Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature

Abstract

Objectives: The objectives were to review published reports of secondary neurologic deterioration in the early stages of care after blunt spinal trauma and describe its nature, context, and associated risk factors. Methods:The authors searched the MEDLINE, EMBASE, and CINAHL databases for English-language studies. Cases were included meeting the criteria age 16 years or older, nonpenetrating trauma, and experiencing neurologic deterioration during prehospital or emergency department (ED) care prior to definitive management (e.g., discharge, spinal clearance by computed tomography, admission to an inpatient service, or surgical intervention). Results were qualitatively analyzed for characteristics and themes.Results: Forty-one qualifying cases were identified from 12 papers. In 30 cases, the new deficits were apparently spontaneous and were not detected until routine reassessment. In 12 cases the authors did attribute deterioration to temporally associated precipitants, seven of which were possibly iatrogenic; these included removal of a cervical collar, placement of a halo device, patient agitation, performance of flexion/extension films, "unintentional manipulation," falling in or near the ED, and forced collar application in patients with ankylosing spondylitis. Thirteen cases occurred during prehospital care, none of them sudden and movement-provoked, and all reported by a single study.Conclusions: Published reports of early secondary neurologic deterioration after blunt spinal trauma are exceptionally rare and generally poorly documented. High-risk features may include altered mental status and ankylosing spondylitis. It is unclear how often events are linked with spontaneous patient movement and whether such events are preventable.

Does the novel lateral trauma position cause more motion in an unstable cervical spine injury than the logroll maneuver?

“…A recent systematic review did not reveal any evidence of neurological harm caused by any type of lateral positioning, including the log-roll maneuver [33]. This result was confirmed by Oto et al [34], who also concluded that "early secondary neurological deteriorations after blunt spinal trauma are exceptionally rare." Although a lack of evidence does not necessarily demonstrate the absence of harm, it seems reasonable that the motion induced by the log-roll maneuver could be used as a base for comparison for other lateral positioning techniques.…”

Practice patterns after implementation of a selective spinal immobilization protocol in a regional trauma system

“…While unstable cervical spine injuries occur in 1% to 2% of trauma patients, cord injury occurs in only 0.1% to 0.4% 33,34 . Most spinal cord injury is sustained during the initial insult, and evidence suggests that secondary cord injury more frequently results from ischemia, edema, or iatrogenic manipulation rather than movement during extrication and transport 4,5,35 . Selective immobilization approaches based on National Emergency X-radiography Utilization Study criteria 36 and the Canadian C-Spine rules 37 aim to minimize harm from unnecessary immobilization while maintaining safety for patients at risk for secondary injury.…”

“…2,3 However, the scientific basis for universal immobilization has never been well established. 4 Several studies have demonstrated an absence of benefit from prehospital immobilization, including a Cochrane review, which concluded that the practice is rooted in tradition rather than science. [5][6][7][8][9] Immobilization is, however, associated with significant risks, including aspiration and impaired airway management, 10,11 pulmonary restriction, 12 obscurement of critical examination findings, 13 increased intracranial pressure, 14,15 scene delays, 16 pressure injury, 17 pain, 18 and false-positive spinal tenderness leading to increased imaging use.…”

Cervical collars and immobilisation: A South African best practice recommendation

“…Evidence of early secondary deterioration from spinal injuries is very rare and records of sudden deterioration following sudden movement are not very readily available [15] , [16] .…”