Spinal Immobilisation

DEFINITION
This card discusses spinal immobilisation in trauma patients
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INCIDENCE
Cervical spine is injured in 2-12% of patients with blunt polytrauma.
Injuries of head and neck are associated 1/3 of the time.

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AETIOLOGY
Trauma.
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BIOLOGICAL BEHAVIOUR
Spinal immobilisation aims to avoid displacing potentially unstable spinal injuries with resultant nerve damage.
Before modern trauma management, missing diagnoses of spinal injuries increased risk of permenant neurological sequelae 10 times.


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MANIFESTATIONS
Presence of head injury confers RR for spinal injury of 8.5.
- and may prevent good examination.

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MANAGEMENT
Assume injury until proven otherwise.

Conscious
Regard spine as stable if ALL of:
1. GCS 15, alert and oriented
2. No intoxicant taken.
3. No serious distracting injuries
4. No signs or syptoms of cervical injury: eg midline tenderness / pain, impaired ROM, neurolgical deficit.
Mobilise under close supervision.

Impaired Consciousness
Spinal injury cannot be exlcluded clinically.
Can either:

1.  Immobilise until consciousness returns
- this has serious complications if prolonged
- removal of immobilisation should be a priority.
- risk of still missing injury clinically perhaps 2%
- appropriate if non-intubated / non-ICU pt, who will not have prolonged immobilisation.

2.  Rely on imaging
Do this in any ICU or intubated patient.
- three view cervical (AP, lateral, open mouth if possible)
- must visualise entire C-spine.
- thoracolumbar AP
- high-res CT (1.5-2mm) craniocervical jx and other suspicious / inadequate areas.

It was traditionally thought ligamentous injuries may be missed with this regiment.
- modern studies show sensitivity >99%.
- probably 99.9% (level 2-3 evidence).
- several large studies support this (BMJ review)
- MRI equally sensitive but unnecessary.
- should really routinely CT entire C-spine at high-res, as no needed to investigate only 8-22 for finding a further injury. (level 2-3 evidence).

Dynamic XRs (flexion/extension views) are unnecessary
- do not add significantly to sensitivity which is already high.
- no. needed to investigate is >500 for 1 further injury.
- false negative (0.33%) near twice as common as true positive.

Myths are widespread:
- >12% of clinicians think XR alone excludes cervical injury (it doesn't).
- >12% of clinicians will clear an unconscious pts c-spine with plain lateral XR (they shouldn't as sensitivity only ~85%).

Complications of Prolonged Immobilisation
Ignored at peril
- 60% orthopaedics specialists think this is of no concern (it certainly is).
Pressure ulceration.
- occurs in 55%, esp after 48 hrs.
- massive morbidity problem if occurs
Elevated ICP
- via venous obstruction
- may worsen brain injury
Difficult airway
- loss of patency
- failed intubation
Difficult CVL access
Mouth access
- poor oral hygeine, risk of septic focus
- difficult enteral nutrition
GI effects
- reflux, aspiration promoted.
Immobility risks
- restricts physio
- risk of DVT



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