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II
AcuteSpinalCordInjuryManagementand
SurgicalConsiderations
10
PrehospitalManagementofSpinalCord
Injury
WilliamD.Whetstone
INTRODUCTION
Managementof the spinalcord injured (SCI)patientbegins immediatelypostinjury by the first providers at the accident scene. Evidence-based guidelines
from the American Association of Neurological Surgeons (AANS) have been
used to improve techniques of prehospital management (1). It has been
previouslyestimatedthat3%to25%ofspinalcordinjuriesoccuraftertheinitial
traumaticinsult,eitherduringtransitorearlyinthecourseoftreatment(2).
Overthepast40years,therehasbeenadramaticimprovementinprehospital
management and thus an improvement in the neurologic prognosis of SCI
patientsarrivingintheemergencydepartment.Duringthe1970s,themajorityof
SCIpatientsarrivedwithcompletecordlesions.Thisstatistic,however,changed
duringthe1980s,whenthemajorityofpatientswerefoundtohaveincomplete
lesions(3).
In 1989, Garfin (4) stated that “no patient should be extricated from a
crashed vehicle or transported from an accident scene without spinal
stabilization.” Stabilization of the cervical spine is credited as a key factor
responsibleforthedeclineofthepercentageofcompleteSCIlesionsfrom55%
inthe1970sto39%inthe1980sandforthesignificantreductioninmortalityof
multiple-injurypatientswithcervicalspinalinjuries(4).Unfortunately,there is
noclassIorclassIImedicalevidencetosupportthisclaim.
On a practical basis, it is presumed that a large portion of traumatic SCI
outcome improvement was the product of the development of emergency
medical services (EMS). EMS systems train providers in proper extrication
techniquesandcoordinateexpeditioustransfertoatrauma center. Thischapter
defines and discusses the five responsibilities of prehospital care (evaluation,
resuscitation,immobilization,extrication,andtransportation)(5).
EVALUATION
Theevaluationphaseconsistsofprimaryandsecondarysurveysasemphasized
by ATLS guidelines (6). The “ABCDE” of the trauma primary survey are
Airway maintenance with cervical spine control; Breathing and ventilation;
Circulation with hemorrhage control; Disability assessment (e.g., neurologic
status); and Exposure/environmental control (e.g., completely undressing the
patientwhilepreventinghyper-orhypothermia).
After completing the primary survey, the prehospital provider should
performanabbreviatedsecondarysurveythatconsistsofamoredetailedheadto-toe evaluation of the injured patient. During thisevaluation, itisof utmost
importancetoassumethatthepatienthasnotonlyaspinalcordinjury,butalsoa
potentiallyunstablespinal fracture.Thus,theentireevaluationmusttake place
withfullspinalimmobilization.
The prehospital spinal cord evaluationattempts to quickly identifyinjured
areas.It isimportant tonote whetherapatientiscomplaining ofneck orback
painorhastendernessuponpalpationinthoseareas.Inordertobetterevaluate
the spine, the patient should be logrolled by three providers and the spine
checkedforbonytendernessorgrosssignsoftrauma(Figures10.1and10.2).
Theeffectivenessof thelogroll transfertechnique has beenquestioned (7)
but still remains the standard transfer method. Alternatives to the logroll
maneuverinclude the HighArm IN EndangeredSpine(HAINES) methodand
the multihand, or fireman-lift, method. In the HAINES method, the patient is
placed supine. With the upper portion of the “away” (contralateral) arm
positionedin180° ofabduction, the“near”(ipsilateraltothe kneelingrescuer)
arm is placed across the victim’s chest. Both lower limbs are flexed. The
rescuer’shandsareusedtostabilizetheheadandneck,andthepatientisrolled
awayontoanextricationboardorothertransportdevice(8).Themultihand,or
fireman-lift,methodinvolvesseveralrescuerson either side of the patient; all
rescuers slide their arms underneath the patient and lift the patient from one
positiontotheotherontoanextricationboardordevice.
Followingevaluation,asuccinctmotorexaminationshouldbeperformed.A
motorexaminationincludesassessmentofgripstrengthandfootdorsiflexionin
addition to a gross sensory examination, which should alert the prehospital
provider to the presence of a complete or partial cord injury. Signs of
incontinence,urinary retention, priapism, or loss of anal sphinctertoneshould
also be noted. Skin temperature and appearance should be evaluated. Warm,
flushedskin suggestsloss ofsympatheticvascular tonebelow theinjurylevel.
Evenintheabsenceofanyoftheaforementionedfindings,themultiplyinjured
ormajor traumapatient mustbe placedinarigidcollar andimmobilized ona
backboardfortransporttoahospital.
FIGURE 10.1 Logroll technique. One provider (designated logroll
leader)attheheadofthepatientcontrolstheheadandcervicalspine.
Meanwhile, two assistants with interlinked arms control trunk and
lowerbody.
RESUSCITATION
Resuscitation begins as early as during the evaluation and primary survey.
Airwaycontrolisof thehighestpriorityanditshouldstartwiththeimmediate
application of oxygen while the cervical spine is being immobilized. Initial
airwaymanagementincludesplacementofanasalororalairway.Suctionshould
beavailableinordertoremoveblood,secretions,andpossibleforeignbodies.If
adequateoxygenationcannotbemaintainedandtheparamediccrewisproperly
trained, the patient should be prepared for intubation. Either a supraglottic
airwaydevicesuchastheKingtubeLTororotrachealintubationareconsidered
appropriate, assuming they are performed with proper in-line cervical spine
stabilization. Many studies have now demonstrated that orotracheal intubation
with in-line stabilization (Figure 10.3) is a safe method if performed by
experiencedpersonnel(9–11). In a cadavermodel, Gerling et al. (12) showed
thatintubation within-linestabilization did notcause any significantvertebral
body movement. Intubation attempts with cervical collar immobilization, in
contrast, did produce a significant amount of vertebral distraction. Thus, the
cervicalcollarshouldalwaysbeopenedpriortoattemptedintubation.
FIGURE10.2Logrolltechnique.Ontheleader’scommand,allthree
providersrollthepatientinasingle,fluidmotion(carefullyavoiding
anytwistingmotion).Thefourthproviderevaluatestheentirespinefor
tenderness.
FIGURE 10.3 In-line stabilization. With rigid collar open, the
assistant prevents motion of the head and neck while the patient is
intubated.
Prehospital circulatory resuscitation consists of aggressive pursuit of
intravenousaccessandproperfluidresuscitation.ThecervicalSCIpatientmay
presentwitheither neurogenic or hemorrhagic shock. Neurogenic shock isthe
resultofanSCIatorabovethefourththoracicvertebra.Theseinjuriescausea
loss of sympathetic peripheral vascular tone and thus reduce central venous
return. In contrast to hemorrhagic shock, in which there is compensatory
tachycardia to hypovolemia, neurogenic shock is associated with bradycardia,
the result of loss of sympathetic cardiac innervations leading to unopposed
parasympathetic signals. Both hemorrhagic and neurogenic shock may be
initially treated by placing the patient in a spine-immobilized Trendelenburg
position(13). This maneuverwillhelp decrease pooling of blood inthelower
extremitiesandincreasecentralvenousreturn.Bleedingfromtheneckorspinal
areashouldbe controlledby directpressure.Large-boreperipheralintravenous
linesshouldbeplacedinanticipationofsalineandbloodinfusion.
IMMOBILIZATION
To prevent further spinal cord injury, all prehospital personnel must be well
trainedinthetechniquesofimmobilization.InmostareasoftheUnitedStates,
all major trauma victims, patients complaining of neck pain or neurologic
symptoms, and patients with altered mental status of uncertain cause are
immobilized. With these liberal guidelines, cervical spine immobilization has
becomeoneofthemostfrequentlyperformedprehospitalprocedures(14).Itis
estimatedthatnearly5millionpatientsreceivespinalimmobilizationannuallyat
an average cost of $15 per person (15). In addition to the cost, overzealous
immobilization can cause unnecessary patient discomfort and increased
paramedicscenetime.Evidencesupportsthe notionthat spinalimmobilization
increasestheriskofpressureinjuries.Pressureinjurieswerefoundasearlyas2
hoursafter injury in one study (16). In another study, the length of timeon a
rigidspineboardwassignificantlyassociatedwiththedevelopmentofpressure
injurieswithin8daysofinjury(17).
There is some debate about whether immobilization changes outcomes.
Hauswald et al. (18) examined the effect of emergency out-of-hospital spinal
immobilizationonneurologicinjurybycomparingtraumapatientsinMalaysia,
where no prehospital EMS are available, to trauma patients in New Mexico,
where prehospital spinal immobilization is routine. Interestingly, Malaysian
patients were found to have a lower rate of neurologic disability.These data,
however,havebeencriticizedbecausepatientswhodiedatthesceneorduring
transport were excluded. Thus, it is difficultto apply these conclusions to the
effectivenessofEMSintheUnitedStates(19).
Clinicalcriteria intended toidentifya subset ofpatients that maynotneed
immobilizationhave been studied. In a multicenter prospective studyof6,500
trauma patients, the application of clinical criteria—namely altered mental
status, focal neurologic deficit, evidence of intoxication, spinal pain or
tenderness,orsuspectedextremityfracture—predictedthemajorityofcervical
spinal injuries that required immobilization. The predictive value was
maintainedwithbothhigh-andlow-riskmechanismsofinjury(20).Theauthors
suggestedthatclinicalcriteriaratherthanthemechanismofinjurybeusedasthe
standardbywhichspinalimmobilizationshouldbeemployed.Clinicalcriteriato
selectappropriatepatientsforspinalimmobilizationhavealsobeenadoptedina
majorityofEMSsystemsthroughouttheUnitedStates(21).EMSpersonnelwho
make these assessments require intensive education and careful quality
assurance scrutiny to ensure that trauma patients with potentialspinal injuries
areappropriatelytriagedandmanaged.Theconsensusopinionfromthebodyof
class II clinical studies, anatomical and biomechanical data, and clinician
experienceisthatallpatientswithcervicalspinalcolumninjuriesorthosewith
thepotentialforacervicalspinalinjuryfollowingtraumashouldbetreatedwith
immobilization until injury has been excluded or definitive management has
beeninitiated(1).
FIGURE 10.4 Immobilization equipment: rigid board, rigid collar,
prefabricatedimmobilizationkitwithcushionsandVelcrostraps.
TechniqueofImmobilization
At the scene of the injury, the provider should place the patient in a neutral,
supineposition.Withgentletractionappliedbylockinghandsunderthejawand
neck,the patient’shead should be moved tobe invertical alignment withthe
body. Thisneutral position is critical in preventing any further damage to the
cord.Whenremovingapatient fromaseatedposition,a cervicalcollar isfirst
placed.Oneproviderisresponsiblefortheheadandneckastheotherpersonnel
helpmovethepatient’sbodyinacoordinatedmovementwhilekeepingthehead
and body in a neutral position. The patient is then placed on a backboard
immediately, whilethe person responsible for the head and neck continues to
maintainin-linestabilization.
Because as many as 25% of spinal column injuries involve multiple
noncontinuousvertebrallevels,theentirespinalcolumnispotentiallyatriskand
shouldbeimmobilized(22).The best methodis tousea rigidbackboard. The
neckisfirstsecuredwitharigidcollarusingaprefabricatedimmobilizationkit
with its own cushions and sandbag equivalent (Figure 10.4). Tape and Velcro
strapsareplacedoverthepatient’sforeheadtopreventflexionoftheneck.Itis
important to note that cervical collars alone are relatively ineffective in
restrictingneckmotion(23).Collarsmustbecombinedwithtapingtolimitboth
flexionand extension (7,24). Following proper neck immobilization, the chest
and abdomen are immobilized with seatbelts tightly fastened but allowingfor
inspiration(Figure10.5).
HelmetRemoval
On-sitemanagementof theneck-injured,helmetedpatientdiffersfromthatfor
othertraumaticcervicalspineinjuries.Ahelmetcausesthepatient’snecktobe
slightly flexed, particularly in the absence of shoulder pads, and may conceal
life-threatening head injuries. Its removal, henceforth, may be required in the
field.Ifthehelmetisremoved,thetwo-persontechniquerecommendedbythe
AmericanCollege of Surgeonsshould be used: one provider maintains in-line
immobilization,whiletheotherprovidergentlyremovesthehelmet(25).
Unique management issues can arise when caring for an injured athlete.
These include on-field evaluation, immobilization techniques, and removal of
protective equipment. The first step in evaluating the athlete with a potential
cervicalspineinjury isthe on-fieldevaluation.Theunconsciousathlete should
becarefullylogrolledintoasupineposition.Theathlete’smouthpieceshouldbe
removed while the airway, breathing, and circulation are assessed. Protective
equipment, such as a helmet or shoulder pads, should be left in place until
adequate immobilization of the head and neck has occurred (26). Multiple
studies have demonstrated that immobilizing the neck-injured football player
with only the helmet or only the shoulder pads in place causes significant
cervicalspinemalalignment(27–29).Ifprotectiveequipmentmustberemoved
intheprehospitalsetting,theAmericanCollegeofSurgeonsrecommendsusing
ateamofthreetofourmembers,asdetailedearlier(see"HelmetRemoval").The
helmetshould first be removed usingthetwo-persontechnique (25). Shoulder
padsmust also be removedin an orderly mannerwhilethe head andneckare
stabilizedatthelevelofthetorso.Theanteriorandaxillarystrapsshouldbecut
first.Thentheheadandthoraxshouldbeelevatedasaunitastheshoulderpads
areslidfromundertheathlete.Finally,thepatientisloweredbackdowntothe
spineboardandacervicalcollarisapplied(28).
FIGURE10.5Properlyimmobilizedpatient.
Ina pool or surf situation, a different version of this technique is applied.
Thefirstrescuerinthewaterimmobilizestheneckintheneutralpositionusing
manualin-linesupportintheface-upposition.Asecondrescuerentersthewater
andpositionsasemi-rigidcollarifavailabletotheneck.A floatingfull-length
spineboardis thensubmergedby thesecond rescuerandpositionedbelowthe
patient.Allstrapsaretightenedwhileinthewaterandwhensecured,thepatient
canberemovedfromthewaterbyfourrescuersorloadedontoarescueboator
rescuesurfmatattachedtothebackofajetski(30).
EXTRICATIONANDTRANSPORTATION
Accessibility of the accident site is the primary consideration in extricating a
patient. Once the patient has been properly immobilized, the prehospital
personnel must make a decision regarding the safest and fastest method of
transportation.Inremoteruralregions,helicoptertransportisanexcellentoption
for direct evacuation to a trauma center. Given the suggestion that there is
improvedoutcomeswithearlierspinalsurgery,patientsshouldbepreferentially
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