension, axial rotation, and lateral bending) during the intubation trials with each device. Intubation was performed by either an emergency medical technician or attending anesthesiologist.

RESULTS

Overall, 153 intubations were recorded with the 4 devices. The Lightwand technique resulted in significantly less flexion-extension and axial rotation at C1-2 than with the intubating LMA (mean difference in flexion-extension 3.2° [95% confidence interval {CI}, 0.9°-5.5°], P = 0.003; mean difference in axial rotation 1.6° [95% CI, 0.3°-2.8°], P = 0.01) and Macintosh laryngoscope (mean difference in flexion-extension 3.1° [95% CI, 0.8°-5.4°], P = 0.005; mean difference in axial rotation 1.4° [95% CI 0.1°-2.6°], P = 0.03).

CONCLUSIONS

In cadavers with instability at C1-2, the Lightwand technique produced less motion than the Macintosh and intubating LMA.

Motion generated in the unstable cervical spine during the application and removal of cervical immobilization collars

BACKGROUND

Many studies have compared the restriction of motion that immobilization collars provide to the injured victim. No previous investigation has assessed the amount of motion that is generated during the fitting and removal process. The purpose of this study was to compare the three-dimensional motion generated when one-piece and two-piece cervical collars are applied and removed from cadavers intact and with unstable cervical spine injuries.

METHODS

Five fresh, lightly embalmed cadavers were tested three times each with either a one-piece or two-piece cervical collar in the supine position. Testing was performed in the intact state, following creation of a global ligamentous instability at C5-C6. The amount of angular motion resulting from the collar application and removal was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). The measurements recorded in this investigation included maximum values for flexion/extension, axial rotation, medial/lateral flexion, anterior/posterior displacement, axial distraction, and medial/lateral displacement at the level of instability.

RESULTS

There was statistically more motion observed with application or removal of either collar following the creation of a global instability. During application, there was a statistically significant difference in flexion/extension between the one-piece (1.8 degrees) and two-piece (2.6 degrees) collars, p = 0.009. There was also a statistically significant difference in anterior/posterior translation between the one-piece (3.6 mm) and two-piece (3.4 mm) collars, p = 0.015. The maximum angulation and displacement during the application of either collar was 3.4 degrees and 4.4 mm. Statistical analysis revealed no significant differences between the one-piece and two-piece collars during the removal process. The maximum angulation and displacement during removal of either collar type was 1.6 degrees and 2.9 mm.

CONCLUSIONS

There were statistically significant differences in motion between the one-piece and two-piece collars during the application process, but it was only 1.2 degrees in flexion/extension and 0.2 mm in anterior/posterior translation. Overall, the greatest amount of angulation and displacement observed during collar application was 3.4 degrees and 4.4 mm. Although the exact amount of motion that could be deleterious to a cervical spine-injured patient is unknown, collars can be placed and removed with manual in-line stabilization without large displacements. Only trained practitioners should do so and with great care given that some motion in all planes does occur during the process.

Methods for evaluating cervical range of motion in trauma settings

Immobilisation of the cervical spine is a common procedure following traumatic injury. This is often precautionary as the actual incidence of spinal injury is low. Nonetheless, stabilisation of the head and neck is an important part of pre-hospital care due to the catastrophic damage that may follow if further unrestricted movement occurs in the presence of an unstable spinal injury. Currently available collars are limited by the potential for inadequate immobilisation and complications caused by pressure on the patient's skin, restricted airway access and compression of the jugular vein. Alternative approaches to cervical spine immobilisation are being considered, and the investigation of these new methods requires a standardised approach to the evaluation of neck movement. This review summarises the research methods and scientific technology that have been used to assess and measure cervical range of motion, and which are likely to underpin future research in this field. A systematic search of international literature was conducted to evaluate the methodologies used to assess the extremes of movement that can be achieved in six domains. 34 papers were included in the review. These studies used a range of methodologies, but study quality was generally low. Laboratory investigations and biomechanical studies have gradually given way to methods that more accurately reflect the real-life situations in which cervical spine immobilisation occurs. Latterly, new approaches using virtual reality and simulation have been developed. Coupled with modern electromagnetic tracking technology this has considerable potential for effective application in future research. However, use of these technologies in real life settings can be problematic and more research is needed.

Eliminating log rolling as a spine trauma order

BACKGROUND

Currently, up to 25% of patients with spinal cord injuries may experience neurologic deterioration during the initial management of their injuries. Therefore, more effective procedures need to be established for the transportation and care of these to reduce the risk of secondary neurologic damage. Here, we present more acceptable methods to minimize motion in the unstable spine during the management of patients with traumatic spine injuries.

METHODS

This review summarizes more than a decade of research aimed at evaluating different methods of caring for patients with spine trauma.

RESULTS

The most commonly utilized technique to transport spinal cord injured patients, the log rolling maneuver, produced more motion than placing a patient on a spine board, removing a spine board, performing continuous lateral therapy, and positioning a patient prone for surgery. Alternative maneuvers that produced less motion included the straddle lift and slide, 6 + lift and slide, scoop stretcher, mechanical kinetic therapy, mechanical transfers, and the use of the operating table to rotate the patient to the prone position for surgical stabilization.

CONCLUSIONS

The log roll maneuver should be removed from the trauma response guidelines for patients with suspected spine injuries, as it creates significantly more motion in the unstable spine than the readily available alternatives. The only exception is the patient who is found prone, in which case the patient should then be log rolled directly on to the spine board utilizing a push technique.

Total motion generated in the unstable cervical spine during management of the typical trauma patient: a comparison of methods in a cadaver model

STUDY DESIGN

Biomechanical cadaveric study.

OBJECTIVE

We sought to analyze the amount of motion generated in the unstable cervical spine during various maneuvers and transfers that a trauma patient would typically be subjected to prior to definitive fixation, using 2 different protocols.

SUMMARY OF BACKGROUND DATA

From the time of injury until the spine is adequately stabilized in the operating room, every step in management of the spine-injured patient can result in secondary injury to the spinal cord.

METHODS

The amount of angular motion between C5 and C6, after a surgically created unstable injury, was measured using an electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). A total sequence of maneuvers and transfers was then performed that a patient would be expected to go through from the time of injury until surgical fixation. This included spine board placement and removal, bed transfers, lateral therapy, and turning the patient prone onto the operating table. During each of these, we performed what has been shown to be the best and commonly used (log-roll) techniques.

RESULTS

During bed transfers and the turn prone for surgery, there was statistically more angular motion in each plane for traditional transfer with the spine board and manually turning the patient prone as commonly done (P < 0.01). During spine board placement, there was more motion in all 3 planes with log-rolling, and this reached statistical significance for axial rotation (P = 0.015) and lateral bending (P = 0.004). There was more motion during board removal with log-rolling in all 3 planes. This was statistically significant for lateral bending (P = 0.009) and approached significance in flexion-extension (P = 0.058) and axial rotation (P = 0.058). During lateral therapy, there was statistically more motion in flexion-extension and lateral bending with the manual log-roll technique (P < 0.001). The total motion was decreased by more than 50% in each plane when using an alternative to log-roll techniques during the total sequence (P < 0.006).

CONCLUSION

We have demonstrated the total angular motion incurred to the unstable cervical spine as experienced by the typical trauma patient from the field to stabilization in the operating room using the best compared with the most commonly used techniques. As previously reported, using log-roll techniques consistently results in unwanted motion at the injured spinal segment.

Total motion generated in the unstable thoracolumbar spine during management of the typical trauma patient: a comparison of methods in a cadaver model

OBJECT

The proper prehospital and inpatient management of patients with unstable spinal injuries is critical for prevention of secondary neurological compromise. The authors sought to analyze the amount of motion generated in the unstable thoracolumbar spine during various maneuvers and transfers that a trauma patient would typically be subjected to prior to definitive fixation.

METHODS

Five fresh cadavers with surgically created unstable L-1 burst fractures were tested. The amount of angular motion between the T-12 and L-2 vertebral segments was measured using a 3D electromagnetic motion analysis device. A complete sequence of maneuvers and transfers was then performed that a patient would be expected to go through from the time of injury until surgical fixation. These maneuvers and transfers included spine board placement and removal, bed transfers, lateral therapy, and turning the patient prone onto the operating table. During each of these, the authors performed what they believed to be the most commonly used versus the best techniques for preventing undesirable motion at the injury level.

RESULTS

When placing a spine board there was more motion in all 3 planes with the log-roll technique, and this difference reached statistical significance for axial rotation (p = 0.018) and lateral bending (p = 0.003). Using logrolling for spine board removal resulted in increased motion again, and this was statistically significant for flexion-extension (p = 0.014). During the bed transfer and lateral therapy, the log-roll technique resulted in more motion in all 3 planes (p ≤ 0.05). When turning the cadavers prone for surgery there was statistically more angular motion in each plane for manually turning the patient versus the Jackson table turn (p ≤ 0.01). The total motion was decreased by almost 50% in each plane when using an alternative to the log-roll techniques during the complete sequence (p ≤ 0.007).

CONCLUSIONS

Although it is unknown how much motion in the unstable spine is necessary to cause secondary neurological injury, the accepted tenet is to minimize motion as much as possible. This study has demonstrated the angular motion incurred by the unstable thoracolumbar spine as experienced by the typical trauma patient from the field to positioning in the operating room using the best and most commonly used techniques. As previously reported, using the log-roll technique consistently results in unwanted motion at the injured spinal segment.

Comparison of 4 airway devices on cervical spine alignment in a cadaver model with global ligamentous instability at C5-C6

STUDY DESIGN

Human cadaveric study using various intubation devices in a cervical spine instability model.

OBJECTIVE

We sought to evaluate various intubation techniques and determine which device results in the least cervical motion in the setting of a global ligamentous instability model.

SUMMARY OF BACKGROUND DATA

Many patients presenting with a cervical spine injury have other injuries that may require rapid airway management with endotracheal intubation. Secondary neurologic injuries may occur in these patients because of further displacement at the level of injury, vascular insult, or systemic decrease in oxygen delivery. The most appropriate technique for achieving endotracheal intubation in the patient with a cervical spine injury remains controversial.

METHODS

A global ligamentous instability at the C5-C6 vertebral level was created in lightly embalmed cadavers. An electromagnetic motion analysis device (Liberty; Polhemus, Colchester, VT) was used to assess the amount of angular and linear translation in 3 planes during intubation trials with each of 4 devices (Airtraq laryngoscope, lighted stylet, intubating LMA, and Macintosh laryngoscope). The angular motions measured were flexion-extension, axial rotation, and lateral bending. Linear translation was measured in the medial-lateral (ML), axial, and anteroposterior planes. Intubation was performed by either an emergency medical technician or by a board-certified attending anesthesiologist. Both time to intubate as well as failure to intubate (after 3 attempts) were recorded.

RESULTS

There was no significant difference shown with regards to time to successfully intubate using the various devices. It was shown that the highest failure-to-intubate rate occurred with use of the intubating LMA (ILMA) (23%) versus 0% for the others. In flexion/extension, we were able to demonstrate that the Lightwand (P = 0.005) and Airtraq (P = 0.019) resulted in significantly less angular motion than the Macintosh blade. In anterior/posterior translation, the Lightwand (P = 0.005), Airtraq (P = 0.024), and ILMA (P = 0.021) all caused significantly less linear motion than the Macintosh blade. In axial rotation, the Lightwand (P = 0.017) and Airtraq (P = 0.022) resulted in significantly less angular motion than the Macintosh blade. In axial translation (P = 0.037) and lateral bending (P = 0.003), the Lightwand caused significantly less motion than the Macintosh blade.

CONCLUSION

In a cadaver model of C5-C6 instability, the greatest amount of motion was caused by the most commonly used intubation device, the Macintosh blade. Intubation with the Lightwand resulted in significantly less motion in all tested parameters (other than ML translation) as compared with the Macintosh blade. It should also be noted that the Airtraq caused less motion than the Macintoshblade in 3 of the 6 tested planes. There were no significant differences in failure rate or the amount of time it took to successfully intubate in comparing these techniques. We therefore recommend the use of the Lightwand, followed by the Airtraq, in the setting of a presumed unstable cervical spine injury over the Macintosh laryngoscope.

Motion in the unstable thoracolumbar spine when spine boarding a prone patient

INTRODUCTION

Previous research has found that the log roll (LR) technique produces significant motion in the spinal column while transferring a supine patient onto a spine board. The purpose of this project was to determine whether log rolling a patient with an unstable spine from prone to supine with a pulling motion provides better thoracolumbar immobilization compared to log rolling with a push technique.

METHODS

A global instability was surgically created at the L1 level in five cadavers. Two spine-boarding protocols were tested (LR Push and LR Pull). Both techniques entailed performing a 180° LR rotation of the prone patient from the ground to the supine position on the spine board. An electromagnetic tracking device registered motion between the T12 and L2 vertebral segments. Six motion parameters were tracked. Repeated-measures statistical analysis was performed to evaluate angular and translational motion.

RESULTS

Less motion was produced during the LR Push compared to the LR Pull for all six motion parameters. The difference was statistically significant for three of the six parameters (flexion-extension, axial translation, and anterior-posterior (A-P) translation).

CONCLUSIONS

Both the LR Push and LR Pull generated significant motion in the thoracolumbar spine during the prone to supine LR. The LR Push technique produced statistically less motion than the LR Pull, and should be considered when a prone patient with a suspected thoracolumbar injury needs to be transferred to a long spine board. More research is needed to identify techniques to further reduce the motion in the unstable spine during prone to supine LR.

Cervical spine trauma in children and adults: perioperative considerations

A wide spectrum of cervical spine injuries, including stable and unstable injuries with and without neurologic compromise, account for a large percentage of emergency department visits. Effective treatment of the polytrauma patient with cervical spine injury requires knowledge of cervical spine anatomy and the pathophysiology of spinal cord injury, as well as techniques for cervical spine stabilization, intraoperative positioning, and airway management. The orthopaedic surgeon must oversee patient care and coordinate treatment with emergency department physicians and anesthesia services in both the acute and subacute settings. Children are particularly susceptible to substantial destabilizing cervical injuries and must be treated with a high degree of caution. The surgeon must understand the unique anatomic and biomechanical properties associated with the pediatric cervical spine as well as injury patterns and stabilization techniques specific to this patient population.