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

Abstract

Introduction: Early cervical spine immobilisation has long been considered the standard of care in the management of trauma patients with suspected spinal cord injury. There has been conflicting evidence regarding its benefits and risks. This article reviews the current literature and whether the continued use of routine cervical spine immobilisation is still appropriate in modern trauma care. Method: A literature search was conducted using the Medline PubMed, Google Scholar and Cochrane Library online databases. The searches were limited to full text, English language studies conducted on adults in the last 20 years (July 1997 to July 2017). Results: The entrenchment of cervical spine immobilisation in trauma management is multifactorial. In the pre-hospital setting, immobilisation is recommended whilst awaiting full assessment. Fear of missed diagnoses of spinal injuries encourages defensive medicine and over-immobilisation. Effective cervical spine immobilisation is appropriate in certain cases and reduces the risk of further spinal cord injury. However, research has shown that we are over-immobilising, and in penetrating trauma, cervical spine immobilisation increases the risk of mortality. Conclusions: The practice of routine cervical spine immobilisation for trauma patients is outdated, ineffective and results in iatrogenic injury. Routine cervical spine immobilisation is not backed up by robust evidence. It has been clearly shown that in cases of penetrating spinal injuries, cervical spine immobilisation is not only ineffective but is also linked to an increased risk of mortality. Special considerations must also be taken in patients who have pre-existing spinal conditions, impending airway compromise, or at risk of aspiration and those with head injuries or suspected traumatic brain injuries. A selective approach to cervical spine immobilisation is recommended and should be reserved for cases deemed high risk rather than a standard rule for all trauma patients.

Comparison of different techniques for prehospital cervical spine immobilization: Biomechanical measurements with a wireless motion capture system

“…However, several studies have pointed out possible side effects of a rigid neck brace, such as difficult airway management [ 12 ], cranial pressure due to drainage obstruction [ 13 ], or lack of patient compliance. Therefore, Phaly et Khan [ 14 ] recommended performing cervical spine immobilization only in patients who are considered particularly high-risk. Uzun et al [ 15 ] showed that headblocks and various harness systems may also effectively reduce range of motion.…”

How to deliver an effective primary survey report for the trauma CT: A radiological and surgical perspective

“…In reality however, a more pragmatic approach is often required, particularly in patients with pre-existing spinal conditions, head injury and those at risk of airway compromise or aspiration. 44…”

“…In reality however, a more pragmatic approach is often required, particularly in patients with pre-existing spinal conditions, head injury and those at risk of airway compromise or aspiration. 44 Awareness of the presence of significant spinal injury is useful at the primary survey as the injury pattern may suggest a constellation of further injuries, for example blunt cervical vascular injury, requiring further assessment with CT angiogram and retroperitoneal injury with thoracolumbar Chance-type fracture following lap-belt injury. 45,46 The presence of a rigid spine for example in a patient with ankylosing spondylitis is also worth noting, since this will be more likely to sustain a hyperextension/flexion injury.…”

Manual in‐line stabilisation during tracheal intubation: effective protection or harmful dogma?

“…Pre-hospital spinal immobilisation is one such example of this. Like MILS, there is a lack of evidence supporting its efficacy in preventing secondary spinal cord injury and yet this practice is entrenched in trauma practice despite being associated with adverse effects and iatrogenic injury [21,22]. There is now a slow movement towards change in this regard, with some organisations now recommending more selective approaches to the use of spinal immobilisation, especially in cases of penetrating trauma [23,24].…”