A Review of the Literature: Managing Cervical Spine Injuries

Transcription

1 A Review of the Literature: Managing Cervical Spine Injuries MaryBeth Horodyski, EdD, LAT, ATC, FNATA Professor and Director of Research Department of Orthopaedics and Rehabilitation

2 Funding Sources for Research Laerdal Foundation NOCSAE NCAA Southwestern Medical Foundation Stryker

3 Objectives Current Research and Best Practices Positioning on Spine Board Supine Prone Helmet & Equipment Removal Stabilization for Transport Cervical Collars Strapping Techniques Future Directions

4 What Happens After the Timeout? You are now Prepared to Act Appropriate equipment for spine boarding procedures has been assembled You met with Paramedics and all Medical Team personnel But are you using the best/safest practices? Position on Spine board Equipment Removal Secure to Spine board

5 No one ever wants to be in this situation but.. will you know what is best to do when you are?

6 Why Immobilize? Case reports of exacerbation of injuries from standard actions or procedures Harrop et al Powell et al Amount of motion and forces required to create secondary neurologic injury unknown

7 Epidemiology Annual immobilization numbers in the US Between 1 and 5 million patients (Stiell et al., 2001, Orledge and Pepe, 1998) Estimates for the US range from 10-12,000 new SCI annually (NSCISC, 2012) 7.6% caused by traumatic sports-related events Majority due to diving and swimming (Ghiselli, et al., 2003) ~ 7% of patients have unstable spinal fractures but not complete SCI (Haut et al., 2010)

8 Research Team Goal: Investigate and develop techniques to Prevent neurologic deterioration during initial stages of prehospital care, during transport, in the ED, and in the OR when preparing for surgery. 8

9 Research Methods An electromagnetic tracking device (Liberty - Polhemus Inc., Colchester, VT) To quantify the amount of segmental motion generated Receivers of the tracking device were fastened onto the forehead and sternum

10 Methods: Variables Measured Dependent variables: Angular motion ( o ) Flexion/extension Right and left lateral flexion Right and left rotation Linear displacement (mm) Anteroposterior displacement Medial/lateral displacement Distraction/compression Independent variables: Technique Injury condition

11 Traditional Hand Hold 1 1

12 Modified Hand Hold 1 2 Modified Hand Hold

13 1 3 Hand Placement * # Axial rotation and lateral bending: Significant differences between techniques (p<0.001) - both LR techniques had more motion

14 Supine Patient Options Log roll (traditional) Lift-and-slide (straddle lift or 8 person lift) Mechanical device (Scoop stretcher, motorized spine board) Influencing factors Patient size Personnel Number Relative strength Preparedness (practice)

15 Supine Patient - Spine Board Transfer Techniques Log roll vs lift-and-slide (Del Rossi et al., JAT, 2003) Training study 48 healthy subjects (8 teams)

16 Supine Patient - Spine Board Transfer Techniques Log roll vs lift-and-slide (Del Rossi et al., JAT, 2003) Flexion- Extension Axial rotation Lateral flexion

17 Supine Patient - Spine Board Transfer Techniques Cadaveric study Log roll vs lift-and-slide vs 8 person lift (Del Rossi et al., JAT, 2008)

18 Supine Patient - Spine Board Transfer Techniques Log roll vs lift-and-slide vs 8 person lift (Del Rossi et al., JAT, 2008)

19 Supine Patient - Spine Board Transfer Techniques Mechanical Transfer Devices Log roll vs scoop stretcher (SS) (Krell et al., Prehosp Emerg Care, 2006) 31 healthy subjects Electromagnetic sensors Forehead, C3 (surface), T12 (surface) Results 6-8 degrees greater motion in all three planes during LR compared to SS

20 Angular Motion (degrees) Linear Translation (cm) Supine Patient - Spine Board Transfer Techniques Mechanical Transfer Devices Log roll vs LS vs Scoop Stretcher (Del Rossi et al., AJEM, 2010) Cadaveric study Destabilized C5-C Flexion - Extension Axial Rotation Lateral Flexion Medial - Lateral Translation Distraction - Compression Anterior - Posterior Displacement LR Technique LS SCOOP 0 LR Technique LS * SCOOP *

21 Supine Patient - Spine Board Transfer Techniques Log roll vs lift-and-slide vs 8 person lift (Del Rossi et al., Spine, 2008) Thoracolumbar instability Cadaveric - L1 burst fracture

22 Eliminating the Log Roll When using log roll techniques for transfers Sum of the largest displacements during the total sequence 2 times for flexion/extension 2.6 times for axial rotation 2.8 times for lateral bending Prasarn et al Spine Journal No log roll Sum of the greatest displacements for the complete sequence was significantly decreased Prasarn et al Journal of Neurosurgery Overall cumulative motion to the unstable spine can be reduced by approximately 50% if the log roll is avoided and alternative measures are employed Conrad et al. 2012

23 Supine Obese/Large Patient Spine Board Transfer Techniques Personnel or strength concerns 2001 NATA Consensus Statement suggested adding more personnel to 6+ person lift = 8+ Log roll might be only other option Equipment concerns Scoop stretchers might be too narrow or too short to accommodate large patients.

24 Supine Patient Equipment-laden Spine Board Transfer Techniques NATA Consensus Statement LS or 8 person lift with equipment on Rolling over equipment may induce motion (2001) Equipment fit Youth helmets may not fit securely as would be needed to be able to safely transfer patient May need to consider removing helmet before transferring patient

25 Supine Patient - Summary LS and 8 (6+) person lift generate less motion than LR Scoop stretcher As safe as LS Consider LS, 8 person and scoop stretcher as alternative to LR (supine patient) 8 person and scoop stretcher are possible alternatives for equipment-laden athletes 8+ for large patients

26 Prone Patient Options Log roll (pull) vs. log roll (push) Log roll (1x) vs. log roll (2x) Influencing factors History (convention) Personnel Availability of spine board Preparedness (practice)

27 Prone Patient Spine Board Transfer Techniques Push vs Pull Cadaveric study Thoracolumbar instability Conrad et al., J Spinal Cord Med, 2012

28 Prone Patient Spine Board Transfer Techniques Significantly less motion with the Push technique Flexion/Extension; Axial Translation; Ant/Post Translation

29 Prone Patient Spine Board Transfer Techniques Prone to supine (Prasarn et al., in preparation) Options LR to supine + LR onto spine board LR to supine + LS or 8 person or scoop stretcher LR directly to spine board Cadaveric study C5-C6 instability

30 Millimeters Prone Patient Spine Board Transfer Techniques Prone to supine (Prasarn et al., in preparation) Preliminary data Prone Spine Boarding LR LR/6+ LR/LR 5 0 Medial/Lateral Sup/Inf Ant/Post C5-C6 Translation

31 Prone Patient Equipment-laden Equipment fit Hockey Mihalik et al Might this be a good time to initiate removal of equipment?

32 Prone Patient Summary LR only option; but how many times should you move the patient? Decide in advance how the situation should be handled based on circumstances. With every transfer there is the potential or opportunity for motion to occur.

33 Spinal immobilization Spine board is current gold-standard for prehospital spinal immobilization Full body immobilization on a vacuum mattress also possible Pro and cons Vacuum Mattress

34 Vacuum Mattresses Spinal immobilization Vacuum mattress vs spine board Johnson et al., AJEM, subjects Immobilization during lateral tilting (90 o )

35 Equipment Issues in the Cervical Spine Injured Athlete Injured player s helmet and shoulder pads pose challenges to the medical team s ability to Properly assess the cervical spine region Immobilize the cervical spine

36 Facemask Removal Cordless screwdriver was the best way to remove a football helmet Pruners should be carried as a backup in case the cordless screwdriver fails Facemask removal practice and hardware inspection reduce chances of failure Brandey et al. JAT, 2013

37 Facemask Removal Combined tool approach CSD and cutting tool resulted in 100% success Average time: ± 15.37sec Copeland et al. Clin J Sport Med, 2007 On-field conditions throughout football season 98.6% (75/76) of removal attempts were successful with combined tool approach Average removal time 40.1 ± 15.1 seconds Gale et al. JAT, 2008

38 Quick Release Facemask Removal Removal time of quick release face guard Riddell Quick Release Helmet After a season of football Removal of facemask Satisfactory time and success rate Gruppen et al. JAT, 2012; Scibek et al. JAT, 2012 Quick release More effective than other facemask removal techniques Better success rate Swartz et al. JAT, 2010

39 Facemask: Other Options Feed mask through facemask The PMI (Pocket Mask Insertion) technique significantly faster ± 5.92 seconds QRM ± seconds CSD ± seconds Toler et al. Clin J Sport Med, 2011 PMI time seconds Ray et al. JAT, 2002

40 Time vs. Motion: Translational Movement for Airway Access

41 Time vs. Motion: Rotational Movement for Airway Access

42 Helmet Removal: Techniques Helmet bladders should be left inflated when the helmet is removed It takes longer to deflate a helmet and remove a helmet It is not always possible to access all the bladders in a supine athlete Beltz et al (

43 Helmet Removal: Techniques After the helmet is removed, padding should be placed under the head to prevent hyperextension Del Rossi G et al., 2014 DeCoster LC et.al., Spine, 2012 Waninger KM et.al., Current Sports Medicine Reports, 2011 Shoulder pads can remain on if spinal alignment can be maintained

44 Helmet Removal Study A comparison between two removal techniques Facemask removal then helmet removal Direct helmet removal Helmet removal techniques were measured in cadaveric model with a suspected cervical spine injury

45 Helmet Removal Study Facemask removal then helmet removal (FMH) Facemask was removed first with an electric screwdriver Right ear side, left ear side, right frontal, and then left frontal was the screw removal order Helmet was then removed according to NATA position statement

46 Helmet Removal Study Direct helmet removal (Helmet) The helmet was removed using the two rescuer-two hands approach For both the FMH and Helmet removal techniques, cheek pads were removed. Spinal alignment was maintained throughout the helmet removal Head was placed on padding to maintain spinal alignment

47 Degrees ( ) Helmet Removal Study 10 Means of Angular Displacement at C5-C FMH Helmet 0 Flex/Ext Axial Rot Lat Bend FMH caused significantly less flexion-extension (p=0.023) and axial rotation (p=0.023) than the Helmet technique.

48 Milimeters (mm) Helmet Removal Study Means of Translation Displacement at C5-C6 Med/Lat Axial Trans Ant/Post FMH Helmet FMH caused significantly less anterior-posterior (p=0.035), mediallateral (p=0.013), and axial (p=0.028) translations than the Helmet technique.

49 Shoulder Pad Removal

50 Traditional Pad Removal

51 Elevated Torso Removal

52 Shoulder Pad Removal Alterations to shoulder pads allow for quick removal if necessary Riddell RipKord Shoulder pads are separated into two halves and slid from under the athlete Allowed less motion than flat torso removal Kordecki M et al., J of Sports Phys Ther, 2011

53 Shoulder Pad Removal Methods of removal Levitation Tilt Log roll Levitation caused more anterior displacement, shear and moment when compared to the other two methods Dahl et al. J Applied Biomechanics

54 Equipment Removal Football shoulder pads can be removed using the elevated torso method Horodyski et al 2009 A new shoulder pad system has been developed RipKord Kordecki 2011 Vest and racing collar assembled with front and back pieces Removal by elevated torso method 54

55 Cervical Collar NATA Position Statement Manual stabilization of the head should be converted to restriction using a combination of external devices Cervical collars Various head stabilizing devices

56 Effectiveness of Cervical Collars Application of one and two piece collar on intact and unstable spine Significantly more movement when applying the collar to an unstable spine Two piece collar had significantly more movement than the one piece Clinical relevance? - small difference Collars can be placed and removed with manual in-line stabilization and (potentially) minimal risk Prasarn et al., Trauma Acute Care Surg, 2012

57 Effectiveness of Cervical Collars Application of a cervical collar caused increased separation at the injury site C1-C2 level Ben-Galim et al. J Trauma, 2010 Biomechanics of cervical restriction with collars Rigid collars create pivot points that shift the center of rotation lateral to the spine and contribute to the intervertebral motion Lador et al. J Trauma, 2011

58 Effectiveness of Cervical Collars Often cannot correctly apply cervical collars when the athlete is wearing equipment Time of application and impact to beginning critical life saving procedures Why do we put cervical collars on conscious trauma patients? Benger J and Blackham J, Scand J Trauma Resuscitation Emerg Med, 2009

59 Effectiveness of Cervical Collars Cervical collars do not effectively reduce motion in an unstable cervical spine Horodyski et al. J Emerg Med, 2011 Miller CP et al. Spine, 2010 Bearden et al. J Neurosurgery, 2007 Del Rossi et al. The Spine Journal, 2004

60 6 0 Strapping Techniques Minimize excess movement Secure enough to roll spine board if athlete vomits Hands secured on top of the chest Journal of Athletic Training 2009;44(3):

61 Degrees Millimeters Degrees Degrees Results Flexion-Extension at C5-C6 Lateral Bending at C5-C6 3.0 p= SPIDER 3 7 SPIDER Axial Rotation at C5-C6 Medial-Lateral Translation at C5-C SPIDER 3 7 SPIDER

62 Conclusions: Strapping Techniques 3-Strap technique was significantly inferior in four of the six outcome measures Measured difference was small SPIDER technique resulted in less motion than the 7-Strap Not significantly different Overall, our study demonstrated that the SPIDER technique resulted in less slipping motion in the event the immobilized patient must be rolled to clear the airway

63 Spine Board Centering Methods Examine which method causes the least amount of angular and translational movement Techniques tested Horizontal Slide Diagonal Adjustment V-Adjustment Technique

64 Results: Spine Board Centering

65 Results: Spine Board Centering

66 Conclusions: Spine Board Centering First responder should minimize movement Horizontal slide has less movement than diagonal and V-adjustment Horizontal slide easier to complete

67 NEW STUFF: Calculating SAC Our lab has developed a program that can calculate the space available for the cord during range of motion trials Tested cadaveric model using a intact and total instability in a cervical spine specimen Data was collected in mm 2

68 Calculating SAC Specimen and robot set-up for calculating SAC

69 Calculating SAC Three dimensional representation of the cervical spine specimen.

70 Calculating SAC Spinal canal overlap of the C5-C6 vertebrae The black and white image is the SAC in the C5-C6 segment 70

71 Calculating the SAC Levels of instability Intact cervical spine First interspinous ligament Second anterior longitudinal ligament Third the entire facet joint Results No significant differences between the levels of instability As the level of instability increased, the SAC decreased Extension caused the greatest decrease in SAC

72 Future Research Further develop the software to account for changes in soft tissue inside the spinal canal Intervertebral disc, posterior longitudinal ligament, ligamentum flavum Use this program to calculate SAC during prehospital treatment techniques Collar application, spine boarding, bed transfers Lesser chance of secondary injury 72 72

73 What is Next? Inter-association Spine Task Force Spinal Precautions versus Immobilization Spinal Motion Restriction versus Immobilization Restriction: cervical collar; caution patient Potential risks to patients on spine board

74 What is Next? What MOIs require immobilization Blunt trauma and altered level of consciousness Spinal pain or tenderness Neurologic complaint Numbness or motor weakness Anatomic deformity of the spine High-energy mechanism of injury Any of the following Drug or alcohol intoxication Inability to communicate Distracting injury

75 THANK YOU