this and that - Cervical Paranoia

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Karim,

We are talking about different situations. I read an article recently that
states what you said, that in 10-15% of patients with spinal cord injury,
"secondary" spinal cord damage (mobilizing unstable cervicals with
unsuspected fractures) occurs. But we were considering a different clinical
picture: the alert patient, with no neurological deficit, but with midline
tenderness.

I agree that in the unconscious, intubated patient, without an adequate
neurological examination, we have to worry about ligamentous injuries. In
fact, such injuries can be pretty unstable. And I agree with the fact that
CT will show angulation, rotation and translation in those unstable spines.
And even if the spine seems to be aligned, there could be instability. But
the point is that no passive movement can compromise the canal more than the
initial insult. If the initial insult compresses the spinal cord, further
movement can increase the damage. If the initial insult does not damage the
cord, do you believe that head flexion by the nursing team washing the
patient´s head, for example, could do that?

But in the alert patient, without neuro deficit, a normal CT rules out
medullary compression risk. This is based on logic, not on evidence (just
like your statement). I guess this is the problem with those injuries. Try
to imagine an injured cervical spine, with ligamentous rupture. Can you
imagine a greater angulation of the spinal canal than the initial injury?
Even the cervical muscle spasm that comes with cervical injuries prevents
the anatomy from being disrupted.

Cheers,

Felix Albers.

HPS-POA
Brazil



----- Original Message -----
From: "Karim Brohi" <karim at trauma.org>
To: "'Trauma & Critical Care mailing list'" <trauma-list at trauma.org>
Sent: Sunday, October 09, 2005 11:54 PM
Subject: RE: this and that - Cervical Paranoia




-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Felix Albers
Sent: 10 October 2005 02:27
To: Trauma & Critical Care mailing list
Subject: Re: this and that - Cervical Paranoia


>>If you consider a ligamentous injury in a patient without neuro deficit,
taking the collar off can be of no harm, since no active
or passive movement of the spine could cause a greater anatomical disruption
than the initial trauma (like hyperflexion in a frontal
car crash). If the cervical instability caused by ligament rupture could
harm the medulla, it would have already done it.

>>So, treatment is the same. Neck pain, no deficit, and normal CT: a Schantz
collar to minimize movement and that´s it. Some NSAIDs.

Felix,

This statement is not true.  A pure disco-ligamentous injury can be
completely unstable and can have, as yet, not damaged the spinal
cord.  Passive movements in these patients may well lead to deterioration in
neurology and even quadriplegia.  The notion that the
initial trauma must be the one that does all the damage is fallacious.

The point is that CT with reconstructions will identify indirect evidence of
significant disco-ligamentous disruption: translation,
rotation or angulation.  If normal they shouldn't need a collar.

Now this is our protocol for unconscious, intubated patients, and we have
published our early results of over 400 patients.  These
need to be borne out in larger number of patients and with data from other
centres.  I am not off-hand aware whether the studies of
whole c-spine CT in awake patients clear the neck regardless of midline
tenderness etc.

Karim


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