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

Funding Sources for Research

• Laerdal Foundation

• NOCSAE

• NCAA

• Southwestern Medical Foundation

• Stryker

Objectives

• Current Research and Best Practices

– Positioning on Spine Board

• Supine

• Prone

– Helmet & Equipment Removal

– Stabilization for Transport

• Cervical Collars

• Strapping Techniques

• Future Directions

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

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

Why Immobilize?

• Case reports of exacerbation of injuries from standard actions or procedures

– Harrop et al. 2001

– Powell et al. 1995

• Amount of motion and forces required to create secondary neurologic injury unknown

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)

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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.

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

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

1

1

Traditional Hand Hold

1

2

Modified Hand Hold

Modified Hand Hold

1

3

Hand Placement

* #

Axial rotation and lateral bending: Significant differences between techniques (p<0.001) - both LR techniques had more motion

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)

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)

Supine Patient - Spine Board Transfer Techniques

• Log roll vs lift-and-slide (Del Rossi et al., JAT, 2003)

Flexion- Extension

Axial rotation

Lateral flexion

Supine Patient - Spine Board Transfer Techniques

• Cadaveric study

• Log roll vs lift-and-slide vs 8 person lift (Del Rossi et al., JAT, 2008)

Supine Patient - Spine Board Transfer Techniques

• Log roll vs lift-and-slide vs 8 person lift • (Del Rossi et al., JAT, 2008)

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

LRLS

SCOOP

0

1

2

3

4

5

6

7

An

gu

lar

Mo

tio

n (

deg

rees)

Technique

Flexion - Extension

Axial Rotation

Lateral Flexion

LRLS

SCOOP

0

0.1

0.2

0.3

0.4

0.5

0.6

Lin

ear

Tra

nsla

tio

n (

cm

)

Technique

Medial - Lateral Translation

Distraction - Compression

Anterior - Posterior Displacement

*

*

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-C6

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

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. 2012 Spine Journal

• No log roll • Sum of the greatest displacements for the complete

sequence was significantly decreased • Prasarn et al. 2012 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

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.

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

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

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)

Prone Patient – Spine Board Transfer Techniques

• Push vs Pull Cadaveric study • Thoracolumbar instability

– Conrad et al., J Spinal Cord Med, 2012

Prone Patient – Spine Board Transfer Techniques

• Significantly less motion with the Push technique • Flexion/Extension; Axial Translation; Ant/Post Translation

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

Prone Patient – Spine Board Transfer Techniques

• Prone to supine (Prasarn et al., in preparation)

– Preliminary data

0

5

10

15

20

25

30

35

40

45

Medial/Lateral Sup/Inf Ant/Post

Mill

imet

ers

C5-C6 Translation

LR

LR/6+

LR/LR

Prone Spine Boarding

Prone Patient – Equipment-laden

• Equipment fit – Hockey

• Mihalik et al. 2011

• Might this be a good time to initiate removal of equipment?

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.

•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

Vacuum Mattresses • Spinal immobilization

• Vacuum mattress vs spine board • Johnson et al., AJEM, 1995

• 30 subjects

• Immobilization during lateral tilting (90o)

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

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

Facemask Removal

• Combined tool approach • CSD and cutting tool resulted in 100% success

• Average time: 37.84 ± 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

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

Facemask: Other Options

• Feed mask through facemask – The PMI (Pocket Mask Insertion) technique significantly

faster • 19.86 ± 5.92 seconds

– QRM 50.37 ± 13.13 seconds

– CSD 68.98 ± 15.42 seconds • Toler et al. Clin J Sport Med, 2011

• PMI time – 14-19 seconds

• Ray et al. JAT, 2002

Time vs. Motion: Translational Movement for Airway Access

Time vs. Motion: Rotational Movement for Airway Access

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 (http://www.nhmi.net/deflate.php)

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

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

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

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

Helmet Removal Study

0

2

4

6

8

10

Flex/Ext Axial Rot Lat Bend

Deg

rees

(•)

Means of Angular Displacement at C5-C6

FMH

Helmet

FMH caused significantly less flexion-extension (p=0.023) and axial rotation (p=0.023) than the Helmet technique.

Helmet Removal Study

0

1

2

3

4

5

6

7

8

9

Med/Lat Axial Trans Ant/Post

Mili

met

ers

(mm

)

Means of Translation Displacement at C5-C6

FMH

Helmet

FMH caused significantly less anterior-posterior (p=0.035), medial-lateral (p=0.013), and axial (p=0.028) translations than the Helmet technique.

Shoulder Pad Removal

Traditional Pad Removal

Elevated Torso Removal

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

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

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

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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

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

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

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

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

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):306–331

Results

Axial Rotation at C5-C6

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3 7 SPIDER

Deg

rees

Lateral Bending at C5-C6

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

3 7 SPIDER

Deg

rees

Flexion-Extension at C5-C6

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3 7 SPIDER

Deg

rees

p=.003

Medial-Lateral Translation at C5-C6

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

3 7 SPIDER

Millim

ete

rs

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

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

Results: Spine Board Centering

Results: Spine Board Centering

Conclusions: Spine Board Centering

• First responder should minimize movement

• Horizontal slide has less movement than diagonal and V-adjustment

• Horizontal slide easier to complete

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 mm2

Calculating SAC

Specimen and robot set-up for calculating SAC

Calculating SAC

Three dimensional representation of the cervical spine specimen.

Calculating SAC

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

segment

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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

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 pre-hospital treatment techniques – Collar application, spine boarding, bed transfers

• Lesser chance of secondary injury

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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

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

THANK YOU