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Three Part Question

In [a patient with isolated penetrating neck wound], is [the risk of cervical spine injury so low] that [cervical 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 cervical spine, and you wonder if you should apply cervical 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.

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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Apfelbaum et al	One patient with unstable c-spine fracture without initial neurological deficit after cervical GSW	Case report		The cervical collar was removed by 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	Single case report
Barkana et al, 2000, Israel	44 military casualties with PNI (penetrating neck injury) - High velocity GSW (13), projectiles (38), and knife injuries (2). All had stabilisation devices applied	Retrospective analysis of hospital charts and autopsy reports	Indications, benefits & risks associated with C-spine stabilisation during pre-hospital care:	In 8 of 36 (22%) hospitalised casualties a life-threatening sign (large/expanding haematoma, or subcutaneous emphysema) was diagnosed in the exposed neck, which may have been hidden by a collar. No casualties required internal surgical stabilisation of the c-spine	Population not applicable to typical UK ED. The force and mechanism of injury is more severe than that expected in a civilian setting
Connell et al, 2003, UK	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	Retrospective analysis of data from the Scottish Trauma Audit Group (STAG)	Incidence of mechanically unstable spinal column injuries and spinal cord injuries:	All 12 patients with spinal cord injury either had obvious initial clinical evidence of a spinal cord injury or were in traumatic cardiac arrest. None of the initially neurologically intact patients subsequently showed to have a cord injury or unstable CSF	Large population with low incidence of PNI studied. Small cohort. Looked at full spinal immobilisation
Medzon et al, 2005, USA	81 patients with gunshot wounds to the head and neck potentially involving the cervical spine. 19 had c-spine fracture (CSF)	Retrospective chart review using a trauma registry	Of 11 patients with acute neurologic deficit:	8 had stable CSF, and 3 were unstable (requiring surgical stabilisation)	Small series in a single centre
			Of 65 patients without neurologic deficit:	3 had stable CSF (4.6%; 95% CI 1-12.9%) - all treated in hard collar alone. No patients (0%; 95% CI 0-5.5%) were found to have unstable CSF
			Of 5 patients with Altered Levels of Consciousness:	All 5 had stable CSF
			Potential risk factors for unstable CSF:	All 5 patients who presented with altered mental status had a stable CSF. All 11 patients with a neurological deficit had CSF (8 stable and 3 unstable)
Klein et al 2005 USA	228 Patients with Spinal Injuries (with single GSW and survived > 24h) after GSW to the trunk, neck, or head	Retrospective cohort	Occurrence of spine injuries among neurologically intact patients with GSW to the head, neck and torso	Out of 183 patients with GSW to the neck, 33 (18%) had a spinal injury, of which 17 (51%) were significant*, and only one (3%) had an unsuspected significant spinal injury**. (*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 neurologic finding at admission )	Likely selection bias. Spinal damage probably established at presentation. No further specific information given about patients with unsuspected significant injury, or follow up mentioned. Significant injury may not necessarily mean unstable spinal injury. Study did not focus on c-spine injuries, and looked more into the question of complete radiological spine evaluation
Rhee et al, 2006, USA	24,446 patients with blunt or penetrating cervical injury studied to determine the incidence of cervical spine fracture (CSF) and cervical spinal cord injury (CSCI) based on mechanism following gunshot wounds (GSW), stab wounds (SW) or blunt assault (BA)	Retrospective cohort	Incidence rates for CSF (Cervical spine fracture):	Significantly different (p<0.05) for different mechanisms: GSW = 1.35% (n=12,573); SW = 0.12% (n=7,483); BA = 0.41% (n=4,390)
			Incidence rates for CSCI (Cervical spinal cord injury):	Significantly different (p<0.05) for GSW: GSW = 0.94% (n=12,573); SW = 0.11% (n=7,483); BA = 0.14% (n=4,390)
			CSCI and Recovery:	All GSW patients with CSCI had their injury at the time of assault. No penetrating injury patient with CSCI regained significant neurologic recovery during hospitalisation
			% of neurologically intact patients requiring surgical or halo stabilisation:	0% of patients after SW and 0.03% of patients after GSW

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 cervical 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 cervical spine injury after penetrating neck injury. The rate of cervical 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 cervical 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, cervical spinal cord injury; CSF, 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

1. Apfelbaum JD, Cantrill SV, Waldman N. Unstable cervical spine without spinal cord injury in penetrating neck trauma. Am J Emerg Med. 2000;18:55-7.
2. 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.: CD002803. DOI: 10.1002/14651858.CD002803.
3. Barkana Y, Stein M, Scope A, Maor R, Abramovich Y, Friedman Z, Knoller N. Prehospital stabilization of the cervical spine for penetrating injuries of the neck - is it necessary? Injury. 2000 Jun;31(5):305-9.
4. Connell RA, Graham CA, Munro PT. Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma? Injury. 2003 Dec;34(12):912-4.
5. Medzon R, Rothenhaus T, Bono CM, Grindlinger G, Rathlev NK. Stability of cervical spine fractures after gunshot wounds to the head and neck. Spine. 2005 Oct 15;30(20):2274-9.
6. Klein Y, Cohn SM, Soffer D, Lynn M, Shaw CM and Hasharoni A. Spine Injuries Are Common Among Asymptomatic Patients After Gunshot Wounds. J Trauma. 2005 Apr; 58:833-6.
7. 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. 2006 Nov;61(5):1166-70.