C-spine Clearance—A Real Pain in the Neck.
I’ve seen quite a change in the use of spinal immobilization in my career. When I began practice the universal application of a C-collar and long spine board to all trauma patients was the standard of practice. Practitioners felt that was the safest intervention to protect the patient from devastating neurologic injury. As medicine has evolved to more evidence-based practice we’ve learned that is universal spinal immobilization is not indicated in all patients and in certain cases may be causing harm.
It is challenging to change what has been accepted as the standard of care for such a long time but hopefully we can provide some resources to help make your decisions rationale, reasonable, and clinically responsible.
In my practice I prefer to use the Canadian C-Spine Rule. This is an evidence based algorithm that will guide you through the steps necessary to clear a patient’s neck or to confirm that they need immobilization and imaging. There are many online resources with both calculators and algorithm images. A quick Google search led me to this image at: https://canadiem.org/tiny-tip-canadian-c-spine-rule/
As you can see it all starts with the mechanism and then progresses through a quick history and physical exam. Then an assessment of whether or not you can clear their c-spine without imaging. One caveat to this algorithm is the impaired patient. I like to use “impaired” to cover a broad range of mental and/or physical factors that make the patient unreliable. That may include physical issues like a traumatic brain injury, a major distracting injury, or mental status changes from hypothermia. A very common impairment in trauma is having some drug or toxin onboard. Substances like alcohol, marijuana, and methamphetamine can all render the Canadian C-Spine rule useless.
So that’s all well and good if you have a 64 slice CT scanner down the hall to help evaluate the C-spine but what if you’re 10 miles into the backcountry? What trekking in a 3rd world country and the nearest access to any imaging is days away? Therein lies some of the challenges of wilderness medicine. If your patient rules out by the criteria above you can feel very confident that they have an extremely low risk of a catastrophic C-spine injury. If they don’t rule out then it is time to protect the C-spine.
I’ve been focusing on the C-spine but what about the rest of the spine? There are 17 more vertebrae in the thoracic and lumbar spine that have the potential to be damaged as well. C-Spine injuries, arguably, have the risk for greatest morbidity and mortality so let’s approach that first. If there is any question of injury then immobilize the C-spine. How? Well, what do you have with you or around you? Ideally you have a commercially made, size adjustable, dedicated C-collar with you. That may be an option if your medical kit has no limits on space, size, or weight. Most of us don’t carry one in the backcountry but that’s OK. SAM splints, backpack Lumbar support, and self-fashioned horse collars can all be used. Courses such as AWLS teach these techniques. Once the C-spine is immobilized it is time to work on an extrication plan to get them to a higher level of care for further evaluation and management.
If the patient has additional spinal injury, which is common, further immobilization may be needed for transport and/or extrication. In austere conditions patients may have to self extricate/evacuate and if they can that is allowable. Research is showing that patients can self-immobilize very well when they’re awake, alert, and cooperative. The same body of research has shown that patients that are immobilized on long spine boards can still have movement in multiple different planes. In cases where they are unable to extricate or ambulate then protection of the thoracic and lumbar spine may also be necessary and that is when we must use a long spine board. A key point with immobilization on any type of spine board is that it is for transport and/or extrication only. Let’s say you have successfully extricated a skier from avalanche debris onto a long spine board, evacuated to a hut, but now it’s dark and a storm has rolled in for the night. In a case such as this it is imperative that he patient be off of a rigid board as much as possible. This is essential for patient comfort as well as prevention of skin breakdown and subsequent ulcer formation.
Vertebral trauma is not unheard of in the wilderness where high risk injury from skiing, climbing, and horse wrecks can cause catastrophic injuries with significant morbidity and mortality. The accurate and appropriate assessment and management of these injuries is imperative to improve patient outcomes. If the management of spinal trauma is not part of your daily routine I think you would benefit from further education through an outdoor life support course. Remember, when the time comes we don’t rise to the occasion, we fall back to our highest level of training.