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Clinical Vignette: Cervical spine care:

Where is the line between more harm than good? Cervical spine care:

Clinical Vignette :Michael Barns. FdSc, MCPara, PHTC Paramedic

The management of suspected cervical spinal injury in the prehospital setting has remained unaltered for more than 30 years; however there is a growing consensus in current literature to suggest against the application of cervical spinal collars as a standardised immobilisation technique, such as the statement on behalf of The Royal College of Surgeons of Edinburgh (Connor et al, 2013). This case study highlights one such case, where the application of a cervical spinal collar would have been of greater detriment to the patient (both short term and long term) than utilising alternative techniques.

In the prehospital setting, application of a cervical spinal collar for all trauma patients is routine practice as a precautionary measure (Joint Royal Colleges Ambulance Liaison Committee, 2013). This is to limit the range of motion of any potentially unstable fractures, thereby protecting the spinal cord from further insult. However this application has been shown, in certain circumstances, to increase the overall risk of damage to both the brain and the spinal cord, either through an increased intracranial pressure, or further movement by an agitated patient. (Hunt, Hallworth & Smith, 2001). Patients who are combative or agitated, through either hypoxia, confusion or any other mechanism can prove difficult to immobilise. Forced restraint of the cervical spine has been shown to increase the risk of further insult to the spinal cord due to increased movement. (Joint Royal Colleges Ambulance Liaison Committee, 2013)

Case Description
I was recently involved in the treatment of a patient who had presented with a severe neurological deficit accompanying polytrauma, including a suspected fracture of the cervical spine. The patient was a young motorcycle rider, without protective equipment, involved in a road traffic collision. Evidence suggested an approximated impact of 40 miles per hour, colliding with the rear of a stationary vehicle.
This mechanism led to a suspected frontal skull fracture, suspected cervical spinal fracture, multiple rib fractures resulting in flail segments, pulmonary contusion secondary to truncal blunt force trauma, an open fracture of the right ulna and a suspected external rotation of the hemipelvis.
The patient had a Glasgow Coma Scale score of 8, consisting of no eye response (1), a verbal response of incomprehensible sounds (2) and a motor response localising painful stimuli (5). Due to the patient’s decreased level of consciousness, I protected the airway with the insertion of two nasopharyngeal airways and a jaw thrust maneuver. Oropharyngeal airway insertion stimulated the patient’s pharyngeal reflex, and so was promptly removed, to avoid any further airway issues. This reduction in the level of consciousness provided further clinical challenges in relation to cervical spine immobilisation, as the patient was combative to any attempts to apply a cervical spinal collar.
It was clear that without sedation, there would be no way of immobilising the cervical spine, increasing the risk of secondary insults to the spinal cord, due to the patient’s own movements, alongside any small movements caused by the transportation to definitive care. Due to this, the utilisation of an advanced paramedic, who was able to administer a sedative to the patient, was required to minimise the risk of secondary spinal cord insult. Unfortunately, this resource was not available for some time, requiring a difficult clinical decision to be made: apply a cervical spinal collar while using forced restraint of the patient, or to find a “best possible alternative” to minimise the movement of the cervical spine more than absolutely necessary.
I chose to postpone application of a cervical collar, opting instead to utilise manual in-line stabilisation, alongside the use of head blocks and an orthopaedic scoop. This allowed for minimal patient movement, due to a decrease in patient agitation when the cervical spinal collar was removed, while still providing stabilisation and immobilisation of the cervical spine.
Upon arrival at the emergency department, a rapid sequence induction was performed to gain a more definitive airway, while allowing for further diagnostic investigations to be prepared. Upon radiological investigation, the patient suffered two fractured cervical vertebrae, C5 and C6, with dorsal cord oedema causing compression of the spinal nerve. If a cervical spinal collar had been applied while using forced restraint, the patient would have caused more extensive damage to the spinal cord, dramatically decreasing both the survivability of his injuries and quality of life in the future.
This highlighted the importance of minimal cervical spinal movement in the prehospital setting, balancing the need to immobilise the cervical spine with a cervical spinal collar, with minimising the negative results of the application. We should be continually assessing the option resulting in the least possible cervical vertebral movement.

In a statement from the Royal College of Surgeons of Edinburgh, in which the Royal College reviewed the current evidence available on the practice of cervical spinal immobilisation in the prehospital setting, it is summarised that the potentially serious outcomes and the litigious nature of modern medicine have lead to an overly conservative approach to cervical spinal immobilisation. (Connor et al, 2013) However, in the prehospital setting, application of a cervical spinal collar for all trauma patients is still routine practice as a precautionary measure (Joint Royal Colleges Ambulance Liaison Committee, 2013).
There is mounting evidence to suggest against the use of cervical spinal collars in many scenarios, however in the prehospital setting, cervical spinal collars are still routinely applied to many patients, where manual in line stabilisation, or self immobilisation have been more appropriate.
There are ongoing debates regarding the effective usage of manual in-line stabilisation versus cervical spinal collar usage, however at the present the appropriateness of each technique is still lead by clinical judgement, as was shown in my own clinical case.
The growing concerns surrounding cervical spinal collar application cover 3 main aspects, which I will briefly explore:
1. Increases in intracranial pressure
2. Deterioration of respiratory function
3. Exacerbation of pre-existing spinal conditions
Firstly, the current literature has made clear that cervical collar application, even in short use, has a marked effect on intracranial pressure. (Ho et al, 2002) Intracranial pressure was shown to have a 4.6mmHg rise when a cervical spinal collar was applied, compared to without (Mobbs, Stoodley & Fuller, 2002), due to compression of the jugular vein by the cervical spinal collar. (Stone, Tubridy & Curran, 2010)
This well documented outcome should be considered when deciding if a cervical spinal collar is most appropriate, or if manual in-line stabilisation would be more advantageous to both clinician and patient.
Secondly, a reduction in respiratory function has been documented while placed in a cervical spinal collar, exacerbated more so when used in conjunction with spinal boards. (Totten & Sugarman, 1999), however this reduction is relatively small, and clinicians must balance the risks of functional respiratory reduction with the need to reduce movement of the cervical vertebrae in the safest possible manner.
Thirdly, the risk of exacerbation of conditions such as ankylosing spondylitis is extremely high, which has lead to detrimental neurological complications. (Clarke, James & Ahuja, 2010) In patients where a full medical history is unavailable, as is quite common in the prehospital setting, this is a hard consideration to be fully aware of. The safest clinical approach would be to continue to consider the application of a cervical spinal collar, until presented with clear information regarding the patient’s pre-existing medical conditions.
Manual in-line stabilisation has been shown in numerous studies to provide either equal (Crosby, 2016) or actually improved immobility of cervical vertebrae during airway management as a cervical spinal collar, while negating the well documented and discussed disadvantages of cervical spinal collar application. (Austin, Krishnamoorthy & Dagal, 2014)

While manual in-line stabilisation may have its own disadvantages, they are widely shared by any cervical spinal immobilisation technique, bolstering the argument that at times, manual in-line stabilisation may be more appropriate than cervical spinal collar usage. This however is extremely dependant on the specific circumstances of each patient, and a thorough assessment of each option should be undertaken before committing to each method of cervical spinal immobilisation.
Conclusion
With the large scale of evidence now available regarding the advantages and disadvantages of cervical spinal collar application, I believe a individualised, tailored approach to prehospital cervical spinal immobilisation should be utilised, as opposed to standardised cervical spinal collar usage. The decision as to which method of cervical spinal immobilisation used should be dictated by the specific circumstances of each patient, the limitations presented by their injuries, their past medical history, and the environment.

References

  • Connor et al.. (2013). Pre-hospital Spinal Immobilisation: An Initial Consensus Statement. Emergency Medical Journal, 30(12), 1067-1069.
  • Joint royal colleges ambulance liaison committee , J.R.C.A.L.C. (2013). UK Ambulance Services Clinical Practice Guidelines 2013. (4th ed.). England: Class Professional Publishing.
  • Hunt, K, Hallworth, S & Smith, M. (2001). The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia, 56(6), 511-513.
  • Joint royal colleges ambulance liaison committee , J.R.C.A.L.C. (2013). UK Ambulance Services Clinical Practice Guidelines 2013. (4th ed.). England: Class Professional Publishing.
  • Ho et al.. (2002). Rigid cervical collar and intracranial pressure of patients with severe head injury. The Journal of Trauma, 53(6), 1185-1188.
  • Mobbs, R, Stoodley, M & Fuller, J. (2002). Effect of cervical hard collar on intracranial pressure after head injury. ANZ Journal of Surgery, 72(6), 389-91.
  • Stone, M, Tubridy, C & Curran, R. (2010). The effect of rigid cervical collars on internal jugular vein dimensions. Academic Emergency Medicine, 17(1), 100-102
  • Totten, V & Sugarman, D. (1999). Respiratory effects of spinal immobilization. Prehospital Emergency Care, 3(4), 347-352.
  • Clarke, A, James, S & Ahuja, S. (2010). Ankylosing spondylitis: inadvertent application of a rigid collar after cervical fracture, leading to neurological complications and death. Acta Orthopaedica Belgica, 76(3), 413-415.
  • Austin, N, Krishnamoorthy, V & Dagal, A. (2014). Airway management in cervical spine injury. International Journal of Critical Injuries and Injury Science, 4(1), 50-56.
  • Crosby, E. (2016). Airway management in adults after cervical spine trauma. Anaesthesiology, 104(6), 1293-1318.

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