C spine immobilisation - the evidence

1. C-Spine
Immobilisation in
Trauma: Is it all it
is cracked up to
be?
Colleen Taylor
CME
12th December 2013

2. Aims and Objectives
Why do we immobilise the c-spine in
trauma?
Why has this been under scrutiny?
So what should I do?

3. 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 212%(2-4)
 Missing unstable c-spine fractures can have severe
physical, social and economic complications

4. 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)

5. 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)

6. 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)

7. 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)

8. 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)

9. So Why Think About It?
 C-spine immobilisation can cause significant
complications, often within 48-72 hours

10. 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

11. 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

12. 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)

13. 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

14. 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

15. 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!

16. 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!

17. 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

18. References
1)
2)
3)
4)
5)
6)
7)
Committee on Trauma, American College of Surgeons (2008). ATLS: Advanced
Trauma Life Support Program for Doctors (8th ed.). Chicago: American College of
Surgeons
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.
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.
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.
Milby AH, Halpem CH, Guo W and Stein SC. . Prevalence of cervical spinal injury in
trauma. Neurosurg Focus. 2008;25(5):E10.
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.
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.

19. References
8.
9.
10.
11.
12.
13.
14.
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.
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
9) Barney RN, Cordell WH, Miller E: Pain associated with immobilisation on rigid
spine boards. Ann Emerg Med 1989, 18:918.
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.
Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure.
Injur. Anaesthesia. 1996; 27: 647–9.
Morris CGT and McCoy E. Cervical immobilisation in ICU: friend or foe?.
Anaesthesia. 2003. 58; 11: 1051–1053
Kosiak M: Etiology of decubitus ulcers. Arch Phys Med Rehabil 1961, 42:19-29.