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Spinal Injuries

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Introduction to Spinal Injuries

• Spinal Injuries are a considerable concern in a remote, industrial or hostile environment given not only the very serious consequences of such an injury but also:

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Introduction to Spinal Injuries

• the increased likelihood of spinal injury due to the prevalence of precipitating Mechanisms of Injury which (with the exception of vehicle accidents) are more commonly seen in these environments than in more domestic or urban settings.

• the implications and difficulties of extended care and a protracted evacuation from these environments.

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Introduction to Spinal Injuries

• The traditional approach of immobilising all suspected spinal injuries with Cervical Collar,  Spinal Board, Blocks and Straps has been the Gold Standard for at least 30 years but recently this dogma is being challenged with increasing momentum as erring on the side of caution may not, in fact, be as necessary or beneficial as once thought:

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Introduction to Spinal Injuries

• While any casualty with a suspected spinal injury is typically immobilised, only 0.5%-3% of these casualties are found to have unstable spinal injury or injury to the spinal cord.

• Of those fractures causing SCI, half involve fractures of the cervical spine, with 37% due to thoracic spine injury and 11% lumbar spine.

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Issues

• Spinal Boards are an extrication device and not a stretcher.  

• Due to the risk of pressure sores, the casualty should be on one for no more than 30 minutes (possibly extended with padding).

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Issues

• Once immobilised a clinician will be unwilling to ‘clear’ a spinal injury until satisfied by not only X-Ray but also CT scanning once in the ED.  How long will your casualty be immobilised for whilst waiting for help and during transit?

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Issues

• Spinal boards increase the risk of aspiration on vomit, potentially reduces airway opening and reduce respiratory efficacy (by an average of 15% on average).  These issues challenge the pre-hospital axiom of ‘airway before injury’ “...the possibility that immobilisation may increase mortality and morbidity cannot be excluded.”

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Issues

• To position a casualty on a spinal board requires log-rolling the casualty to 90 on ⁰their side.  This practice does not limit lateral movement of the casualty and can destabilize clots in the hypotensive casualty

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Issues

• Cervical Collars are not a panacea and come with their own issues including difficulty in application due to aggressive / combative casualties or bulky clothing, difficulty in correct sizing leading to ineffective immobilisation, potentially forced extension of the spine and increased intracranial pressure.

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Issues

• Spinal boards do not provide the immobilisation commonly believed, with Vacuum Mattresses being significantly more effective and without the associate time-bound issues.

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Issues

• Kinematic research shows that the damage done but reasonable movement of a casualty during care is negligible to that of the forces involved in the initial injury which ‘is generally not sufficient to cause further damage’.  Furthermore, the alert patient will probably develop a position of comfort with muscle spasm protecting a damaged spine.

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Issues

• A 2009 review concluded that the alert, cooperative patient does not require immobilisation even if a clinical decision rule is positive; unless their conscious level deteriorates as muscle spasm is a superior method to an artificial procedure.

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Issues

• Despite the low incidence of Spinal or Spinal Cord Injury and the potential issues with unnecessary and/or prolonged Immobilisation, because of the extreme consequences of a mis-diagnosed or mismanaged casualty as well as the potential litigious costs  it is understandable that there is reluctance to apply a more relaxed approach.

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Issues

• Structured guidance would allow the pre-hospital practitioner to make an informed decision which provides best care for the casualty with a suspected spinal Injury whilst negating the need to immobilise those at low risk.

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The Method

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High Risk Mechanism of Injury?• A fall from greater than 3 feet or 5 stairs• A vertical load to the spine (e.g. diving)• A motor collision at more than 60mph

Is the casualty;• Under 16 years or over 65 years?• Intoxicated• Confused, disorientated, or with inappropriate / slurred

speech?

Pain?• Do they have midline spinal pain anywhere along the

length of their spine?

Distracting Injury / Loss of Feeling • Do they have any other significant injury?• Do they have loss of feeling or pins and needles any

where?

NO

NO

NO

IMMOBILISE

YES

YES

YES

YES

DO NOT IMMOBILISENO