Cervical spine stabilization in pediatric patients: evaluation of current techniques

Where Do We Stand on Cervical Spine Immobilisation? A Questionnaire among Prehospital Staff

Background: Cervical collars (CC) are routinely used in prehospital trauma treatment. However, over the past years, their application was discussed more critically since they increase intravenous pressure due to reduced venous drainage and the possibility of secondary cervical spine injury. Guidelines have been adjusted accordingly. The question is how efficient has this been put into practice, and how good, as well as up to date, is the knowledge of prehospital emergency medicine personnel about indications on cervical spine immobilisation? Methods: A 15-item questionnaire regarding the self-evaluation and result checking of the right indications for the use of a cervical collar in the prehospital setting was sent to paramedics and emergency doctors in Germany. Two hundred and nineteen completed surveys were statistically analysed. Results: Mean age of the participants was 30.45 ± 8.8. 72% were male. Regarding subjective safety, the appropriate indication of CC participants reached 79.8 ± 19.5 on a metric scale from 0 (no safety) to 100 (full safety). Mean right answers were as follows: Ambulance man (RS) 0.78 ± 0.84, paramedic (RA) 0.9 ± 0.74, paramedic (NFS) 1.03 ± 0.83 and emergency doctor (ED) 1.75 ± 1.06 (p = 0.013, Kruskal-Wallis Test). Participants who estimated their knowledge < 85% had 0.83 ± 0.8 right answers, and > 85% had 1.14 ± 0.9 right answers. Conclusions: Rational spine immobilisation is still necessary in severely injured patients. This study highlights the importance of continuing education using ongoing training, lectures or online learning with a questionnaire as a monitor for success to ensure the transfer of evidence-based medicine into daily practice.

Traffic Accidents in Children and Adolescents: A Complex Orthopedic and Medico-Legal Approach

Traffic accidents involving children and adolescents present complex challenges from both the medico-legal and orthopedic standpoints. Despite the implementation of road traffic safety laws, pediatric road traffic injuries continue to be a significant contributor to mortality rates, physical harm, and hospitalization on a global scale. For children and young people, automobile accidents are considered to be the primary culprit of mortality in developed nations. Even in highly developed nations, trauma is a significant factor in infant mortality. Each age category, from childhood to young adulthood, has its fracture patterns, as their skeletons are considerably different from those of adults. The consequences of traffic accidents extend beyond the immediate physical trauma. The medico-legal aspects surrounding these incidents add another layer of complexity, as legal repercussions may affect the responsible adult or parent, particularly in cases involving child fatalities. To effectively address traffic accidents in children and adolescents, a comprehensive approach is necessary. This approach should involve not only medical professionals but also legal experts and policymakers. Collaboration between orthopedic specialists, medico-legal professionals, law enforcement agencies, and relevant government bodies can facilitate the development and implementation of strategies aimed at prevention, education, the enforcement of traffic laws, and improved infrastructure. By addressing both the medical and legal aspects, it is possible to enhance road safety for children and adolescents, reducing the incidence of injuries and their associated long-term consequences. In this review, we aimed to summarize traffic accidents in children and adolescents from a complex orthopedic and medico-legal approach.

Pediatric Cervical Spine Injuries and SCIWORA: WFNS Spine Committee Recommendations

Cervical trauma in children have variations from the adults mainly due to anatomic differences. An optimal diagnostic and treatment strategy is critical, particularly when there is a lack of standardized protocols for the management of such cases. This review paper examines the diagnostic and treatment options of pediatric cervical trauma and Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). A literature search for the last 10 years were conducted using key words. Case reports, experimental studies, papers other than English language were excluded. Up-to-date information on pediatric cervical trauma and SCIWORA were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of WFNS Spine Committee. The statements were voted and reached a consensus using Delphi method. This review reflects different aspects of contemporary pediatric cervical trauma decision-making and treatment, and SCIWORA. The mainstay of SCIWORA treatment is nonsurgical with immobilization, avoidance of risky activities. Prognosis generally depends on the initial neurological status and magnetic resonance imaging. Due to a significant discrepancy in the literature on diagnostic and management, future randomized controlled trials are needed to aid in generating standardized protocols.

A Review on the Etiology and Management of Pediatric Traumatic Spinal Cord Injuries

CONTEXT

Pediatric traumatic spinal cord injury (SCI) is an uncommon presentation in the emergency department. Severe injuries are associated with devastating outcomes and complications, resulting in high costs to both the society and the economic system.

EVIDENCE ACQUISITION

The data on pediatric traumatic spinal cord injuries has been narratively reviewed.

RESULTS

Pediatric SCI is a life-threatening emergency leading to serious outcomes and high mortality in children if not managed promptly. Pediatric SCI can impose many challenges to neurosurgeons and caregivers because of the lack of large studies with high evidence level and specific guidelines in terms of diagnosis, initial management and of in-hospital treatment options. Several novel potential treatment options for SCI have been developed and are currently under investigation. However, research studies into this field have been limited by the ethical and methodological challenges.

CONCLUSION

Future research is needed to investigate the safety and efficacy of the recent uprising neurodegenerative techniques in SCI population. Owing to the current limitations, there is a need to develop novel trial methodologies that can overcome the current methodological and ethical limitations.

Management of cervical spine trauma in children

PURPOSE

Paediatric cervical spine injuries are fortunately a rare entity. However, they do have the potential for devastating neurological sequelae with lifelong impact on the patient and their family. Thus, management ought to be exceptional from the initial evaluation at the scene of the injury, through to definitive management and rehabilitation.

METHODS

We set out to review cervical spine injuries in children and advise on current best practice with regards to management.

RESULTS

Epidemiology, initial management at the scene of injury, radiological findings and pitfalls of cervical spine trauma are outlined. Strategies for conservative and surgical management are detailed depending on the pattern of injury. The management of spinal cord injuries without radiological abnormality (SCIWORA) and cranio-cervical arterial injuries is also reviewed.

CONCLUSIONS

Due to a paucity of evidence in these rare conditions, expert opinion is necessary to guide best practice management and to ensure the best chance of a good outcome for the injured child.

Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts

The clinical presentation and diagnostic workup in pediatric cervical spine injuries (CSI) are different from adults owing to the unique anatomy and relative immaturity. The current article reviews the existing literature regarding the uniqueness of these injuries and discusses the current guidelines of radiological evaluation. A PubMed search was conducted using keywords "paediatric cervical spine injuries" or "paediatric cervical spine trauma." Six hundred and ninety two articles were available in total. Three hundred and forty three articles were considered for the review after eliminating unrelated and duplicate articles. Further screening was performed and 67 articles (original articles and review articles only) related to pediatric CSI were finally included. All articles were reviewed for details regarding epidemiology, injury patterns, anatomic considerations, clinical, and radiological evaluation protocols. CSIs are the most common level (60%-80%) for pediatric Spinal Injuries (SI). Children suffer from atlantoaxial injuries 2.5 times more often than adults. Children's unique anatomical features (large head size and highly flexible spine) predispose them to such a peculiar presentation. The role of National Emergency X-Ray Utilization Study, United State (NEXUS) and Canadian Cervical Spine Rule criteria in excluding pediatric cervical injury is questionable but cannot be ruled out completely. The minimum radiological examination includes 2- or 3-view cervical X-rays (anteroposterior, lateral ± open-mouth odontoid views). Additional radiological evaluations, including computerized tomography (CT) and magnetic resonance imaging (MRI) are obtained in situations of abnormal physical examination, abnormal X-rays, inability to obtain adequate X-rays, or to assess cord/soft-tissue status. The clinical criteria for cervical spine injury clearance can generally be applied to children older than 2 years of age. Nevertheless, adequate caution should be exercised before applying these rules in younger children. Initial radiographic investigation should be always adequate plain radiographs of cervical spine. CT and MRI scans should only be performed in an appropriate group of pediatric patients.

Compulsory Use of the Backboard is Associated with Increased Frequency of Thoracolumbar Imaging

BACKGROUND

Backboards have been shown to cause pain in uninjured patients. This may alter physical exam findings, leading emergency department (ED) providers to suspect a spinal injury when none exists resulting in additional imaging of the thoracolumbar spine. New York had previously employed a "Spinal Immobilization" protocol that included compulsory backboard application for all patients with suspected spinal injuries. In 2015, New York instituted a new "Spinal Motion Restriction" protocol that made backboard use optional for these patients. The objective of this study was to determine if this protocol change was associated with decreased backboard utilization and ED thoracolumbar spine imaging.

METHODS

This was a retrospective before-and-after chart review of subjects transported by a single emergency medical services (EMS) agency to one of four EDs for emergency calls dispatched as motor vehicle collisions (MVC). EMS and ED data were included for all calls within a 6-month interval before and after the protocol change. The protocol change was implemented in the second half of 2015. Subject demographics, backboard use, and spine imaging were reviewed for the intervals January-June 2015 and January-June 2016.

RESULTS

There were 818 subjects in the before period and 796 subjects in the after period. Subjects were similar in terms of gender, age and type of MVC in both periods. A backboard was utilized for 440 (54%) subjects in the before period and 92 (12%) subjects in the after period (p < 0.001). ED thoracic spine imaging was performed on 285 (35%) subjects in the before period, and 235 (30%) subjects in the after period (p = 0.02). ED lumbar spine imaging was performed for 335 (41%) subjects in the before period, and 281 (35%) subjects in the after period (p = 0.02).

CONCLUSION

A shift from a spinal immobilization protocol to a spinal motion restriction protocol was associated with a decrease in backboard utilization by EMS providers and a decrease in thoracolumbar spine imaging by ED providers.

Prehospital Extrication Techniques: Neurological Outcomes Associated with the Rapid Extrication Method and the Kendrick Extrication Device

Most emergency medical service personnel rely on one of two techniques to extricate motor vehicle crash victims; the Rapid Extrication Maneuver (REM) or the Kendrick Extrication Device (KED). The purpose of this study was to compare pre- and postextrication neurological outcomes between these two techniques. A retrospective review was conducted of all adult patients with a vertebral column injury resulting from motor vehicle collision and admitted to a Level I trauma center between January 1, 2003 and December 31, 2010. Standardized pre- and postextrication neurological examinations were reviewed for all patients. More than half of patients (N = 81) were extricated using the KED (53.1%, n = 43) and 46.9 per cent (n = 38) were extricated with the REM. Except for the thoracic Abbreviated Injury Score, no differences between groups emerged related to the Glasgow Coma Scale score, Injury Severity Score or Abbreviated Injury Score. There were no pre- and postextrication changes for motor to all extremities and sensation to all extremities using either method. The results of this study suggest that the REM and the KED are equivalent in protecting the patient from neurologic injury after motor vehicle collision.

Craniovertebral junction injuries in children. A Review

The craniovertebral junction (CVJ) is the most complex and dynamic region of the cervical spine. The wide range of movements possible at this region makes it vulnerable to injury and instability. The special anatomical features make children more prone to injuries of CVJ than adults where lower cervical spine is involved more frequently. The classical clinical manifestation in CVJ injury patients are pyramidal signs including weakness and spasticity, stigmata of CVJ anomalies (short neck, low hair line, facial or hand asymmetry, high arched palate, ), torticolis and neck movement restriction. The history of transient loss of consciousness or sudden neurological deterioration following minor trauma may be elicited. Most authors advocate conservative management (in form of immobilization) of CVJ injuries in children as is true in adults. Halo vest provides superior immobilization in upper cervical and CVJ injuries and can be used in a child as young as 1 year of age with minimal difficulty. Early surgical intervention, i.e. within 2 weeks of injury include is indicated in injuries that cannot be reduced and stabilized by external means, partial spinal cord injury with progressive neurological deficit and in children with extradural hematoma.

Cervical Spine Motion During Airway Management Using Two Manual In-line Immobilization Techniques: A Human Simulator Model Study

OBJECTIVE

The aim of this study is to evaluate cervical spine motion using 2 manual inline immobilization techniques with the use of a human simulator model.

METHODS

Medical students, pediatric and family practice residents, and pediatric emergency medicine fellows were recruited to maintain cervical manual in line immobilization above the head of the bed and across the chest of a human simulator while orotracheal intubation was performed. Participants were then instructed on appropriate holding techniques after the initial session took place. Orotracheal intubation followed. A tilt sensor measured time to intubation and cervical extension and rotation angle.

RESULTS

Seventy-one subjects participated in a total of 284 successful orotracheal intubations. No change in cervical spine movement or time to intubation was observed when using 2 different inline manual immobilization techniques with no training. However, a statistically significant difference with assistants above the head versus across the chest was observed after training in: extension 2.1° (95% confidence interval [95% CI], 1.15 to 3.00; P < 0.0001); rotation 0.7° (95% CI, 0.26 to 1.19; P = 0.003) and intubation time of -1.9 seconds (95% CI, -3.45 to -0.13; P = 0.035) after training.

CONCLUSIONS

Cervical spine movement did not change when maintaining cervical spine immobilization from above the head versus across the chest before training. There was a statistically significant change in extension and rotation when assistants were above the head and in time to intubation when assistants were across the chest after training. The clinical significance of these results is unclear.

Pediatric Spinal Cord Injury: Recognition of Injury and Initial Resuscitation, in Hospital Management, and Coordination of Care

Spinal cord injury is uncommon in the pediatric population with a lifelong impact for the patient and family. Knowledge of spine embryology, mechanisms of injury that lead to specific injuries, appropriate utilization of radiographic imaging based on suspected injury, prehospital and hospital management of various spinal cord injuries is essential for providers attending to traumatically injured patients. In addition to patients who present with soft tissue and bony injuries diagnosed with clinical examination and confirmed with computed tomography or magnetic resonance imaging, it is important to note that the pediatric population is at a higher risk for spinal cord injury without radiographic abnormality than the adult population. Patients who survive the acute phase of injury face long-term rehabilitation and have an increased risk of depression and mortality. Understanding the long-term sequelae of spinal cord injuries is also an essential management component of traumatically injured children. A program that provides long-term rehabilitation, psychosocial and spiritual support, and adaptive environmental supports gives patients and their families the best opportunity for long-term recovery. A review of the current literature on the diagnosis, management, and follow-up of pediatric spinal cord injury is presented.

Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature

BACKGROUND

Spinal immobilisation has been a mainstay of trauma care for decades and is based on the premise that immobilisation will prevent further neurological compromise in patients with a spinal column injury. The aim of this systematic review was to examine the evidence related to spinal immobilisation in pre-hospital and emergency care settings.

METHODS

In February 2015, we performed a systematic literature review of English language publications from 1966 to January 2015 indexed in MEDLINE and Cochrane library using the following search terms: 'spinal injuries' OR 'spinal cord injuries' AND 'emergency treatment' OR 'emergency care' OR 'first aid' AND immobilisation. EMBASE was searched for keywords 'spinal injury OR 'spinal cord injury' OR 'spine fracture AND 'emergency care' OR 'prehospital care'.

RESULTS

There were 47 studies meeting inclusion criteria for further review. Ten studies were case series (level of evidence IV) and there were 37 studies from which data were extrapolated from healthy volunteers, cadavers or multiple trauma patients. There were 15 studies that were supportive, 13 studies that were neutral, and 19 studies opposing spinal immobilisation.

CONCLUSION

There are no published high-level studies that assess the efficacy of spinal immobilisation in pre-hospital and emergency care settings. Almost all of the current evidence is related to spinal immobilisation is extrapolated data, mostly from healthy volunteers.

Efficacy of prehospital spine and limb immobilization in multiple trauma patients

Background:

Injuries are a major cause of mortality and disability worldwide and are estimated to become the third leading cause of death by 2020. Most traffic deaths occur during the prehospital phase; consequently, prehospital trauma care has received considerable attention during the past decade. However, there is no study on the prehospital immobilization of spine and limbs in patients with multiple trauma in Iran.

Objectives:

This study aimed to investigate the epidemiology of trauma and the quality of limb and spine immobilization in patients with multiple trauma transferred to Shahid Beheshti Medical Center via emergency medical services (EMS).

Patients and Methods:

This cross-sectional study was conducted in 2013. The study population consisted of all patients with multiple trauma who had been transferred by EMS to the Central Trauma Department of the Shahid Beheshti Medical Center, Kashan, Iran. The study used a checklist and we recruited a convenience sample of 400 patients with multiple trauma. Data were described by using frequency tables, central tendency measures, and variability indices. Moreover, we analyzed data using SPSS.

Results:

The study sample consisted of 301 (75.2%) males and 99 (24.8%) females. The most common mechanism of trauma was traffic injuries (87.25%). Motorcyclists constituted 52.25% of the road traffic injuries victims. Overall, the quality of immobilization was at an undesirable level in 95.8% of patients with spine and limbs injuries. A significant association was observed between the quality of spine and limbs immobilization and the EMS workers’ education level (P = 0.005).

Conclusions:

The quality of spine and limb immobilizations was undesirable in more than 90% of cases. Due to the importance of good spine and limb immobilization in patients with multiple trauma, prehospital EMS technicians should be retrained for proper immobilization in patients suspected of spine or limb injuries. Developing evidence-based protocols and strengthening the regulatory and supervisory system to improve quality of prehospital emergency care in patients with multiple trauma is recommended.

Prehospital use of cervical collars in trauma patients: a critical review

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. 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. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

Variability of prehospital spinal immobilization in children at risk for cervical spine injury

OBJECTIVE

This study aimed to compare prehospital spinal immobilization techniques applied to age-based cohorts of children with and without cervical spine injury (CSI) after blunt trauma.

METHODS

We compared prehospital spinal immobilization in 3 age-based cohorts of children with blunt trauma-related CSI transported to 1 of 17 participating hospitals. We also compared children younger than 2 years with CSI with those at risk for but without CSI after blunt trauma. We identified patients through query of billing and radiology databases. We compared immobilization methods using Fisher's exact test for homogeneity.

RESULTS

We identified 16 children younger than 2 years, 78 children 2 to 7 years old, and 221 children 8 to 15 years old with CSI, and 66 children younger than 2 years without CSI. There were no significant differences in spinal immobilization techniques applied to children younger than 2 years old with and without CSI (P = 0.34). Of the 82 children younger than 2 years, 34 (41%) were fully immobilized in a cervical collar and rigid long board. There was a significant difference between spinal immobilization techniques applied to children with CSI younger than 2 years and 8 to 15 years old (P < 0.01). Six (38%) children with CSI younger than 2 years were fully immobilized versus 49 (63%) children 2 to 7 years old and 175 (79%) children 8 to 15 years old.

CONCLUSIONS

In this retrospective, observational study involving several emergency departments and Emergency Medical Services systems, we found that full spinal immobilization is inconsistently applied to children younger than 2 years after blunt trauma regardless of the presence of CSI. Full spinal immobilization is applied more consistently to older children with CSI.

Pediatric cervical spine injuries: a comprehensive review

INTRODUCTION

Cervical spine injuries can be life-altering issues in the pediatric population. The aim of the present paper was to review this literature.

CONCLUSIONS

A comprehensive knowledge of the special anatomy and biomechanics of the spine of children is essential in diagnosis and treating issues related to spine injuries.

Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines

An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury.

Cervical spine injuries in children, part II: management and special considerations

BACKGROUND

The diagnosis and management of cervical spine injury is more complex in children than in adults.

OBJECTIVES

Part I of this series stressed the importance of tailoring the evaluation of cervical spine injuries based on age, mechanism of injury, and physical examination findings. Part II will discuss the role of magnetic resonance imaging (MRI) as well as the management of pediatric cervical spine injuries in the emergency department.

DISCUSSION

Children have several common variations in their anatomy, such as pseudosubluxation of C2-C3, widening of the atlantodens interval, and ossification centers, that can appear concerning on imaging but are normal. Physicians should be alert for signs or symptoms of atlantorotary subluxation and spinal cord injury without radiologic abnormality when treating children with spinal cord injury, as these conditions have significant morbidity. MRI can identify injuries to the spinal cord that are not apparent with other modalities, and should be used when a child presents with a neurologic deficit but normal X-ray study or CT scan.

CONCLUSION

With knowledge of these variations in pediatric anatomy, emergency physicians can appropriately identify injuries to the cervical spine and determine when further imaging is needed.

Cervical spine injuries in children: attention to radiographic differences and stability compared to those in the adult patient

The relative rarity of pediatric cervical spine injuries can impede rapid response and efficient care of this patient population. An understanding of the unique anatomical, radiographic, and biomechanical characteristics of the pediatric cervical spine is essential to the appropriate care of these challenging patients. Patterns of injury, diagnosis, and issues related to operative and nonoperative management are discussed with a focus on the developing spine. Our aim is to improve the understanding of traumatic cervical spine injuries in children for all practitioners involved with their care.

Effect of cervical spine immobilization technique on pediatric advanced airway management: a high-fidelity infant simulation model

OBJECTIVE

Current guidelines recommend cervical spine immobilization during orotracheal intubation when traumatic injury is suspected in infants. We evaluated the effect of cervical spine immobilization techniques on orotracheal intubation performance with a high-fidelity infant simulator.

METHODS

A randomized control study with repeated measurement. Nonanesthesia pediatric practitioners certified for intubation performed 6 intubations with 3 different cervical spine immobilization techniques (no physical protection, manual in-line immobilization, and cervical collar: C-collar). Time to accomplish key actions, cervical extension angle, and observed intubation associated events such as mainstem intubation, esophageal intubation with or without immediate recognition were recorded.

RESULTS

Twenty-six practitioners performed 156 successful orotracheal intubation. Time to intubation from end of mask assist ventilation was 29.0 +/- 12.2 seconds in no physical protection, 33.0 +/- 17.4 seconds in C-collar, and 33.0 +/- 17.1 seconds in manual in-line immobilization (P = 0.39). Maximal cervical extension angle in no physical protection (2.39 +/- 2.56 degrees ) and C-collar (2.65 +/- 1.79 degrees ) were significantly greater compared with 0.85 +/- 1.05 degrees in manual in-line immobilization (P < 0.0001). The number of intubation attempts and intubation associated events were not different among 3 techniques. Laryngeal visualization measured by Cormack-LehaneScale was more difficult in C-collar compared with other 2 techniques (P< 0.001).

CONCLUSIONS

In this high-fidelity infant simulator model, cervical spine immobilization technique affected cervical extension angle and laryngeal visualization. Tracheal intubation associated events occurred in 33% of intubation attempts but were not different by technique. Time to achieve tracheal intubation, number of intubation attempts needed to succeed, and intubation-associated events were not affected by immobilization techniques. These results support Advanced Trauma Life Support recommendations to perform manual in-line immobilization in infants.

Caring for the patients with cervical spine injuries: what have we learned?

PURPOSE

Anesthesiologists are often involved in the early management and resuscitation of patients who have sustained cervical spine injuries (CSIs). The most crucial step in managing a patient with suspected CSI is the prevention of further insult to the cervical spine (C-spine). In this review, important factors related to initial management, diagnosis, airway and anesthetic management of patients with CSI are presented.

SOURCE

Medline search was performed to seek out the English-language literature using the following phrases and keywords: spine trauma; cervical spine; airway management after CSI.

PRINCIPAL FINDINGS

Cervical spine injury occurs in up to 3% to 6% of all patients with trauma. The initial management of a patient with potential spine injury requires a high degree of suspicion for CSI so that early stabilization of the spine can be used to prevent further neurological damage. Diagnostic radiology has a critical role to play; however, clinical evaluation is equally important in excluding CSI in a conscious and cooperative patient. Although in-line stabilization reduces the movement at C-spine, traction causes clinically significant distraction and should be avoided.

CONCLUSION

A high level of suspicion and anticipation are the major components of decision making and management in a patient with CSI. Endotracheal intubation using the Bullard laryngoscope may have some advantages over other techniques as it causes less head and C-spine extension than the conventional laryngoscope, and this results in a better view. However, the current opinion is that oral intubation using a Macintosh blade after intravenous induction of anesthesia and muscle relaxation along with inline stabilization is the safest and quickest way to achieve intubation in a patient with suspected CSI. In summation caution, close care and maintenance of spinal immobilization are more important factors in limiting the risk of secondary neurological injury than any particular technique.

Cervical spine trauma in children: a review

Injuries of the cervical spine are relatively rare in children but are a distinct clinical entity compared with those found in adults. The unique biomechanics of the pediatric cervical spine lead to a different distribution of injuries and distinct radiographic features. Children younger than 9 years of age usually have upper cervical injuries, whereas older children, whose biomechanics more closely resemble those of adults, are prone to lower cervical injuries. Pediatric cervical injuries are more frequently ligamentous in nature, and children are also more prone to spinal cord injury without radiographic abnormality than adults are. Physical injuries are specific only to children. Radiographically benign findings, such as pseudosubluxation and synchondrosis, can be mistaken for traumatic injuries. External immobilization with a halo brace can be difficult and is associated with a high complication rate because of the thin calvaria in children. Surgical options have improved with the development of instrumentation specifically for children, but special considerations exist, such as the small size and growth potential of the pediatric spine.

Management of pediatric cervical spine and spinal cord injuries

DIAGNOSTIC

STANDARDS

There is insufficient evidence to support diagnostic standards.

GUIDELINES

In children who have experienced trauma and are alert, conversant, have no neurological deficit, no midline cervical tenderness, and no painful distracting injury, and are not intoxicated, cervical spine x-rays are not necessary to exclude cervical spine injury and are not recommended. In children who have experienced trauma and who are either not alert, nonconversant, or have neurological deficit, midline cervical tenderness, or painful distracting injury, or are intoxicated, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained.

OPTIONS

In children younger than age 9 years who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained. In children age 9 years or older who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior, lateral, and open-mouth cervical spine x-rays be obtained. Computed tomographic scanning with attention to the suspected level of neurological injury to exclude occult fractures or to evaluate regions not seen adequately on plain x-rays is recommended. Flexion/extension cervical x-rays or fluoroscopy may be considered to exclude gross ligamentous instability when there remains a suspicion of cervical spine instability after static x-rays are obtained. Magnetic resonance imaging of the cervical spine may be considered to exclude cord or nerve root compression, evaluate ligamentous integrity, or provide information regarding neurological prognosis.

TREATMENT

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

Thoracic elevation or an occipital recess to prevent flexion of the head and neck when restrained supine on an otherwise flat backboard may allow for better neutral alignment and immobilization of the cervical spine in children younger than 8 years because of the relatively large head in these younger children and is recommended. Closed reduction and halo immobilization for injuries of the C2 synchondrosis between the body and odontoid is recommended in children younger than 7 years. Consideration of primary operative therapy is recommended for isolated ligamentous injuries of the cervical spine with associated deformity.

Pediatric trauma. Anesthesia management

Prevention of childhood injury remains the cornerstone of reducing the number of children who present for post-traumatic surgical intervention. Beyond prevention, the next best step is the accurate diagnosis and treatment of traumatic injury. Anesthesiologists contribute to this step by providing timely resuscitation and optimal care to avoid secondary injury. This article classifies trauma in children into different categories depending on the location of the injury. Trauma, of course, is rarely focal, and is often a multisystem entity. With knowledge in management for each subset of trauma, one may be efficient in prioritizing injury and have a good understanding of the appropriate management of the pediatric patient with multiple traumatic injuries.

Part 9: pediatric basic life support. European Resuscitation Council

The epidemiology and outcome of pediatric cardiopulmonary arrest and the priorities, techniques, and sequence of pediatric resuscitation assessments and intervention differ from those of adults. Current guidelines have been updated after extensive multinational evidence-based review and discussion over several years. Areas of controversy in current guidelines and recommendations made by consensus are detailed. A large degree of uniformity exists in the current guidelines advocated by the AHA, Council on Latin American Resuscitation, Heart and Stroke Foundation of Canada, European Resuscitation Council, Australian Resuscitation Council, and Resuscitation Council of Southern Africa. Differences are currently based on local and regional preferences, training networks, and customs rather than scientific controversy. Unresolved issues with potential for future universal application are highlighted.

Optimal positioning for cervical immobilization

STUDY OBJECTIVE

We hypothesized that optimal positioning of the head and neck to protect the spinal cord during cervical spine immobilization can be determined with reference to external landmarks. In this study we sought to determine the optimal position for cervical spine immobilization using magnetic resonance imaging (MRI) and to define this optimal position in a clinically reproducible fashion.

METHODS

Our subjects were 19 healthy adult volunteers (11 women, 8 men). In each, we positioned the head to produce various degrees of neck flexion and extension. This positioning was followed by quantitative MRI of the cervical spine.

RESULTS

The mean ratio of spinal canal and spinal cord cross-sectional areas was smallest at C6 but exceeded 2.0 at all levels from C2 to T1 (P < .05). At the C5 and C6 levels, the maximal area ratio was most consistently obtained with slight flexion (cervical-thoracic angle of 14 degrees) (P < .05). For a patient lying flat on a backboard, this corresponds to raising the occiput 2 cm. More extreme flexion or extension produced variable results.

CONCLUSION

In healthy adults, a slight degree of flexion equivalent to 2 cm of occiput elevation produces a favorable increase in spinal canal/spinal cord ration at levels C5 and C6, a region of frequent unstable spine injuries.

A review of spinal immobilization techniques

Immobilization of the spine is an important skill for all emergency providers. This article reviews the literature regarding the equipment, adjuncts, and techniques involved in spinal immobilization. Current prehospital practice is to apply spinal immobilization liberally in cases of suspected neck or back injury. Rigid cervical collars, long backboards, and straps remain the standard implements for immobilizing supine patients. Tape, foam blocks, and towels can complement the basic items and improve stability. Padding may improve positioning and comfort. Intermediate-stage devices include the short backboard and newer commercial devices. Properly used, all provide reasonable immobilization of the sitting patient. Future directions for study include refinement of optimal body position, dynamic performance of all devices, and broadening study populations to include children and the elderly.

Backboard versus mattress splint immobilization: a comparison of symptoms generated

The study objective was to compare spinal immobilization techniques to a vacuum mattress-splint (VMS) with respect to the incidence of symptoms generated by the immobilization process. We used a prospective, cross-over study in a university hospital setting. Participants consisted of 37 healthy volunteers without history of back pain or spinal disease. Interventions consisted of two phases. In Phase I, subjects were randomly assigned to be immobilized on either a wooden backboard or a mattress-splint for 30 min. The incidence and severity of any symptoms generated by the immobilization process were recorded. In Phase II, the two groups were again tested after a 2-week washout period, with the method of immobilization being reversed. Symptoms and severity were again recorded. Pain symptoms were confined to four anatomic sites: Occipital prominence, lumbosacral spine, scapulae, and cervical spine. After adjusting for the effect of order of exposure, subjects were 3.08 times more likely to have symptoms when immobilized on a backboard than when immobilized on the VMS. They were 7.88 times more likely to complain of occipital pain and 4.27 times more likely to complain of lumbosacral pain. Severity of occipital and lumbosacral pain was also significantly greater during backboard immobilization. We conclude that, when compared to a VMS, standard backboard immobilization appears to be associated with an increased incidence of symptoms in general and an increased incidence and severity of occipital and lumbosacral pain in particular.

Pediatric cervical-spine immobilization: achieving neutral position?

This study was designed to evaluate prospectively the ability of current spine-immobilization devices to achieve radiographic-neutral positioning of the cervical spine in pediatric trauma patients. All trauma patients who required spinal immobilization and a lateral cervical spine radiograph were included in the study. A lateral cervical spine radiograph was obtained while the child was immobilized. The Cobb angle (C2-C6) was measured using a handheld goniometer. The method of immobilization, age at injury, and Cobb angle were compared. One hundred and eighteen patients with an average age of 7.9 years were enrolled. The majority were males (71%). The most frequent mechanisms of injury included motor vehicle accidents (35%) and falls (32%). The average Glascow Coma Scale score was 14. Although 31% of the children complained of neck pain, 92% were without neurologic deficits. The Cobb angles ranged from 27 degree kyphosis to 27 degree lordosis, and only 12 of the patients presented in a neutral position (0 degrees). Greater than 5 degrees of kyphosis or lordosis was observed in 60% of the children. Thirty-seven percent of the patients had 10 degrees or greater angulation. The most frequent methods of immobilization included a collar, backboard, and towels (40%), and a collar, backboard, and blocks (20%), but these techniques provided < 5 degrees kyphosis or lordosis in only 45% and 26% of the children respectively. No single method or combination of methods of immobilization consistently placed the children in the neutral position.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of a new cervical immobilization/extrication device

A new cervical immobilization device (the Philadelphia Red E.M. Collar with Head Immobilizer/Stabilizer), has been introduced as an adjunct in extricating potentially neck-injured patients. This study compared the efficacy of immobilization using the collar to that of a short spine board. In addition, experienced EMS personnel rated the collar in simulated field situations.

METHODS

In Part I of the study, the collar and a short spine board were applied to 25 adult volunteers in a sitting position, using standard methods. Each subject then exerted maximal force in flexion, extension, rotation, and abduction. Degrees of head motion from neutral position were measured in each direction. Mean values were compared using Student's t-test. For Part II, 10 EMS personnel were asked to apply the collar to volunteers. Each rated the performance of the collar on a scale of 1 (poor) to 4 (excellent) regarding: ease of application (sitting and supine), ease of extrication (lifting, logrolling, transfer), access to patient (chest auscultation, CPR, airway management), storage, and overall utility.

RESULTS

The collar was significantly better than the short spine board in both lateral and rotational immobilization (p less than 0.001). There was no significant difference for flexion or extension (p greater than 0.05). The Red E.M. limited motion to a mean of 15 degrees or less in any direction. Ratings by EMS personnel for the device (mean+/- standard error) were: ease of application (sitting) 3.5+/-0.2, (supine) 2.7+/-0.2; ease of extrication 3.1+/-0.2; access to patient 3.4+/-0.2; storage 3.1+/-0.3; and overall utility 3.1+/-0.2.(ABSTRACT TRUNCATED AT 250 WORDS)

Respiratory effects of spinal immobilization in children

STUDY OBJECTIVE

To assess the restrictive effects of two spinal immobilization strapping techniques on the respiratory capacity of normal, healthy children.

DESIGN

Prospective study with each subject serving as his own control.

PARTICIPANTS

Fifty-one healthy children 6 to 15 years old.

INTERVENTIONS

Participants' forced vital capacity (FVC) measurements were first obtained with children standing and lying supine and then in full spinal immobilization using two different strapping configurations, cross straps and lateral straps. Straps were tightened to allow one hand to fit snugly between the strap and child.

MEASUREMENTS AND MAIN RESULTS

Supine FVC was less than upright FVC (P less than .001). FVC in spinal immobilization ranged from 41% to 96% of supine FVC (80 +/- 9%). There was no difference in FVCs between strapping techniques (P = .83).

CONCLUSION

Spinal immobilization significantly reduced respiratory capacity as measured by FVC in healthy patients 6 to 15 years old. There is no significant benefit of one strapping technique over the other.

A practical radiographic comparison of short board technique and Kendrick Extrication Device

Cervical spine immobilization is necessary during the prehospital care of most trauma patients. Earlier studies performed in controlled, indoor settings suggested short board technique (SBT) was the standard against which other methods of cervical stabilization should be measured. Our study approximated the prehospital setting by comparing the use of tape, SBT, and Philadelphia collar (PC) with tape, the Kendrick Extrication Device (KED), and PC after immobilization in and extrication from a compact car. Seven men were immobilized with KED and SBT in addition to PCs and tape. These subjects were extricated and then taken by ambulance stretcher across a 50-yd length of concrete to the radiology suite. Flexion, extension, lateral bending, and rotation were measured. KED-PC (16 degrees +/- 8 degrees) was statistically superior to SBT-PC (41 degrees +/- 5 degrees) in limiting rotation (P less than .001). KED-PC and SBT-PC were similar in their abilities to limit extension (8 degrees +/- 4 degrees vs 6 degrees +/- 5 degrees), flexion (4 degrees +/- 2 degrees vs 4 degrees +/- 4 degrees), and lateral bending (13 degrees +/- 5 degrees vs 17 degrees +/- 6 degrees). In an approximation of the prehospital setting, tape, a PC, and either KED or SBT substantially limit extension, flexion, and lateral bending of the normal cervical spine. KED-PC is more beneficial in rotation.