Lesson of the week: Exacerbating cervical spine injury by applying a hard collar

Papadopoulos, Marios C.; Chakraborty, Anita; Waldron, George W.; Bell, B. Anthony

doi:10.1136/bmj.319.7203.171

Cited by 54 publications

(32 citation statements)

References 9 publications

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“…Worsening of neurological function due to inadequate immobilization, inconsiderate transfers or application of a hard collar on the cervical spine with pre-existing kyphotic deformity was reported in several articles [68,74,89,122]. Compared to studies describing (healthy and considerably younger) individuals sustaining traumatic spine fractures where only 0.08% of the patients deteriorated in neurological function, these numbers are of major concern [124].…”

Section: Discussionmentioning

confidence: 99%

Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications

2008

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The ankylosed spine is prone to fracture after minor trauma due to its changed biomechanical properties. Although many case reports and small series have been published on patients with ankylosing spondylitis (AS) suffering spine fractures, solid data on clinical outcome are rare. In advanced diffuse idiopathic skeletal hyperostosis (DISH), ossification of spinal ligaments also leads to ankylosis. The prevalence of AS is stable, but since DISH may become more widespread due to its association with age, obesity and type 2 diabetes mellitus, a systematic review of the literature was conducted to increase the current knowledge on treatment, neurological status and complications of patients with preexisting ankylosed spines sustaining spinal trauma. A literature search was performed to obtain all relevant articles concerning the outcome of patients with AS or DISH admitted with spinal fractures. Predefined parameters were extracted from the papers and pooled to study the effect of treatment on neurological status and complications. Ninety-three articles were included, representing 345 AS patients and 55 DISH patients. Most fractures were localized in the cervical spine and resulted from low energy impact. Delayed diagnosis often occurred due to patient and doctor related factors. On admission 67.2% of the AS patients and 40.0% of the DISH patients demonstrated neurologic deficits, while secondary neurological deterioration occurred frequently. Surgical or nonoperative treatment did not alter the neurological prospective for most patients. The complication rate was 51.1% in AS patients and 32.7% in DISH patients. The overall mortality within 3 months after injury was 17.7% in AS and 20.0% in DISH. This review suggests that the clinical outcome of patients with fractures in previously ankylosed spines, due to AS or DISH, is considerably worse compared to the general trauma population. Considering the potential increase in prevalence of DISH cases, this condition may render a new challenge for physicians treating spinal injuries.

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Section: Discussionmentioning

confidence: 99%

Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications

2008

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“…Yet, some patients, who were presumably cared for in an appropriate manner, have presented to hospital emergency departments with neurologic injuries believed to have been caused or exacerbated by actions taken during the early stages of management. 22,23 The intimation that interventions designed to minimize the risk of neurologic deterioration may be more perilous than previously thought has brought into question the relative safety of many procedures used in the prehospital management of spine-injured patients. As a result, researchers [7][8][9][10][11][12][24][25][26][27][28][29][30][31][32][33][34] have expressed considerable interest in assessing the effectiveness of these procedures, which include airway management protocols, spinal stabilization strategies, procedures for removing protective sporting equipment, and spine-board transfer techniques.…”

Section: Discussionmentioning

confidence: 99%

The 6-Plus–Person Lift Transfer Technique Compared With Other Methods of Spine Boarding

Rossi

Horodyski

Conrad

et al. 2008

Journal of Athletic Training

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NYContext: To achieve full spinal immobilization during on-thefield management of an actual or potential spinal injury, rescuers transfer and secure patients to a long spine board. Several techniques can be used to facilitate this patient transfer.Objective: To compare spinal segment motion of cadavers during the execution of the 6-plus-person (6+) lift, lift-and-slide (LS), and logroll (LR) spine-board transfer techniques.Design: Crossover study. Setting: Laboratory.Patients or Other Participants: Eight medical professionals (1 woman, 7 men) with 5 to 32 years of experience were enlisted to help carry out the transfer techniques. In addition, test conditions were performed on 5 fresh cadavers (3 males, 2 females) with a mean age of 86.2 6 11.4 years.Main Outcomes Measure(s): Three-dimensional angular and linear motions initially were recorded during execution of transfer techniques, initially using cadavers with intact spines and then after C5-C6 spinal segment destabilization. The mean maximal linear displacement and angular motion obtained and calculated from the 3 trials for each test condition were included in the statistical analysis.Results: Flexion-extension angular motion, as well as anteroposterior and distraction-compression linear motion, did not vary between the LR and either the 6+ lift or LS. Compared with the execution of the 6+ lift and LS, the execution of the LR generated significantly more axial rotation (P 5 .008 and .001, respectively), more lateral flexion (P 5 .005 and .003, respectively), and more medial-lateral translation (P 5 .003 and .004, respectively).Conclusions: A small amount of spinal motion is inevitable when executing spine-board transfer techniques; however, the execution of the 6+ lift or LS appears to minimize the extent of motion generated across a globally unstable spinal segment.Key Words: prehospital care, spine injuries, spinal immobilization, logroll transfer technique, lift-and-slide transfer technique Key Points N The 6-plus-person lift and lift-and-slide transfer techniques appeared to minimize the motion generated across an unstable spinal segment.N Significantly more lateral flexion and axial rotation was generated with the logroll maneuver than with the lift-and-slide and 6-plus-person lift techniques.

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“…It is important that the neck is maintained in a flexed position until definitive treatment. There are many reports of such patients sustaining neurological injury or exacerbation of existing deficits not only as a result of hyperextension in a rigid collar [75,76] or following inadvertent extension of the neck during positioning on an ambulance trolley, but also during transferring to a scanner gantry when undergoing CT or MR examinations [40]. Conventional positioning on a gantry forces the neck into neutral or slight extension similar to being on a spinal board, potentially leading to sudden and devastating neurological consequences [40].…”

Section: Treatmentmentioning

confidence: 98%

“…However, a safe spinal alignment is often difficult to maintain when the spine is rigid as in patients with AS [40,73,74]. Most cervical spine injuries in AS are due to hyperextension forces, and maintaining patients with an ankylosed spine on a blackboard with a hard collar has the effect of forcing the neck into extension, which can act like an opening wedge osteotomy, displacing the fracture, and exposing the spinal cord to further risk of deterioration [40,75,76]. A conscious patient should be able to guide the initial response team on a comfortable position, which is often a slightly flexed position of the neck with the head supported on pillows.…”

Section: Treatmentmentioning

confidence: 99%

Spinal fractures in patients with ankylosing spondylitis

Leone¹,

Marino²,

Dell'atti³

et al. 2016

Rheumatol Int

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The ankylosed spine is prone to fracture even after minor trauma due to its changed biomechanical properties. The two central features of ankylosing spondylitis (AS) that promote the pathological remodeling of the spine are inflammation and new bone formation. AS is also associated with osteoporosis that is attributed to an uncoupling of the bone formation and bone resorption processes. Therefore, bone resorption occurs and promotes weakening of the spine as well as increased risk of vertebral fractures which can be hugely different in terms of clinical relevance. Even in the presence of symptomatic clinical vertebral fractures, the diagnosis can be overruled by attributing the pain to disease activity. Furthermore, given the highly abnormal structure of the spine, vertebral fracture diagnosis can be difficult on the basis of radiography alone. CT can show the fractures in detail. Magnetic resonance imaging is considered the method of choice for the imaging of spinal cord injuries, and a reasonable option for exclusion of occult fractures undetected by CT. Since it is equally important for radiologists and clinicians to have a common knowledge base rather than a compartmentalized view, the aim of this review article was to provide the required clinical knowledge that radiologists need to know and the relevant radiological semiotics that clinicians require in diagnosing clinically significant injury to the ankylosed spine.

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Lesson of the week: Exacerbating cervical spine injury by applying a hard collar

Cited by 54 publications

References 9 publications

Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications

Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications

The 6-Plus–Person Lift Transfer Technique Compared With Other Methods of Spine Boarding

Spinal fractures in patients with ankylosing spondylitis

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