Cervical spine immobilization in penetrating cervical trauma is associated with an increased risk of indirect central neurological injury

Abstract

This study hypothesized that cervical spine immobilization (CSI) in penetrating cervical trauma is associated with increased central neurologic injury rather than prevention. Data abstraction proceeded from a previously constructed patient database formed via retrospective chart analysis of the trauma registries of two independent American College of Surgeons verified Level 1 Trauma centers. Neurologic injuries were categorized as peripheral or central. Central neurologic injuries were further subdivided into spinal cord and brain injuries. Patients were grouped according to the presence and type of neurologic injury, the presence and type of cervical spine fracture, death, and the presence or absence of respiratory and vascular injury. Vascular injury was further subdivided into major and minor categories. Groups were compared statistically. Significance was accepted for p<0.05. Cervical spine fracture (CSFx) was a significant risk factor for cervical spinal cord injury (CSCI) (p<0.00001; RR 20.56; 95% CI 8.44-26.47) but all patients with unstable CSFx presented with complete spinal neurologic devastation. Major vascular injury was associated with brain injury (p=0.01; RR 10.21; 95% CI 6.67-15.65) but was not associated with CSCI (p=0.99) or CSFx (p=0.67). Hypoperfusion was a strong independent risk cervical cord and brain injury (p<0.00001; RR 38.4; 95% CI 16.17-91.2). CSI was a significant risk factor for indirect central neurologic injury (p<0.001; RR 1.63; 95% CI 1.23-1.95). Brain injury was not associated with CSFx (p=0.35) or CSCI (p=0.08). No benefit of CSI in penetrating cervical trauma could be determined from this study. CSI entailed an absolute risk increase for central neurologic injury of 18.69% with a 5.3 number needed to harm (NNH).

Practices of Adult Spine Immobilization During Trauma Resuscitation: Proposal for Improved Guidelines

“…Nine studies were included that investigated the impact of spine immobilization practices during resuscitation in trauma patients with suspected or confirmed spinal injury on clinical outcomes. [9][10][11][12][13][14][15][16][17] Studies were categorized into two groups (A and B) based on the immobilization status of their study population. Of these studies, three in group A compared outcomes in patients with and without cervical spine immobilization, 12,13,15 and the other three in group A evaluated the impact of cervical spine immobilization on outcomes, 14,16,17 and three in group B evaluated outcomes in patients who had missed cervical spine injuries without immobilization.…”

“…[9][10][11][12][13][14][15][16][17] Studies were categorized into two groups (A and B) based on the immobilization status of their study population. Of these studies, three in group A compared outcomes in patients with and without cervical spine immobilization, 12,13,15 and the other three in group A evaluated the impact of cervical spine immobilization on outcomes, 14,16,17 and three in group B evaluated outcomes in patients who had missed cervical spine injuries without immobilization. [9][10][11] For patient populations and injuries, two studies looked at patients with penetrating injuries, 13,16 one evaluated patients with traumatic brain injuries (TBI), 14 one evaluated patients following motorcycle-related injuries, 15 and one looked at older adult (≥60) patients.…”

“…Of these studies, three in group A compared outcomes in patients with and without cervical spine immobilization, 12,13,15 and the other three in group A evaluated the impact of cervical spine immobilization on outcomes, 14,16,17 and three in group B evaluated outcomes in patients who had missed cervical spine injuries without immobilization. [9][10][11] For patient populations and injuries, two studies looked at patients with penetrating injuries, 13,16 one evaluated patients with traumatic brain injuries (TBI), 14 one evaluated patients following motorcycle-related injuries, 15 and one looked at older adult (≥60) patients. 17 Group A: Trauma Patients with Cervical Immobilization Three studies compared outcomes in patients with cervical spine injuries treated either with or without immobilization.…”

“…(Figure 3(A) and (B)) 15 The other three studies in this group evaluated the impact of having a cervical spine collar on clinical outcomes. Among these, three studies evaluated inhospital mortality, 14,16,17 two studies evaluated incidence of neurological deficits, 16,17 and one study each evaluated discharge disposition, 17 long-term functional recovery, 14 and the incidence of vascular and respiratory injuries. 16 In Jung et al, the authors assessed the effect of immobilization on mortality and functional outcomes via the modified Rankin scale in patients with TBI and evaluated how these were associated with mean arterial pressure (MAP) measured in the field (Table 1).…”

Is our current method of cervical spine control doing more harm than good?

“…Three of these patients (both carotid injuries and the central cord syndrome) had been given CSI, and the authors stated that CSI was associated with an increased risk of neurological injury (relative risk 1.635, p < 0.001; 95% CI, 1.23-1.95). 27 Brown et al examined two datasets of patients with gunshot wounds to the torso -357 patients from the trauma registry of the Strong Memorial Hospital, New York State, USA between 2003 and 2007 and 75,210 patients from the American National Trauma Databank from 2001 to 2005. It concluded that pre-hospital spinal immobilisation was not effective for patients with gunshot wounds to the torso due to the relative rarity of an unstable spinal fracture without spinal cord injury, and the fact that spinal cord injuries in trauma due to gunshot wounds are more likely due to direct injury to the cord from the bullet rather than fracture of the surrounding vertebrae.…”