C-Spine For Penetrating Injuries

[medcitool]

I am not a fan of LBB and collar for every trauma in the world but this took me by surprise. I come from an area that has specific no board or to board policies. We get certified in the art of removing a pt. from a c-spine status. I don't know why but we have to do it. It's actually easy and uses common sense and is the same thing the doc's do. How many of you guys have seen the doc's remove a LBB and collar from a pt. without x-ray or CT. Happens all the time. Anyway away from that is the PHTLS guidelines. I asked a trauma doc this very question. Answer is simple. The potential injury from a GSW is nearly immediate according to research and the potential for further injury without c-spine precautions is nearly nothing. I have not found research to substantiate that claim but I continue to look. Because of the pentrating aspect of the injury the body almost self corrects per say. In blunt force there is great potential for swelling and spinal cord compression. Thus a LBB in this situation is recommended due to movement with swelling resulting in possible compression. That is the difference between blunt and penetrating. If you have further specific questions let me know and I will ask.

[p3medic]

A2E, welcome....looking at your flag of Israel reminds me of a study regarding penetrating neck trauma done there, with the conclusion as already state that neurological damage is done at the time of injury, or not at all....http://linkinghub.elsevier.com/retrieve/pii/S0020138399002983

Not sure if this one was posted already, but all seem to come to the same conclusion...

[JPINFV]

A2E, welcome....looking at your flag of Israel reminds me of a study regarding penetrating neck trauma done there, with the conclusion as already state that neurological damage is done at the time of injury, or not at all....http://linkinghub.elsevier.com/retrieve/pii/S0020138399002983

Not sure if this one was posted already, but all seem to come to the same conclusion...

Abstract

The purpose of this study was to assess the specific indications, benefits and risks associated with cervical spine stabilization during pre-hospital care of penetrating neck injuries. We retrospectively reviewed hospital charts and autopsy reports of 44 military casualties in Israel with a penetrating neck injury during a period of 4.5 years. A review of the literature was also carried out. In eight of 36 hospitalized casualties (22%) a life-threatening sign was diagnosed in the exposed neck — large or expanding haematoma, or subcutaneous emphysema. Surgical stabilization of the cervical spine was not performed for any of the casualties. It was concluded that life threatening complications due to penetrating neck injury are common and may be overlooked if the neck is covered by a stabilization device. It is extremely rare for a penetrating injury to result in an unstable cervical spine. New management guidelines concerning pre-hospital stabilization are suggested.

1. Introduction

The question of whether to stabilize the cervical spine during the initial management of a trauma victim who has sustained a penetrating neck injury, has recently stirred debate and controversy among trauma surgeons and neurosurgeons in our country. The trigger was a few cases in which a semi-rigid collar was applied over a penetrating injury, usually due to high velocity bullets or projectiles. Findings such as continuous oozing, subcutaneous emphysema and especially expanding haematoma were initially missed.

Current literature does not directly address the indications, benefit and risk concerning so-called immobilization for penetrating neck injuries. This is true for both journals [1, 2, 3, 4, 5, 6 and 7] and major trauma textbooks [8, 9, 10, 11 and 12]. Most authors simply recommend that all patients with such injuries should be immobilized, or merely state that such is the practice in their emergency department and pre-hospital trauma care. Even the manual of the ATLS® [13] does not make a distinction between blunt and penetrating neck trauma, generally stating that “…any patient with a suspected spine injury must be immobilized above and below the suspected injury site until injury has been excluded by roentgenograms”. In addition it stresses that “…cervical spine injury requires continuous immobilization of the entire patient with a semi-rigid cervical collar, backboard, tape and straps before and during transfer to a definite-care facility”. In depth analysis of the text following these statements reveals that the author is referring only to casualties from blunt injury!

In this study we try to assess the benefit and risk of cervical spine stabilization in penetrating neck injury. New management guidelines for penetrating neck injuries at the pre-hospital setup are suggested.

2. Materials and methods

During the period from January 1993 to June 1997, 54 soldiers of the Israeli army were diagnosed in the field as having a penetrating neck injury. All injuries involved gunshot, projectiles or stab wounds. Military physicians on site performed the initial assessment and began treatment.

Current guidelines in the Israeli Army Medical Corps, based on ATLS, call for early stabilization of the cervical spine for every suspicion of significant neck injury. Accordingly, in all cases in this series a stabilizing apparatus was applied to the neck, either a semi-rigid collar, a rolled blanket, or both.

We conducted a retrospective review of the casualties’ hospital charts or autopsy reports. Of the 14 casualties who had died before reaching hospital, eight underwent an autopsy. Forty casualties were evacuated to seven trauma centers, 37 of them to a level-one trauma center; 36 hospital charts were available for study. Thus, anatomical details of injury were available in 44 cases of the total of 54 (81.5%). The available data were analyzed for details of neck injury, associated injuries and treatment procedures. Specifically, we looked for diagnoses and treatment of cervical spine instability, cases that would have benefited from pre-hospital stabilization; and conditions that could be masked by a collar.

3. Results

Forty-four hospital and autopsy charts were available for analysis, out of a total of 54 injuries during the study period of 4.5 years. Most injuries were due to projectiles (38), or bullets (13). Knife injuries (2 cases), and direct missile hits were a rare occurrence. Table 1 and Table 2 show the distribution of injuries and important signs for the 44 cases we studied. Table 3 shows the treatment performed for the 36 cases that were transported to a hospital.

Table 1. Signs and injuries in the neck among 44 patients with penetrating neck trauma Image

Table 2. Neurological findings and associated injuries among 44 patients with penetrating neck wounds Image

Table 3. Procedures performed on 12 patients with penetrating neck wounds Image

All patients who were admitted to a hospital survived. Of those, 20 patients (56%) suffered only superficial wounds. The remaining neck injuries were diverse. In eight cases (22%) the emergency room staff identified a significant sign in the exposed neck after removal of the stabilization apparatus, a large/expanding haematoma, or subcutaneous emphysema.

None of the patients underwent internal surgical stabilization of the cervical spine. Of the 12 patients with vertebral fracture, a Crutchfield traction device was applied in one case; the injury caused a comminuted fracture of C7 lamina, fracture of posterior arc of C6, chip fractures of D1, D2, D3, with fragments in the spinal canal and complete tetraplegia. No dislocation was noted.

In two of the cases the patients remained with a Philadelphia collar. One case had a comminuted fracture of part of the lateral mass of C1, without joint movement, and was neurologically intact. The second suffered injury to the body of C6 and the lamina of C7, with slight opening of C5–C6 joint and minimal posterior displacement of C5, with complete tetraplegia at the C7 level.

Twelve patients were operated on for indications unrelated to cervical spine stability — Table 3. Of the eight fatalities studied, four had complete transection of the spinal cord. In these cases the vertebral injuries were as follows: (a) bullet passage through the body of C7; ( comminuted fracture of bodies of C1, C2; © complete tear of cartilage between C2 and C3; and (d) fracture of bodies of C3–C5. Furthermore, two casualties died of laceration of major neck vessels. Finally, two fatalities had only superficial neck wounds and died of unrelated injuries.

Ten casualties, in whom penetration of the spinal canal occurred, included four who died of cord transection (diagnosed on autopsy). Three others presented with complete tetraplegia on hospital admission and one had severe tetra-paresis. Two had partial neurological damage — one with left hypaesthesia below the nipple and one with lower extremity paralysis and upper extremity paresis.

4. Discussion

Some trauma surgeons question the indications for cervical spine stabilization during the initial management of a penetrating neck injury. Apparently there is no definite answer in the literature. We believe that the current “standard of care”, the application of a rigid or semi-rigid cervical collar, has evolved inadvertently from the universally accepted procedure for blunt trauma casualties. The risks of rigid/semi-rigid collar application over a penetrating injury justify, to our understanding, the revision of management guidelines for penetrating neck injuries at the pre-hospital setup. Life threatening complications of penetrating neck injury manifest as visible or palpable signs in the neck and may be overlooked if the neck is covered by a device such as a semi-rigid collar. These signs are sometimes indicators for urgent treatment in the pre-hospital setting and the need for immediate surgery in the Emergency Department. Signs such as a large or expanding haematoma, tracheal deviation, subcutaneous emphysema and diminished or absent carotid pulsation are indicators of an impending catastrophe that endangers the victim’s airway and life. Overlooking these signs even for a few minutes may severely affect the outcome. In our review, eight casualties (22%) had developed one of those signs.

In order to characterize penetrating neck injuries, Carducci et al. [2] performed a meta-analysis encompassing 1830 gunshot and stab wounds to the neck. It showed a 40% incidence of damage to a major blood vessel and an 18% damage to the hollow structures in the neck — pharynx, trachea, larynx, and esophagus. In comparison, the cervical spine was injured in 2.7% and the spinal cord in 1.9%. The authors did not correlate the precise association between skeletal and cord injuries. Although they emphasize the need for a complete and detailed physical examination of the neck, they recommend the routine immobilization of the cervical spine at the immediate onset of management with no specific reasoning.

Ordog et al. [3], in their series of 110 gunshot wounds to the neck, reported that 24 patients (21.8%) had endotracheal intubation, three underwent cricothyroidotomy, and two had tracheotomy performed due to massive neck swelling. The authors report a 23% incidence of major arterial and venous injury, all of which required surgical repair.

It should be added that the necessity to keep the neck straight makes endotracheal intubation more difficult [14]. Often, multiple attempts are required, subjecting the patient to longer hypoxia. In the dramatic setting of neck injuries it may lead to more cases of surgical airway, which is especially difficult in penetrating neck injuries because of the haematoma. This is aggravated in military settings where the treating personnel are less experienced. The acceptance that cervical spine control in such a specific circumstance is unnecessary, if not detrimental, can greatly assist the provider of care and give him a more favorable setup.

Common belief maintains that movement of the non-immobilized patient with an unstable vertebral column injury places the spinal cord at risk of primary or worsening damage. It is generally agreed that injuries in which the column remains stable or there is a complete cord injury will not benefit from neck stabilization, but proponents of stabilization state that these diagnoses cannot be made during the initial management of the victim and thus the neck must be splinted. Based on the following data, we challenge this logic and recommend a re-appraisal of this practice.

Arishita et al. [15] reviewed the Wound Data and Munitions Effectiveness Team (WDMET) computer database containing 4555 cases of patients injured in Vietnam over a 3 year period, among them 472 cases of penetrating neck injury. None of them had their spine immobilized before transport. Of the 472, 296 (81%) survived long enough to receive first aid and only 11 (3.7%) of these had cervical spinal column injuries. The authors concluded that of these 11 cases, seven would have had no benefit from neck stabilization — they either had stable fractures or, in one case, complete severance of the spinal cord caused by the original wound. There were four casualties (1.4%) who might have benefited from stabilization as could be inferred from the type of injury and the circumstances surrounding the injury. None of them survived and no definite conclusion could be made. There was no case in which a definite benefit could be attributed to stabilization of the neck prior to movement of the victim. The authors conclude that it is neither prudent nor practical to stabilize all patients with penetrating neck injury under such conditions.

Hammoud et al. [16] reviewed their experience with spinal cord injuries from bullets and shell fragments during the Lebanese civil war. Over the course of 10 years they treated 24 injuries to the cervical spinal cord. In none of the cases had dislocation occurred, and spine instability was not encountered. The authors state that spinal instability occurs very rarely in such spinal cord injuries because the bone architecture is only a little disturbed.

In another series, Kupcha et al. [17] retrospectively reviewed the charts and radiographs of 28 patients with low-velocity gunshot wounds to the cervical spine who were admitted to their center over a 10 year period. In this series too, no case of vertebral instability was observed.

In our series, surgical stabilization was not performed on any of the hospitalized casualties. Traction was applied to one patient whose injury involved multiple laminar fracture and bone fragments in the canal, with complete tetraplegia on admission to hospital. It is very unlikely that pre-hospital stabilization could have prevented the neurological outcome in this case. Of the eight dead casualties studied, four had complete transection of the spinal cord. Autopsy findings suggested no benefit from pre-hospital stabilization.

4.1. Anatomical considerations

Benzel defines instability as the inability to limit excessive or abnormal spinal displacement [11]. This is the reverse definition of White and Panjabi’s definition of stability [12]. Several instability definition schemes use scoring systems to measure the extent of spinal integrity [17]. These schemes are usually based on a “column” concept of spinal structural integrity, such as the two-column theory of Bailey, Holdsworth, Kelly and Whitesides [18, 19 and 20] and three-column theory of Denis [21]. We should emphasize that all the above literature concerning spinal instability is based on experiments and theories of blunt trauma. When we evaluate penetrating injuries to the spine using the methods mentioned above, it is very rare to find unstable penetrating injury. Moreover, it is conceptually impossible for a penetrating injury to cause such substantial spinal damage leading to instability without completely destroying the cord. We have not found in the literature a report describing a missile or fragment (or knife) injury that caused an unstable injury and left an incomplete neurological lesion which might deteriorate.

In our study, there were three cases that suffered partial neurological deficit, all with little skeletal involvement. The deficit was caused in two cases by fragments penetrating the spinal canal and in one case by bilateral large haematomas around the brachial plexuses.

5. Conclusions

We, therefore, conclude that the current routine of pre-hospital stabilization of the neck in penetrating trauma using a collar and additional devices should be seriously re-evaluated. Avoiding the collar should be the rule, and a very good point should be made for applying the device to justify the risk.

The following guidelines are hereby suggested:

1. In penetrating injury to the neck without a clear neurological deficit, there is no place for using a collar or any other device for neck stabilization.

2. Neck stabilization devices may be used when there is overt neurological deficit or the diagnosis cannot be made (i.e. unconscious victim). However, in this case it is obligatory to expose the neck by removing the anterior portion of the device every few minutes, at least in the initial phase of treatment.

3. Neck stabilization devices may be used for the unusual occurrence of a penetrating injury which is combined with blunt trauma. The stabilization is then for the blunt mechanism only and not for the penetrating one.

References

1. E.R. Thal and D.M. Meyer, Penetrating neck trauma. Current Problems in Surgery 29 1 (1992), pp. 1–56.

2. B. Carducci, R.A. Lowe and W. Dalsey, Penetrating neck trauma: consensus and controversies. Annals of Emergency Medicine 15 2 (1986), pp. 208–214.

3. G.J. Ordog, D. Albin, J. Wasserberger et al., 110 bullet wounds to the neck. Journal of Trauma 25 (1985), pp. 238–246. View Record in Scopus | Cited By in Scopus (23)

4. D. Demetriades, D. Theodorou, E. Cornwell et al., Evaluation of penetrating injuries to the neck: prospective study of 223 patients. World Journal of Surgery 21 (1997), pp. 41–48. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (58)

5. D. Demetriades, D. Theodorou, E. Cornwell et al., Penetrating injuries of the neck in patients in stable condition. Archives of Surgery 130 (1995), pp. 971–976.

6. D. Demetriades, D. Theodorou, E. Cornwell et al., Transcervical gunshot injuries: mandatory operation is not necessary. Journal of Trauma 40 5 (1996), pp. 758–760. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (32)

7. D. Demetriades, Complex problems in penetrating neck trauma. Surgical Clinics of North America 76 4 (1996), pp. 661–684.

8. E.E. Moore, K.L. Mattox and D.V. Feliciano Editors, Trauma Appleton and Lange, Norwalk (1991).

9. R.R. Ivaturi and G.C. Cayten Editors, The Textbook of penetrating trauma Williams and Wilkins, Media (1996).

10. G.J. Ordog Editor, Management of gunshot wounds Appleton and Lange, Norwalk (1988).

11. E.C. Benzel Editor, Biomechanics of spine stabilization — principles and clinical practice McGraw-Hill, New York (1996), pp. 24–41.

12. A.A. White and M.M. Panjabi Editors, Clinical biomechanics of the spine Lippincot, Philadelphia (1990), pp. 30–34.

13. American College of Surgeons Committee on Trauma, . Advanced trauma life support® student manual American College of Surgeons, Chicago (1993).

14. F.R. Kennedy, P. Gonzalez, A.L. Beitler et al., Incidence of cervical spine injury in patients with gunshot wounds to the head. Southern Medical Journal 87 6 (1994), pp. 621–623. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (13)

15. G.I. Arishita, J.S. Vayer and R.F. Bellamy, Cervical spine immobilization of penetrating neck wounds in a hostile environment. Journal of Trauma 29 3 (1989), pp. 332–337. View Record in Scopus | Cited By in Scopus (16)

16. M.A. Hammoud, F.S. Haddad and N.A. Moufarrij, Spinal cord missile injuries during the Lebanese civil war. Surgical Neurology 43 (1995), pp. 432–442. Abstract | Abstract + References | PDF (1221 K) | View Record in Scopus | Cited By in Scopus (13)

17. P.C. Kupcha, H.S. An and J.M. Cotler, Gunshot wounds to the cervical spine. Spine 15 10 (1990), pp. 1058–1063. View Record in Scopus | Cited By in Scopus (22)

18. R.W. Bailey, Fractures and dislocations of the cervical spine: orthopedic and neurosurgical aspects. Postgraduate Medicine 35 (1964), pp. 588–599.

19. F.W. Holdsworth, Fractures, dislocations and fracture dislocations of the spine. Journal of Bone and Joint Surgery 45B (1963), pp. 6–20.

20. R.P. Kelly and T.E. Whitesides, Treatment of lumbosacral fracture-dislocations. Ann. Surg. 167 (1968), pp. 705–717. View Record in Scopus | Cited By in Scopus (16)

21. F. Denis, The three-column spine and its significance in the classification of acute thoracolumbar spine injuries. Spine 8 (1983), pp. 817–831. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (447)

[AnthonyM83]

Still seems weird to me that there's not concern for the bullet's energy dissipating causing blunt force style trauma in the neck and that swelling/compression concern from blunt trauma mentioned above.

So, as long as we're good with the neuro and not altered, we're good with no c-spine?

I previously said also no pain and no deformity, but if you add those, then that's pretty much clearing cspine criteria for blunt AND penetrating....so nothing new there. So main thing is neuro deficit then..

[stcommodore]

I could be totally off, but I don't think the bullets kinetic energy can really be classified at all in the blunt trauma catagory.

[AnthonyM83]

At all? What would it be classified as (I'm not really classifying, rather trying to liken it more to blunt than penetrating)?

Most other penetrating creates a direct slice/puncture that's usually limited to the area it has made contact with. It's a cutting. If it didn't cut into spine, then it won't later. But blunt trauma comes from the force distributed across the area from outside matter hitting against the body.

Cavitation seems more like that force than a clear thin cut force. In the end it seems blunt and penetrating trauma are the same thing, just distributed over a wider or smaller area. We differentiate by whether it was concentrated enough to penetrate skin. Primary shock wave injury from an explosion (similar to what I imagine cavitation injury to be) seems more like blunt than penetrating (if we only have those two to liken it to since it's what the studies are dividing the trauma into)

[mediccjh]

Blunt trauma is a pretty broad term. Can you give an example of what kind of blunt trauma you are talking about? There aren't many thoracic blunt traumas I would board for.

I considered myself pretty well read on cavitation at one time, but perhaps I am behind the times now. What exactly would thoracic cavitation have to do with spinal compromise?

That makes two of us, since sometimes Brick City can be as bad as Baghdad at times (I had a pt shot w/ an AK-47 multiple times this past Saturday night).

You beat me to it about the cavitation. If you think about it, the organs would have to hit the spine at a high velocity to cause damage. The only thing that would damage the spine itself would be the bullet itself. And if the spine is hit, 99% of the time, you will get neuro defect, or your patient may even be in neurogenic shock.

[SSG G-man]

Two cases:

20 YOM, GSW to left shoulder with no exit would, cardiac arrest. Unsafe/Unstable scene, Do you LSB?

35 YOM GSW Chest, No Neuro Deficit, A0x4, CC: Resp Distress corrected via Needle D, Do you LSB?

Both patients I treated during medic school and neither got LSB, in fact in the many GSW cases I saw we never LBS'ed a single one. This was a hospital based system, with the hospital being a trauma center.

Case 1 I would probably have used reeves to get out of immediate area and had a LSB on cot. We usually put cardiac arrest patients on LSB to assist us when doing compressions, the LSB wont give like the mat on the cot.

[AnthonyM83]

You beat me to it about the cavitation. If you think about it, the organs would have to hit the spine at a high velocity to cause damage. The only thing that would damage the spine itself would be the bullet itself. And if the spine is hit, 99% of the time, you will get neuro defect, or your patient may even be in neurogenic shock.

The concern wouldn't be from organs hitting the spine, it would be from the pressure wave itself hurting the spine.

[Dustdevil]

The concern wouldn't be from organs hitting the spine, it would be from the pressure wave itself hurting the spine.

Cavitation is what prevents that, not what would cause it. Think three dimensional. The kinetic energy is dissipated in all directions, thre dimensionally, which prevents a seriously focused energy wave in any one direction. It's the same theory that body armour works on.