C-Spine Immobilisation in Trauma: Is it all it is cracked up to be?

Colleen Taylor

CME

12th December 2013

Aims and ObjectivesWhy do we immobilise the c-spine in trauma?

Why has this been under scrutiny?So what should I do?

Evidence for C-Spine Immobilisation in Trauma

C-spine immobilisation in trauma has been standard teaching in trauma courses for the last 30 years

"The staff must be continually cognizant that injudicious manipulation or movement, and inadequate immobilisation can cause additional spinal injury and decrease the patient's overall prognosis” ATLS(1)

Figures quoted for c-spine injury in polytrauma range from 2-12%(2-4)

Missing unstable c-spine fractures can have severe physical, social and economic complications

Evidence for C-Spine Immobilisation in Trauma High risk factors:- Head injury: relative risk of 8.6(6)

- Reduced GCS: The prevalence in alert patients of c-spine injury was 2.8%, whereas un-evaluable patients have a prevalence of 7.7%(5)

- Penetrating neck trauma- Mechanism (fall from > 3feet, axial loading, MVA >100km,

MVA with rollover/ejection, motorised recreational vehicle)

So Why Think About It? Contradictory evidence regarding secondary c-spine injury:- One study suggested only 20% of patients with a c-spine

injury actually have a spinal cord injury(6)

- Retrospective study comparing neurological outcome in patients with a cervical spine injury who were immobilised versus not immobilised showed no difference in outcome(7)

So Why Think About It? Another retrospective study suggests that only 0.03% to 0.16% of all

out-of-hospital trauma patients may be expected to have secondary injury, with the minimum number of indiscriminately immobilized patients needed to prevent one secondary injury is thus likely between 625 and 3333 trauma patients(6)

In a multi-centre study of more than 30,000 patients with penetrating trauma, 443 (1.43%) had spine fractures, and 116 (0.38%) had unstable spine fractures. Of those with unstable spine fractures, 86 (74%) had completed spinal injuries prior to immobilization. The authors concluded that in order to potentially benefit one person with spinal immobilization, 1,032 people would have to be immobilized. But in order potentially harm/contribute to one death, just 66 would have to be(8)

So Why Think About It? Does c-spine immobilisation actually reduce movement?- Collars are often poorly fitted and poorly tolerated.

Inappropriately sized or applied collars exaggerate vertebral mal-alignment

- Collars may actually promote paradoxical motion of vertebrae

- Even correctly fitted collars allow over 30° of flexion/extension and rotation(9)

So Why Think About It? Spinal boards are uncomfortable!- 21% of patients with cervical spine pain and 33% of patients

with lumbar spine pain while immobilised on a long board experienced complete resolution of their symptoms once removed from the board(10)

So Why Think About It? C-spine immobilisation can cause significant complications,

often within 48-72 hours

C-Spine Immobilisation and Raised ICP Postulated that c-spine collars restrict venous drainage from

the brain and increase ICP Evidence suggests that on average they raise ICP by

4.6mmHg(11, 12) and the higher the baseline ICP, the greater the increase(11)

Given that CPP = MAP-ICP, may worsen neurological outcome and promote secondary neurological injury

Airway Compromise and C-spine Immobilisation Makes airway management more difficult- Several studies have shown that 7 to 28% of patients with

trauma require definitive airway management(13)

- Airway obstruction is a preventable cause of trauma-related deaths

- The presence of c-spine precautions limits airways manoeuvre's and increases difficulty of visualisation of vocal cords

Ulceration from C-Spine Immobilisation

Pressure necrosis leads to ulceration, infection, and ultimately sepsis

Experimental studies have suggested that a constant pressure of 70 mm Hg for more than two hours produces tissue ischaemia and irreversible tissue damage(13)

Prolonged collar use in unconcious patients can cause decubitus ulceration in up to 31% of patients(14)

So Why Don’t we Just Collar Every Trauma? - Difficult central venous cannulae insertion and increased risk

of line-associated bacteraemia- Increased risk of pulmonary thromboembolism  - Increased risk of infection including ventilator-associated

pneumonia- High staffing requirements

So Why Don’t we Just Collar Every Trauma? - Increased intracranial pressure - Makes airway management more difficult- Difficult central venous cannulae insertion - Increased risk of pulmonary thromboembolism - Pressure necrosis leading to ulceration, infection and sepsis

 - Increased risk of infection including ventilator-associated

pneumonia, line-associated bacteraemia- High staffing requirements

So What Does the Evidence Say? A Cochrane review in 2009 which set out to look at the

evidence for spinal immobilisation in trauma (including traditional immobilisation vs no immobilisation) found NO RCT’s!

So What Do I Do? Conscious patients: Canadian c-spine rules Obtunded patients- ? remove collars for intubated patients with possible head

injury General principles- Convert those who you are not able to clear clinically (e.g

intoxicated) into philly collar- ? Quicker consultant radiology reporting of CT- Any patient not tolerating c-spine precautions, remove them!

Summary C-spine fractures are rare but have potentially devastating

complications C-spine immobilisation has no evidence to suggest it is

effective in reducing the complications of c-spine fractures C-spine imobilisation can be detrimental to patients,

particularly those who are polytrauma patients with head injuries/requiring ICU

Lack of evidence makes decision-making difficult

References1) Committee on Trauma, American College of Surgeons (2008). ATLS: Advanced Trauma

Life Support Program for Doctors (8th ed.). Chicago: American College of Surgeons

2) MacDonald RL, Schwartz ML, Mirich D. Diagnosis of cervical spine injury in motor vehicle crash victims: how many X-rays are enough? J Trauma 1990;30: 392-7.

3) Chiu WC, Haan JH, Cushing BM, Kramer ME, Scalea TM. Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation and outcome. J Trauma 2001;50: 457-63.

4) Demetriades D, Charalambides K, Chahwan S, Hanpeter D, Alo K, Velmahos G, et al. Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. J Trauma 2000;48: 724-7.

5) Milby AH, Halpem CH, Guo W and Stein SC. . Prevalence of cervical spinal injury in trauma. Neurosurg Focus. 2008;25(5):E10.

6) Sundheim S and Cruz M. The Evidence for Spinal Immobilization: An Estimate of the Magnitude of the Treatment Benefit. Ann Em Med 2006; 48 (2): 217-218.

7) Hauswald M, Ong G, Tandberg D, Omar Z: Out-of-hospital spinal immobilisation: its effect on neurologic injury. Academic Emer Med 1998, 5(3):214-9.

References8. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma:

more harm than good? J Trauma, 2010; 68: 115–20, discussion 20–1.

9. James CY, Riemann BL, Munkasy BA, Joyner AB: Comparison of Cervical Spine Motion During Application Among 4 Rigid Immobilization Collars. J Athl Train 2004, 39(2):138-145

10. 9) Barney RN, Cordell WH, Miller E: Pain associated with immobilisation on rigid spine boards. Ann Emerg Med 1989, 18:918.

11. Hunt1, S. Hallworth1, M. Smith2. The effects of rigid collar placement on intracranial and cerebral perfusion pressure.Anaesthesia. Article first published online: 20 Dec 2001.

12. Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injur. Anaesthesia. 1996; 27: 647–9.

13. Morris CGT and McCoy E. Cervical immobilisation in ICU: friend or foe?. Anaesthesia. 2003. 58; 11: 1051–1053

14. Kosiak M: Etiology of decubitus ulcers. Arch Phys Med Rehabil 1961, 42:19-29.