Context

Cervical spine injuries are rare but potentially devastating. Historically Immobilisation of the cervical spine on the slightest suspicion of injury is recommended by most resuscitation courses including ALS, ATLS, APLS, PHTLS, as well as by NICE and JRCALC (National Ambulance Service Guidelines). To that end, cervical spine immobilisation was previously the most commonly performed procedure in pre-hospital care.²³

According to NICE guideline,²¹ on assessment, maintain In-line manual immobilisation when assessing/instrumenting the airway.

At all stages, protect the spine and avoid moving the remainder of the spine.

Assess the person for spinal injury, initially taking into account the factors listed below. Immobilise if any of:

• has any significant distracting injuries
• is under the influence of drugs or alcohol
• is confused or uncooperative
• has a reduced level of consciousness
• has any spinal pain
• has any hand or foot weakness (motor assessment)
• has altered or absent sensation in the hands or feet (sensory assessment)
• has priapism (unconscious or exposed male)
• has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.

In a review of the literature (209,320 patients) evaluating the potential for cervical spine injury in a trauma population, Milby et al.  found that the overall incidence of actual cervical spine Injury was 3.7%. In alert patients the incidence was only 2.8%, whilst those who were clinically unevaluable (because of depressed conscious level, intoxication, etc) there was a higher incidence of 7.7%. This means that, in patients who present to hospital with potential neck injuries, the vast majority of them will not actually subsequently be shown to have a cervical spine injury.

Cervical spine immobilisation is not a benign procedure:

• Collars significantly raise intracranial pressure: an effect that is potentially significant in the presence of head injury
• Long boards and collars cause pain and tissue ischaemia which can lead to pressure sores
• Supine immobilisation causes considerable deterioration in respiratory function

A large number of patients present to Emergency Departments (ED) with their necks immobilised; as significant cervical spine injury is rare and there are potentially adverse consequences of cervical spine immobilisation, reliable methods are needed to clinically exclude cervical spine injury wherever possible (‘clearing their necks’). The initial clinical assessment and, where necessary, subsequent radiological assessment, of potential cervical spine injury is the subject of this session.

Learning Bite

Cervical spine immobilisation is not a benign intervention. It is associated with significant morbidity.