C-spine Immobilisation and Clearance
Cervical collars have been used since the Vietnam War and after their implementation in the ATLS guidelines they have been considered the benchmark in trauma patients when there were any concerns about the C-Spine stability.
Studies about the real utility of these devices to date haven’t shown a clear benefit, mostly of them have been poorly conducted with a limited number of patients due to the potential catastrophic consequences of secondary spinal injuries. Subsequently the pre-hospital and intra-hospital management hasn’t changed for years.
So, collars have been introduced to prevent secondary injury to the spinal cord but what does the literature say about this practice? Are they really game-changing?
In a recent review by OTO (2015), the authors reviewed the published literature from 1979 till 2013 and they concluded that the cause of deterioration of the 24 c-spine injuries in a total of 12 different studies, were non specific and more importantly not care related.
They identified 3 categories of high- risk patients for secondary deterioration after c-spine trauma:
- altered mental status
- ankylosing spondylitis
- iatrogenic manipulation.
And their conclusion about Secondary injury was mostly linked to:
- but NOT care related.
So, we don’t have a clear demonstration of their utility but what about their potential harm?
What we know so far……
- increased intracranial pressure by reducing the venous drainage ( up to 4.5 mmHg)
- aspiration/ respiratory compromise
- limiting mouth opening. More difficult airway management.
- pain from local ischaemia
- hiding other injuries
- delays in transport
In this review by Benger (2009), the authors discuss the drawbacks associated with collars and immobilisation devices and suggest not to use them in co-operative patients even if an underlying cervical spine fracture is suspected for these reasons:
- Unstable C-spine injuries in awake and co-operative patients are rare (UK 10-15 per million per year spinal cord trauma. Half of them are cervical #).
- Unlikely, in awake patients, further movement will cause more harm than the initial force which created an unstable injury.
- Often cervical collars are poorly applied and even if well fitted, they don’t avoid neck movements (30 degrees flexion and extension are still permitted).
- Potential harms discussed previously.
Moreover in patient with a penetrating cervical trauma we already know the harms caused by general immobilisation hence the cervical collar must be avoided. Once of the most representative studies about this topic was published by Haut (2010). A retrospective analysis of penetrating trauma patients.
Primary outcome: mortality. Calculated NNT and NNH for spine immobilisation.
Total of 45,284 pts.
4.3% underwent spinal immobilisation. Overall mortality 8.1%
OR of death 2.06 if immobilised (95% CI: 1.35-3.13)
Evidence Surround C-Spine Clearance
In 2000 Hoffman et al published the NEXUS study (overall 34 069 blunt trauma patients).
Briefly, if patients meet all the 5 criteria, no imagining is needed and the C-spine can be cleared……..
In 2001, Stiell et al published a study which became famous as the Canadian C-Spine rule (CCR). (in total 8924 awake blunt trauma patients)……
In 2003 Stiell et al compared NEXUS vs CCR in a prospective cohort study (8283 patients) (12)
With CCR: 1 missed injury;
Nexus 16 missed injuries, 4 of which unstable
CCR was statistically more sensitive than the NEXUS in the detection of significant cervical spine injury.
C-spine Clearance and Guidelines
In 2009 the Eastern Association for surgery of trauma (EAST) published their guidelines about the management of cervical spine clearance in the traumatically injured patient.
The first edition can be easily summarised with these 4 points:
- In awake, non symptomatic patients the c-spine can be cleared following the NEXUS criteria.
- MDCT scan has got Class I Level I evidence of being superior to cervical x-ray.
- In obtunded patients or awake but symptomatic a MRI should be done
- Hard collar should be removed within 72 hrs and avoid prolonged immobilisation
There has been a long debate about the superiority of MRI towards CT.
Several studies and meta-analysis failed to highlight any superiority of the former.
Finally, BADHIVALA (2015) completed a systematic review of 28 observational studies (3627 patients with blunt trauma and obtunded) 20 retrospective cohort and 8 prospective (0% significant injuries missed if CT negative).
The conclusion was: WELL-INTERPRETED AND HIGH-QUALITY SCAN can avoid prologued collar use and routine adjust images
Primary outcome: clinically significant (mechanical instability) c-spine injuries missed by CT scan and detected with other tests.
Limits: retrospective studies. Only in English. No paeds.
Morevoer, CCT requires less time to complete the exam and there is an all in all reduction of costs!
In September 2015, EAST published the updated guidelines for C-spine clearance in obtunded patients. The conditional recommendation is to clear the c-spine in the obtunded patient who sustained blunt trauma after a negative MDCT alone. (conditional due to the very low-quality evidence).
They based their suggestion on a Systematic Review. The lack of RCT and complete cohort study designs was stressed out
Of 52 studies identified, only 12 were included in the qualitative synthesis and data extraction. Of 5 articles with a total follow-up of 1,017 patients none reported changes after collar removal. Of 11 studies with a total of 1,718 patients, no unstable c-spine fracture missed.
NPP MDCT 100% for unstable injury
91% any stable injury.
Their primary outcomes were new neurologic changes after cervical clearance and identification of an unstable injury.
Secondary ones: stable C-spine injury and their treatment, post-clearance imaging, false-negative CT, pressure ulcers and time to cervical removal
strenghts: multilevel systematic dual-review of the literature
limitations: low quality data and bias. Possible type II error (underpowered studies). Non homogeneous interpretation of the term obtunded.
If all the NEXUS criteria are met or the CCS is negative: clear the c-spine
If MDCT is negative, c-spine can be cleared even in the obtunded patients without requiring any other imaging.
Further information in February 2016 when NICE will publish the “Spinal Injury Assessment”guidelines.
- American College of Surgeons Committee on Trauma. ATLS–9th Edition 2012, American College of Surgeons, Chicago.
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