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- Imaging of Vertebral Trauma by Richard H. Daffner
Imaging of Vertebral Trauma, third edition, is an invaluable and essential tool in the assessment of any patient with suspected vertebral or spinal cord injury. Review of the second edition: To send content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about sending content to. To send content items to your Kindle, first ensure no-reply cambridge.
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Get access Buy the print book. Check if you have access via personal or institutional login. Log in Register Recommend to librarian. Cambridge University Press Online publication date: April Print publication year: Medicine , Emergency Medicine , Medical Imaging. There is no other data nor material. All authors have contributed to the drafting of this manuscript and have approved this final version. Not applicable as this manuscript is a literature review and a clinical guideline. The systematic reviews that were identified in our search for new literature.
Imaging of Vertebral Trauma
Daniel K Kornhall, Email: Per Kristian Hyldmo, Email: National Center for Biotechnology Information , U. Published online Jan 5. Received Oct 11; Accepted Dec This article has been cited by other articles in PMC. Abstract The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. Electronic supplementary material The online version of this article doi: Prehospital emergency care, Spinal cord injury, Stabilisation, Airway management, Guideline. Background Traumatic injury to the spinal cord SCI or cauda equina is uncommon but may have devastating consequences [ 1 , 2 ].
Methods The multi-disciplinary faculty included members from all Norwegian health trusts representing the medical specialties of neurosurgery 1 , trauma surgery 1 , prehospital care 3 , anesthesiology 1 and EMS 1 , all with expert knowledge of trauma management. Clinical question P I C O Does routine use of spinal stabilisation prevent secondary neurological injury? Trauma population Spinal stabilisation Stabilisation vs no stabilisation Neurological morbidity Are there alternative ways of stabilising the spinal column?
Trauma population Spinal stabilisation Stabilisation vs no stabilisation Neurological morbidity Pain, discomfort, ulceration Are there sub-groups of patients that in particular should not be stabilised? Open in a separate window. Results Six guidelines were identified in the scoping stage [ 2 , 19 , 46 , 54 — 56 ]. Table 2 Summary of recommendations, quality of evidence and strength of recommendation.
Recommendation Quality of evidence Strength of recommendation Rationale Benefits, harms and the preferences of patients and clinicians 1 Victims with potential spinal injury should have spinal stabilisation. Very low Strong Paucity of literature supporting spinal stabilisation. Very little literature documenting serious harm. Spinal cord injury can have devastating consequences. Potential benefits outweigh harms 2 A minimal handling strategy should be observed.
Potential benefits outweigh possible harms 3 Spinal stabilisation should never delay or preclude life-saving intervention in the critically injured trauma victim. Very low Good clinical practice Literature supporting this recommendation was considered too heterogenous for synthesis. The faculty finds that it is logical that spinal stabilisation in the critically injured patient may cause serious harm 4 Victims of isolated penetrating injury should not be immobilised.
Moderate Strong One large study of moderate quality directly supports this recommendation. Spinal injury in patients with isolated penetrating injury is rare 5 Triaging tools based on clinical findings should be implemented. Moderate Strong Consistent evidence supporting triaging tools based on clinical findings rather than mechanism. No harmful effects documented 6 Cervical stabilisation may be achieved using manual in-line stabilisation, head-blocks, a rigid collar or combinations thereof.
Very low Conditional Consistent experimental evidence demonstrating how rigid collars can stabilise the cervical spine. However, there is also evidence suggesting harm from rigid collars. No evidence proving superiority of any one method 7 Transfer from the ground or between stretchers should be achieved using a scoop stretcher. Very low Conditional General paucity of evidence. Some evidence for significant spinal motion during log-roll.
Some evidence documenting improved stability with scoop stretcher transfers. Safety of scoop stretcher systems is good. No harmful effects documented 8 Patients with potential spinal injury should be transported strapped supine on a vacuum mattress or on an ambulance stretcher system. Very low Conditional Evidence supporting harm from hard surface stretcher systems. No consistent evidence demonstrating increased stability with any one method.
Increased comfort associated with soft surface systems. No evidence exploring spinal stability of common stretcher systems 9 Hard surface stretcher systems may be used for transports of shorter duration only. Increased comfort associated with soft surface systems 10 Patients should under some circumstances be invited to self-extricate from vehicles. Very low Conditional Two experimental studies demonstrating improved stability with self-extrication from vehicles. Reasonable and practical alternative as long as used cautiously.
Rationale and evidence base Higher level evidence supporting spinal stabilisation is lacking Despite spinal stabilisation being one of the most frequently performed prehospital interventions, higher grade evidence demonstrating beneficial effects is lacking [ 46 ].
Rationale and evidence base While the faculty recommends adhering to the prehospital stabilisation doctrine, it must also be recognised that SCI is uncommon and that spinal stabilisation is not, in itself, always a benign intervention [ 43 , 46 ]. Spinal stabilisation may interfere with or delay life-saving intervention The incidence of SCI in hospitalised trauma victims has been reported in the range of 0.
Recognising time critical injury Staging and defining time critical injury in trauma is controversial. The lateral trauma position Historically, first responders without advanced airway skills have placed unconscious or obtunded victims in the recovery position in order to facilitate the clearance of fluids and to maintain airway patency [ 45 ]. Rationale and evidence base Victims of isolated penetrating trauma suffer increased mortality with routine spinal stabilisation [ 57 ]. Rationale and evidence base Triaging tools In order to address over-triage, authors have advocated implementing triaging tools to assist in identifying low-risk patients who do not require stabilisation [ 41 , 78 — 81 ].
Triaging tools based on clinical findings reduce over-triage Authors have recommended implementing tools that, similar to NEXUS, are predominantly based on clinical findings [ 78 , 86 , 87 ]. Rationale and evidence base The approach to cervical stabilisation should be informed and selective, observing the pros and cons of several techniques. The efficacy and harms of the rigid cervical collar No high quality studies have identified the true efficacy of the rigid collar. The rigid collar should not be applied routinely The aforementioned reports support a selective approach to rigid collar use.
Rationale and evidence base A significant amount of spinal motion is generated as the patient is transferred from the ground onto or between stretcher systems or beds. The log-roll may generate undue spinal motion and should be avoided in favour of alternative techniques Log-rolling has traditionally been used to transfer the patient onto or off stretcher systems or to gain access to patients back for examination, despite authors questioning its safety [ ].
Rationale and evidence base We wish to differentiate between hard and soft surface stretcher systems. Hard surface stretcher systems The backboard was designed to facilitate extrication but has since its inception been used as a transportation device and quickly became the gold standard for spinal stabilisation during transport [ , ]. Soft surface stretcher systems The vacuum mattress , while not rigid enough for extrication, is a useful transportation device.
Rationale and evidence base The traditional approach to extrication of victims with potential spine injury from vehicles or other settings has been to stabilise the victim with a cervical collar and then to carefully transfer the passive victim onto a backboard for extrication [ ]. Self-extrication Over the years, authors have argued that this practice often is unnecessary, resulting in prolonged extrication times and avoidable complications related to spinal stabilisation.
A generous approach to self-extrication Despite the scant evidence, we recommend self-extrication in some circumstances. Summary This guideline, based on consensus and the best available evidence, is an attempt to address concerns about over-triage, harms and costs associated with the traditional management of potential spinal injury. Funding Designing this guideline required travelling to six meetings. Availability of data and materials We have submitted our detailed search vocabulary and literature tables as supplementary material. Ethics approval and consent to participate Not applicable as this manuscript is a literature review and a clinical guideline.
Grant The authors have received no financial support. Additional files Additional file 1: DOCX kb Additional file 2: DOCX 24 kb Additional file 3: DOCX 23 kb Additional file 4: Characteristics of injuries to the cervical spine and spinal cord in polytrauma patient population: Neurologic recovery following rapid spinal realignment for complete cervical spinal cord injury.
Stabilization of spinal injury for early transfer. The removal of injured personnel from wrecked vehicles. Early management of the patient with trauma to the spinal cord. Med Serv J Can. The initial movement of the injured. Extrication of victims--surgical principles.
Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am. An educational training program for the care at the site of injury of trauma to the central nervous system. Cervical bracing after trauma. A comparison of methods of cervical immobilization used in patient extrication and transport. Triage and stabilization for safe transfer. Arch Orthop Trauma Surg. Death in a Ditch. Bull Am Coll Surg. Orthotics for spinal cord injuries.
Electronic supplementary material
Clin Orthop Relat Res. Acute neurologic management of the patient with spinal cord injury. Urol Clin North Am. Emergency department evaluation and treatment of the neck and cervical spine injuries. Emerg Med Clin North Am. Spinal immobilization on a flat backboard: Nypaver M, Treloar D. Neutral cervical spine positioning in children. Immobilizing the cervical spine in trauma: Is sub-occipital padding necessary to maintain optimal alignment of the unstable spine in the prehospital setting?
ABC of major trauma. Trauma of the spine and spinal cord--I. J Miss State Med Assoc.
Advanced trauma life support program for physicians: American College of Surgeons; Mazolewski P, Manix TH. The effectiveness of strapping techniques in spinal immobilization. A review of spinal immobilization techniques. The efficacy of head immobilization techniques during simulated vehicle motion. Spine Phila Pa ; Cervical spine immobilization before admission to the hospital.
A radiographic comparison of prehospital cervical immobilization methods. A new device for the care of acute spinal injuries: The effect of a soft collar, used as normally recommended or reversed, on three planes of cervical range of motion. J Orthop Sports Phys Ther. Use of an adjustable, transportable, radiolucent spinal immobilization device in the comprehensive management of cervical spine instability: The Kendrick extrication device used for pediatric spinal immobilization.
Unnecessary out-of-hospital use of full spinal immobilization. Kwan I, Bunn F. Effects of prehospital spinal immobilization: Abram S, Bulstrode C. Routine spinal immobilization in trauma patients: Prehospital use of cervical collars in trauma patients: Is the supine position associated with loss of airway patency in unconscious trauma patients? A systematic review and meta-analysis. Prehospital cervical spinal immobilization after trauma.
BMJ Best Practice [ http: National Institute for Health and Care Excellence [ http: Guidelines International Network [ http: Pre-hospital care management of a potential spinal cord injured patient: The prehospital management of suspected spinal cord injury: Prehospital care of the adult trauma patient [ http: Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee.
Does turning trauma patients with an unstable spinal injury from the supine to a lateral position increase the risk of neurological deterioration? Should suspected cervical spinal cord injury be immobilised?: Acute spinal cord injury: Cent Nerv Syst Trauma. Stabilization of patients prior to interhospital transfer. Am J Emerg Med. Care of the multiply injured patient with cervical spine injury.
Imaging of Vertebral Trauma by Richard H. Daffner
Clin Orthop Relat Res ; Emergency, acute, and surgical management of spine trauma. Arch Phys Med Rehabil. New focus on spinal cord injury. Deterioration following spinal cord injury. Prevention of neurological deterioration before admission to a spinal cord injury unit. Secondary neurological deterioration in traumatic spinal injury: Moss R, Greaves I.
Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Lung function compromised by spinal immobilization. Respiratory effects of spinal immobilization in children. Respiratory effects of spinal immobilization. Spine immobilization in penetrating trauma: How should an unconscious person with a suspected neck injury be positioned? The lateral trauma position: A cross-sectional survey of all Norwegian emergency medical services.
Prehospital clinical findings associated with spinal injury. Neck collar used in treatment of victims of urban motorcycle accidents: Cervical spine fractures in elderly patients with hip fracture after low-level fall: Morrison J, Jeanmonod R. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma, National Emergency X-Radiography Utilization Study Group.
N Engl J Med. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: Stroh G, Braude D. Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. A statewide, prehospital emergency medical service selective patient spine immobilization protocol.
The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Comparison of three prehospital cervical spine protocols for missed injuries. West J Emerg Med. Prospective validation of out-of-hospital spinal clearance criteria: Can EMS providers adequately assess trauma patients for cervical spinal injury?
Out-of-hospital cervical spine clearance: Multicenter prospective validation of prehospital clinical spinal clearance criteria. Outcome of trauma patients immobilized by emergency department staff, but not by emergency medical services providers: Examining motion in the cervical spine. Imaging systems and measurement techniques. Efficacy of cervical spine immobilization methods.
Comparison of the effectiveness of different cervical immobilization collars. Evaluation of current extrication orthoses in immobilization of the unstable cervical spine. Comparison of two new immobilization collars. The effectiveness of extrication collars tested during the execution of spine-board transfer techniques. Do cervical collars and cervicothoracic orthoses effectively stabilize the injured cervical spine?
Value of a rigid collar in addition to head blocks: Raphael JH, Chotai R. Effects of the cervical collar on cerebrospinal fluid pressure. The effect of a rigid collar on intracranial pressure. Cervical collar-induced changes in intracranial pressure. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury.
Neurologic complications following immobilization of cervical spine fracture in a patient with ankylosing spondylitis. Spinal cord injury in patients with ankylosing spondylitis: Prospective evaluation of craniofacial pressure in four different cervical orthoses. The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects. Effect of spinal immobilization on heart rate, blood pressure and respiratory rate.
Skin necrosis caused by a semi-rigid cervical collar in a ventilated patient with multiple injuries. Complication of hard cervical collars in multi-trauma patients. Aust N Z J Surg. Marginal mandibular nerve palsy due to compression by a cervical hard collar. Solving the problem of pressure ulcers resulting from cervical collars. Comparative study of risk factors for skin breakdown with cervical orthotic devices: Motion in the unstable cervical spine during hospital bed transfers. Motion generated in the unstable cervical spine during the application and removal of cervical immobilization collars.
J Trauma Acute Care Surg.