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Tue Sep 4 18:29:07 BST 2007

Ignoring for the sake of brevity the provocative revelation that
radiologists can be nitpicky (OMG!), and admitting from the start that
EVERYONE IN GREAT BRITAIN IS SMARTER THAN ME, I must nonetheless express
almost infinite skepticism: 
You've seen "numerous" cases of spinal column injury converting to SCI
during imaging?  And you haven't "[found] the time look more closely at
these incidents to determine exactly what was happening?"
Sorry, Paul.  I'm not buying.  This is the sort of unsubstantiated,
unquantified summary of anecdotal memory from which urban mythology
takes nourishment.
You owe it to the world to identify and publish those cases of yours.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of
Paul.Harrison at sth.nhs.uk
Sent: Tuesday, September 04, 2007 12:44 PM
To: trauma-list at trauma.org
Subject: RE: Unstable SCI, can they move arms in CT?

I reviewing radiological literature, keeping the arms above the head for
PET/CT examinations appears to be required to avoid serious streak
artifacts on CT. In clinical practice, the continued use of the rescue
board and extrication collar and / or head blocks in suspected / actual
acute cervical spinal/SCI  patients usually prevents this from being
undertaken easily or comfortably by the patient. Obviously, any trauma
patient demonstrating physical difficulty in raising arms above head
increases suspicion of shoulder injury but difficulty / pain experienced
when asked to voluntarily raising arms is also a sign of
actual/potential cervical/high thoracic spinal /spinal cord injury.
Passively raising limbs in such patients is known to cause
cervico-thoracic pain resulting in reflex head/upper body movement (even
against restraining protective devices) such as lifting, hyperextension
or rotation of head/upper body with at least the potential for secondary
injury. 

As in the previous report I can recall no specific secondary cord
injury/extension related to this actual manoeuvre but can recall
numerous incidences of conversion of actual spinal injury to spinal cord
injury during CT/MRI scanning and this discussion suggests to me that
perhaps I should find the time look more closely at these incidents to
determine exactly what was happening at the time that the patient
complained of/demonstrated neurological deterioration. Also actual
conversion incidents in patients asked or 'assisted' to raise arms to
remove clothing.

In my own and SCI Centre colleagues clinical experience in UK we cannot
recall a request for positioning a patient with actual or grossly
suspected high spinal or spinal cord injury in this way. I have put in a
request to the SCI-LINK network and will report as I hear back.  Once
the patient is referred to the SCI team it is common practice throughout
the UK to initially limit upper limb movement above the shoulder girdle
until radiological survey has been reviewed by SCI consultant. This is a
consensus guideline supported by all disciplines - particularly
physiotherapists involved in early passive limb movements. Time
restrictions will be applied on an individual basis. The particular
dynamic sequencing of passively moving a paralysed upper limb above the
shoulder girdle is well established within SCI centres to reduce the
muscular movement at the cervico-thoracic junction during this exercise
and is often taught to radiographers along with a similar sequence to
enhance 'shoulder pulling' for flat x-ray views.

In cervical disc disease patients often present holding the arm elevated
and behind the head, presumably because this manoeuvre reduces the
tension on the nerve root and thus lessens the pain, illustrating the
extent to which vertebral movement can be occasioned during the
manoeuvre.

I'll try to add more to this post when replies from colleagues come in.

Johan, I will be hopefully visiting Sahlgrenska SCI centre in late
October and may have opportunity to call in to Crit Care if convenient?

Paul Harrison

Clinical Development Officer

Princess Royal Spinal Injuries Centre

Sheffield UK

+44 (0) 114 2715616

________________________________

From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of
johan.malmgren at vgregion.se
Sent: 02 September 2007 10:16
To: trauma-list at trauma.org
Subject: Unstable SCI, can they move arms in CT?

Everytime we have a patient with suspected spinal cord injury there's a
discussion when doing the initial trauma-CT about mobilization of the
arms. To get the best possible CT pictures the CT tech wants the patient
to have his/her arms above head (well, above in the direction of
continuing the bed :) ), and it is up to the traumaleader's approval to
arrange this. The patients are on spine board and with stiff neck
collar.

Now, we're having a meeting in a few days about problems concerning
trauma patients in the xray dept (why are they there if unstable etc
etc), and it turns out that our spinal cord dept wants to send a nurse
or physiotherapist on every suspected SCI-trauma to be the one giving
approval for arm movement. Personally I think we're too crowded as it
is. 

My question for the group is: Has there been any well performed studies
of what actually happens with an unstable SCI when doing these
manouvres? What are your local traditions with this? I would like to
attend this meeting with some good science in my back pocket! :)

Johan Malmgren 
Resident, Anaesthesia, Critical Care & Traumatology
Dept of Anaesthesia and Critical Care
Sahlgrenska University Hospital
Gothenburg, Sweden
+46313428073 [Work]
+46707696961 [Mobile]

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Unstable SCI, can they move arms in CT?