Is Cervical spine protection always necessary following penetrating neck injury

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1 Is Cervical spine protection always necessary following penetrating neck injury Report By: Search checked by Institution: Date Submitted: Date Completed: Last Modified: Status: Carel Kruger - Senior Clinical Fellow Fiona Lecky - Consultant in Emergency Medicine Salford Royal Hospital, Manchester 4th June th December th December 2009 Green (complete) Three Part Question In [a patient with isolated penetrating neck wound], is [the risk of spine injury so low] that [ spine immobilisation may be omitted]? Clinical Scenario A 23 year old male is brought to the ED after an alleged assault. He sustained a gunshot wound to his neck, is haemodynamically stable, and currently there is no bleeding from the wound. Your secondary survey does not reveal any neurological deficit. The ambulance crew has not immobilised his spine, and you wonder if you should apply spine immobilisation. Search Strategy Using MEDLINE via the Ovid interface, 1950 to August 2009, week 3: Medline:[exp Neck OR exp Wounds, Gunshot OR exp Wounds, Penetrating OR exp Neck Injuries OR exp Spinal Fractures OR neck trauma.mp] AND [exp Orthotic Devices OR exp Orthopedic Equipment OR collar.mp. OR stabili$.mp. OR immobili$.mp] AND [spinal cord injury.mp. OR exp Spinal Cord injuries] LIMIT TO [English language and Humans] Using Cochrane: spinal immobilisation. 1 di 7 03/04/14 12:45

2 Search Outcome A total of 311 papers were found of which six were relevant to the question asked. One further paper was found by hand searching references from these papers. Relevant Paper(s) type Apfelbaum One patient Case report The collar Single case et al with was removed by report unstable c-spine fracture without initial neurological deficit after GSW EMS in an effort to control bleeding. In the ED the patient was neurologically intact, but the C-spine was immobilised again after x-rays revealed a comminuted C5 fracture and 2 mm subluxation of C5 on C6. At hospital discharge the patient had a possible C6 nerve root injury Barkana 44 military Retrospective Indications, In 8 of 36 (22%) Population not et al, 2000, casualties with PNI analysis of hospital benefits & risks hospitalised associated with casualties a applicable to typical UK ED. Israel (penetrating neck injury) - High velocity GSW (13), charts and autopsy reports C-spine stabilisation during pre-hospital care: life-threatening sign (large/expanding haematoma, or subcutaneous The force and mechanism of injury is more severe than that expected projectiles emphysema) was in a civilian (38), and knife injuries (2). All had stabilisation diagnosed in the exposed neck, which may have been hidden by a setting 2 di 7 03/04/14 12:45

3 Connell et al, 2003, UK Medzon et al, 2005, USA type devices applied 34,903 trauma patients, of which 1929 (5.5%) sustained penetrating trauma. 12 out of 27 patients had penetrating trauma and concurrent spinal injury. (15 excluded who also had major blunt mechanism or had trivial injury to the spine). One GSW, others were sharp weapons 81 patients collar. No casualties required internal surgical stabilisation of the c-spine Retrospective Incidence of All 12 patients analysis of mechanically with spinal cord data from the unstable spinal injury either had with gunshot chart review wounds to the head and neck registry potentially involving the spine. 19 had c-spine Scottish column injuries obvious initial Trauma Audit and spinal cord clinical evidence Group (STAG) injuries: of a spinal cord injury or were in traumatic cardiac arrest. None of the initially neurologically intact patients subsequently Retrospective Of 11 patients using a trauma showed to have a cord injury or unstable CSF 8 had stable CSF, with acute and 3 were neurologic unstable deficit: (requiring surgical stabilisation) Of 65 patients 3 had stable CSF without (4.6%; 95% CI neurologic %) - all deficit: treated in hard Large population with low incidence of PNI studied. Small cohort. Looked at full spinal immobilisation Small series in a single centre 3 di 7 03/04/14 12:45

4 Klein et al 2005 USA fracture (CSF) 228 s with Spinal Injuries (with single GSW and survived > 24h) after GSW to the trunk, neck, or head type collar alone. No patients (0%; 95% CI 0-5.5%) were found to have unstable CSF Of 5 patients All 5 had stable with Altered CSF Levels of Consciousness: Potential risk All 5 patients who factors for presented with unstable CSF: altered mental status had a stable CSF. All 11 patients with a neurological deficit had CSF (8 stable and 3 unstable) Retrospective Occurrence of Out of 183 Likely selection cohort spine injuries patients with bias. Spinal among GSW to the neck, damage neurologically 33 (18%) had a probably intact patients spinal injury, of established at with GSW to which 17 (51%) presentation. the head, neck were significant*, No further and torso and only one specific (3%) had an information unsuspected given about significant spinal patients with injury**. unsuspected (*Significant significant spine injury injury, or defined as either follow up cord involvement, mentioned. spine-related Significant surgical injury may not procedure necessarily performed, or mean unstable prolonged spinal spinal injury. immobilisation did not 4 di 7 03/04/14 12:45

5 Rhee et al, 2006, USA type needed. focus on **Unsuspected c-spine spine injury injuries, and defined as proven looked more spine injury with into the no neurologic question of finding at complete admission ) radiological spine evaluation 24,446 patients with cohort blunt or penetrating injury studied to determine the incidence of spine fracture (CSF) and spinal cord injury (CSCI) based on mechanism following gunshot wounds (GSW), stab wounds (SW) or blunt assault (BA) Retrospective Incidence rates Significantly for CSF different (Cervical spine (p<0.05) for fracture): different mechanisms: GSW = 1.35% (n=12,573); SW = 0.12% (n=7,483); BA = 0.41% (n=4,390) Incidence rates Significantly for CSCI different (Cervical spinal (p<0.05) for cord injury): GSW: GSW = 0.94% (n=12,573); SW = 0.11% (n=7,483); BA = 0.14% (n=4,390) CSCI and All GSW patients Recovery: with CSCI had their injury at the time of assault. No penetrating injury patient with CSCI regained significant neurologic recovery during hospitalisation 5 di 7 03/04/14 12:45

6 type (level of Outcomes Key results % of 0% of patients neurologically after SW and intact patients 0.03% of patients requiring after GSW surgical or halo stabilisation: Comment(s) Since penetrating neck injury is not commonly encountered in the civilian environment, it is not surprising that most evidence is from military settings. Contemporary trauma teaching does not make a distinction between blunt and penetrating trauma in terms of the need for spinal immobilisation. In contrast with blunt injuries, the value of spine protection by means of a neck collar is questionable and may be harmful after penetrating neck trauma. The incidence of airway injury needing advanced airway protection and that of major vascular injury is much higher than the incidence of unstable spine injury after penetrating neck injury. The rate of spinal fracture or cord injury following assault is dependent on the mechanism of injury. Thus, the concern and extent of evaluation should also be dependent on the mechanism of injury. The purpose of applying a collar is to prevent further neurological deficit from an unstable c-spine fracture. The latter is extremely rare in the context of stab wounds, but has a significant incidence when the mechanism has been a high-velocity gunshot wound, where massive destruction of the bone and ligament structures of the spine may cause instability. However, these injuries in themselves are more than likely associated with severe irreversible spinal cord destruction, making spinal immobilisation of limited practical value. Neurological deficit from penetrating assault seems to be established and final at the time of presentation, apart from a single inconclusive case report. Concern for protecting the neck with a stabilisation device should not hinder or compromise life-saving interventions (airway and haemorrhage control) or the clinical evaluation process of life-threatening complications of penetrating injury (which manifest as visible or palpable signs in the neck and may be missed in up to 22% Editor Comment *Significant spine injury defined as either cord involvement, spine-related surgical procedure performed or prolonged spinal immobilisation needed. {Unsuspected spine injury defined as proven spine injury with no neurological finding at admission. BA, blunt assault; CSCI, spinal cord injury; CSF, 6 di 7 03/04/14 12:45

7 c-spine fracture; ED, emergency department; GSW, gunshot wound; PNI, penetrating neck injury; SW, stab wound Clinical Bottom Line From the above it may be concluded that: (1) In stab wounds to the neck (with or without neurological deficit) an unstable spinal injury is very unlikely and c-spine immobilisation is not needed. (2) In gunshot wounds the value of cspine immobilisation is limited: for gunshot wounds without neurological deficit no immobilisation is required, while in cases of gunshot wounds with neurological deficit, or where the diagnosis cannot be made (ie, altered mental status), a collar or sandbag is advised once ABCs are stable, with close observation and intermittent removal to inspect and reassess. (3) In the rare event of penetrating injury with combined blunt force trauma, a collar or sandbag is advised if possible, once ABCs are stable, with intermittent removal to reassess. References Apfelbaum JD, Cantrill SV, Waldman N. Unstable spine without spinal cord injury in penetrating neck trauma. Am J Emerg Med. 2000;18:55-7. Kwan I, Bunn F, Roberts I, on behalf of the WHO Pre-Hospital Trauma Care Steering Committee. Spinal immobilisation for trauma patients. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD DOI: / CD Barkana Y, Stein M, Scope A, Maor R, Abramovich Y, Friedman Z, Knoller N. Prehospital stabilization of the spine for penetrating injuries of the neck - is it necessary? Injury Jun;31(5): Connell RA, Graham CA, Munro PT. Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma? Injury Dec;34(12): Medzon R, Rothenhaus T, Bono CM, Grindlinger G, Rathlev NK. Stability of spine fractures after gunshot wounds to the head and neck. Spine Oct 15;30(20): Klein Y, Cohn SM, Soffer D, Lynn M, Shaw CM and Hasharoni A. Spine Injuries Are Common Among Asymptomatic s After Gunshot Wounds. J Trauma Apr; 58: Rhee P, Kuncir EJ, Johnson L, Brown C, Velmahos G, Martin M, Wang D, Salim A, Doucet J, Kennedy S, Demetriades D. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma Nov;61(5): di 7 03/04/14 12:45