Spinal Trauma: The Legend of the C-Spine Collar - A Case Report

Editor's Notes

• #7: Can anyone describe this xray? There are fractures through C7 and T1 spinous processes.
• #8: Can anyone describe this xray? In addition, there is a wedge compression fracture of T7 vertebral body, with 35% anterior vertebral body height loss. See CT cervicothoracic spine for further details.
• #9: There is little population-based data concerning fracture rates in Australia. SCIs are a major cause of morbidity and mortality for skiiers and snowboarders. One nationwide inpatient sample 200-2008 demonstrated 8634 patients presented with spinal injuries. Another large tertiary centre study carried out in July 200-2006 showed 728 SCIs with severe SCI (Fracture – subluxation/dislocation found in 73 patients. From a paper on thoracic and lumbar spine fractures associated with skiing thoracic ocmpression injuries accounted for 94.7% [1] Sanders KM1, Seeman E, Ugoni AM, Pasco JA, Martin TJ, Skoric B, Nicholson GC, Kotowicz MA. Age- and gender-specific rate of fractures in Australia: a population-based study. Osteoporosis International. 1999; 10 (3) 240-7 [2] Hubbard M.E., Jewell R.P., Dumont T.M., Rughani A.R. (2011). Spinal injury patterns among skiers and snowboarders. Neurosurgical FOCUS. Nov 2011; 31: 5
• #10: It is important with any patient with this mechanism of action to have a high index of suspicion and understand the architecture / anatomy of the spine. This will allow a better understanding of the classification of fracture and whether the fracture is stable or unstable. The spinal column has three main sections-the cervical spine, the thoracic spine, and the lumbar spine.
• #11: It is worth noting: normally the cervical spinal nerves are named for the vertebra that they emerge under; T9 spinal nerve emerges in the intervertebral foramen between T9 and T10 the first cervical spinal nerve (C1/sub-occipital nerve) emerges above C1 vertebra (actually between the skull and C1) therefore C7 spinal nerve emerges above the C7 vertebra and the C8 spinal neve emerges below the C7 vertebra C1 is the Atlas C2 is the Axis Transverse Process Spinous Process Body of the vertebrae The cervical vertebrae allow greater range of motion than all the other vertebrae. Each vertebra has several important parts: the body, vertebral foramen, spinous process, and transverse process. The body is the main weight-bearing region of a vertebra, making up the bulk of the bone’s mass. Extending from the body, the transverse processes are thin columns of bone that point out to the left and right sides of the body. The spinous process extends from the ends of the transverse processes in the posterior direction. Between the body, transverse processes and spinous process is the vertebral foramen, a hollow space that contains the spinal cord and meninges.
• #12: The spine is commonly split up into three columns Anterior – ant longitudinal ligament and ant 2/3 of vertebral bodies Middle – post longitudinal ligament and post 1/3 of vertebral bodies Posterior – ligamentum flavum and pedicles, lamina, spinous processes If one column is disrupted, other columns may provide sufficient stability to prevent spinal cord injury. If 2 columns are disrupted, the spine may move as 2 separate units, increasing the likelihood of spinal cord injury. Understanding of this anatomy is important when assessing the stability of a c-spine fracture
• #13: Cervical spinal injuries are classified by their mechanism of action.
• #14: It is important to undestand the diffrence between a stable and an unstable cervical spine as the treatment and outcome differs greatly. [3] White AA 3rd, Johnson RM, Panjabi MM. Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop. 1975;(109):85-96. [Medline]. [4] Leemans and Calder. The Unstable Cervical Spine. In: (eds) Johnston I, Harrop-Griffiths W. and Gemmell L. AAGBI Topics in Anaesthesia 2012. Chichester, UK: Wiley-Blackhall 2012 p88-104
• #15: White and Punjabi Scale for measuring instability of a c spine fracture where >5 indicative of an unstable c spine White and Panjabi's work on cervical instability culminated in the creation of a scoring checklist to serve as an algorithm and an objective assessment of instability. Patients are assessed anatomically, radiographically, neurologically, and physiologically. The patient is graded on each of these criteria, and the grades are added to obtain the final score. A total score of 5 or more is indicative of a patient with an unstable spine. So if we go through our patient’s case step by step we can assess the stability of her spinal injury…. Ant elements in tact – 0 Posterior elements destryed – 2 Stretch test . In the stretch test, the patient is placed supine with the head supported on a roller platform to reduce friction. The head is placed in a traction rig with and 10-lb loads of weight are applied. The 10-lb weights are added in the presence of the treating physician. The maximum weight allowed is equivalent to 33% of the patient's body weight. The physician performs serial neurologic assessments of the patient with each addition of weight. A lateral C-spine radiograph is obtained with each addition of weight. The time interval between weight increments should be at least 5 minutes. The stretch test is considered positive for instability if one of the following situations occurs: (1) the patient sustains a change in neurologic function, (2) on comparison with the pretraction radiograph, there is greater than 1.7 mm of interspace separation of the anterior or posterior elements, or (3) there is greater than 7.5° change in the angle between vertebrae. Theoretically useful but not performed in practice Radiographic criteria – Flexion/ext xrays not done - Resting xrays: Sagital displacement – neg. 1 for relative angulation Disc narrowing – 0 Spinal canal – no narrowing SC Damage – 0 Nerve route damage – 0 Dangerous loading – 1 Total 4-5 ???Stable Vs unstable As mentioned before in the classfication [3] White AA 3rd, Johnson RM, Panjabi MM. Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop. 1975;(109):85-96. [Medline].
• #16: The distance (a) is measured from the posterior-inferior corner of the vertebral body above the allegedly unstable disk space, to the posterior-superior corner of the vertebral body below the allegedly unstable disk space. The distance (b) is the anterior-posterior sagittal-plane diameter of the vertebral body above the allegedly unstable disk space. According to White and Panjabi's outline, evidence of instability exists if the distance (a) is greater than 20% of distance (b). Alternatively, if the linear distance (a) is greater than 3.5 mm, instability is evident. In conclusion: If (a)/(b) x 100 > 20%, or if (a) > 3.5 mm, then instability is evident.
• #17: Neck pain - whiplash injury; NICE CKS, January 2009 (UK access only)
• #18: The American Spinal Injury association imparment scale is widely used by neurosurgeons to aid assessment of the patient. Assess for manifestations of injury at the cervical / thoracic or lumbar region
• #19: So how do we assess the c-spine? We are all familiar with the Canadian Cspine rules and the Nexus C spine rules
• #20: CCR was developed to help physicians determine which trauma patients need c-spine imaging CCR is highly sensitive for CSI with the majority of studies finding it catches 99-100% of these types of injury Applying the CCR allows HC providers to safely decrease need for imaging among this patient pop by over 40% Subsepquent studies have found a sens of 90-100% for CSI with 99-100% sens. Patients that are high risk due to age, dangerous mechanism of injury, or presence of  paresthesias must have radiography. 2.Patients with any 1 to 5 low risk characteristics may safely undergo clinical assessment if active range of motion is possible. Low risk criteria include: a. Ambulatoryb. Without midline tenderness or immediate onset of painc. Able to sit upd. Simple rear-end motor vehicle collisione. Cna cctively turn head 45 degrees in both directions 3. Patients who are able to actively rotate their neck 45 degrees to the left and right regardless of pain do not require imaging. Exclusion criteria Non trauma patients GCS <15 Unstable vitals Age <16 Acute paralysis Known vertebral diseasee Previous c spine surg [3] Sundstrøm T, et al. Prehospital use of cervical collars in trauma patients: a critical review. Review article J Neurotrauma. 2014.
• #21: A study included a prospective observational sample of 34,069 patients aged 1-101 presenting to 21 us trauma centres. 1.7% had clinically significcant CSI. NEXUS criteria senstivity of 99.6% for ruling out CSI Detected 99.0% of ALL cspine injuries Unlike ccr, nexus does not have age cut offs and is theoretically application to all patients. However literature suggest caution when applying to >65 yoa as sensitibity 66-84% One trial to prospective head to head complarison of nexus to ccr and ccr was found to have superior sensitvity 99.$ vs 90.7. also there is increasing sway towards using ct as a more appropriate imaging modality in this patient population [5] Sundstrøm T, et al. Prehospital use of cervical collars in trauma patients: a critical review. Review article J Neurotrauma. 2014.
• #22: So once we have clarified that we need to image the patient, what imaging should we perform? The National Institute for Health and Care Excellence (NICE) recommends using an adapted version of the Canadian cervical spine rules that incorporates some aspects of the NEXUS rule to identify patients who need imaging of the cervical spine A standard series of X-rays of the cervical spine consists of three views: anteroposterior, lateral and anteroposterior odontoid peg views. The lateral view must show the top of the T1 vertebral body, and the odontoid peg view should show the lateral masses of the atlanto-axial articulation. In children aged <10, use anterior/posterior and lateral radiographs without an anterior/posterior peg view, and use CT imaging to clarify abnormalities or uncertainties. The following patients should have plain radiography (three views) of the cervical spine:[6] Patients with neck pain or midline tenderness if aged ≥65 years, or any age if there was a dangerous mechanism of injury (see 'Risk factors for severe injury', above). Patients where a definitive diagnosis of cervical spine injury is needed urgently (eg, before surgery). Any patients where it is considered unsafe to assess movement. [6] Wee B, Reynolds JH, Bleetman A; Imaging after trauma to the neck. BMJ. 2008 Jan 19;336(7636):154-7. Triage - assessment - investigation and early management of head injury in infants, children and adults; NICE Clinical Guideline Sept 2007
• #23: The patient had a Glasgow coma scale <13 on initial assessment The patient has been intubated, or is being scanned for multi-region trauma If clinical suspicion of injury continues despite a normal radiograph CT is superior to plain radiography, with a reported sensitivity of 100% and specificity of 99%. [6] Wee B, Reynolds JH, Bleetman A; Imaging after trauma to the neck. BMJ. 2008 Jan 19;336(7636):154-7. Triage - assessment - investigation and early management of head injury in infants, children and adults; NICE Clinical Guideline (September 2007)
• #24: MRI depicts soft tissue structures well, with reported sensitivities for intervertebral disc injury of 93%, posterior longitudinal ligament injury of 93%, and interspinous ligament injury of 100%.[5] MRI is indicated for patients with neurological signs, even if plain films are negative. MRI can distinguish haematoma from oedema, which can have prognostic importance. [6] Wee B, Reynolds JH, Bleetman A; Imaging after trauma to the neck. BMJ. 2008 Jan 19;336(7636):154-7. Triage - assessment - investigation and early management of head injury in infants, children and adults; NICE Clinical Guideline (September 2007)
• #25: At this point it is important to remember the potential devastating effects SCIs.
• #26: So back to our patient. On xray she was diagnosed with c7 fracture, t1 spinous process fracture and t7 vertebral body compression fracture.
• #27: So how was our patient managed… Initially she was put in full spinal precautions with c-spine collar/immobilization and log rolling A full history and examination was taken and neurology was reassuringly normal 4 hourly neurology observations were taken And some further imaging was performed including a ct cervico-thoracic spine and full mri spine
• #28: CT imaging showed C7 bilateral lamina fractures. The left fracture line extends into the left facet joint. Importantly there is no dislocation Minimally displaced C7 and T1 spinous process fractures are seen with no associated soft tissue swelling Compression wedge fracture of T7 with 25% loss of height anteriorly.
• #29: Minimally displaced C7 and T1 spinous process fractures are seen with no associated soft tissue swelling Compression wedge fracture of T7 with 25% loss of height anteriorly.
• #30: Here the MRI is highlighting the fractures at C7/ T1 and T7 are highlighted
• #32: Here you can see the stylish aspen collar…
• #35: So what is the evidence for the cspine collar The cervical collar has been routinely used for trauma patients for more than 30 years and is the standard of care in the emergency medical service. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars [5] undstrøm T, et al. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma. 2014.
• #36: The American Association of neurological surgeons produced guideline for the mx of acute cervical spine and scis which highlight why we use the collar. During the 1970s the majority of patients referred to regional SCI centres arrived with complete neurological lesions. In the 1980s, however the majority of scis arrived with incomplete lesions. This improvement in the neurological statys of patients has been attributed to the the development of EMS initiated in 1971 and introduction of the hard collar. [6] Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries. American Association of Neurological Surgeons. May 2001. Full guidelines. [
• #37: But hey it’s a harmless intervention so why wouldn’t we use collars. Wrong…. Cspine collars can lead to Ulcers Raised icp Believed that in fact they may worsen fractures Cause more problems and aggravate the combative intoxicated patient Difficult airway management – trying to intubate a collared patient is not an easy feat! Painful – study showed that in a group of people told to wear collar 100% complained of pain after 30 minutes Also with increased cost and time it is not going to be conducive to the 4 hr rule!!!
• #38: One interesting article addresses the case of the cervical collar. It is a review article in the Scandinavian journal of trauma by benger et al and addresses some of the “myths of the cervical collar Myth 1 Of course, trauma patients may have an unstable cervical spine injury. But the incidence seems to be low. In two studies on trauma patients who were considered at high risk of head and neck trauma, they found an incidence of 0,7% for significant cervical spine injury. Myth 2 In a patient cohort with confirmed cervical vertebral injury, 8% of them did not have their spine immobilised – but outcome did not differ. In a study comparing the incidence of neck injuries in a first world country where cervical collars are applied, to a third world country without collars, there was no difference in the incidence of neurological injuries from the cervical spine Myth 3 I don’t know if you have every applied or seen a collared patient but the collar is pretty useless at stabilising the neck. Even a perfectly apllied collar allows for at least 30 degrees of flexion/extension/rotation. Myth 4 Just out the collar on to be on the safe side….Well as mentioned before there are risks with the collar…. In a cadaver study where they inflicted neck injury on the cadavers and then place a semi rigid collar around the neck, radiological studies showed that the collar increased the fracture crease by over 7 mm! The conclusion was that a cervical collar on these patients probably would have made the neck injury worse. The collar we put on millions of trauma patients every year has no proven benefit, no proven protection against secondary injuries. Still, we put it on with the A in ABC and take focus and time from more important interventions. For the patient with a high suspicion of spine injury, careful handling is needed – but not a cervical collar. For all other trauma patients, they will more than likely be better off without the collar. [7] Benger et al. Why do we put cervical collars on conscious trauma patients? SJTREM, 2009. Full text.
• #39: So what are the take home messages from this case…..