Risk assessment for spinal injury after trauma

The guidelines are simple and evidence based

About 600-700 people sustain acute traumatic injuries to the spinal cord in the United Kingdom each year. Previously published data indicate that the injury to the spinal cord remains unrecognised in 4-9% of individuals.1 2 Inadequate management of patients with injury to the spinal cord has the potential to lead to neurological deterioration, additional functional handicaps, and possibly medical litigation. Thousands of patients, however, routinely present to primary care centres every day with injuries to the neck and back. The immediate care and appropriate assessment of patients with spinal injury is a skill that is expected of all doctors. General practitioners and hospital doctors with little or no training and experience of caring for patients with trauma might have to help the victims of a recent accident. They will certainly have to advise patients who complain of spinal pain after injury. This article is written to guide clinicians in these situations.

The evidence base for this subject has improved recently with some large scale studies from North America.3 4 Several consensus guidelines have been published by the National Institute for Clinical Excellence and the British Trauma Society.5 6 Most of the patients in these studies have been treated in secondary care, but the principles of management should help guide primary care physicians and other clinicians.

A patient who walks into the consulting room three days after a minor rear end shunt in their car does not need immediate spinal immobilisation. The victims of other high velocity road traffic incidents, those who have fallen down stairs, or injured themselves diving into water must be assumed to have had a spinal injury until proved otherwise.

How should you treat the patient at the scene of an accident? If the patient has obvious injuries that will require hospital assessment, minimise movement and await the arrival of the ambulance. The risks of moving the patient always need to be balanced against the risks of possibly making a spinal injury worse. If you need to move the patient, the principle is not “don't move” but “move carefully,” supporting the entire spine, “keeping spine in line.” Support the head and ensure the head and body move as one. Generally a safe log roll needs informed help from three to four people (figs 1 and 2). The care of the airway is a priority, but in almost all cases this can be managed with due care of the spine. These precautions should be maintained until the emergency services arrive and formal spinal immobilisation can take place.

Safe log roll

Safe log roll

If the patient has evidence of pre-existing spinal disease such as ankylosing spondylitis, keeping spine in line implies that the spine should be kept in the line that is normal for the patient before the injury. Many patients with ankylosing spondylitis who have severe kyphotic deformity of the thoracic spine and compensatory extension of the craniocervical junction suffer further neurological deficit when the neck is extended in an attempt to keep the spine in line.

Box 1 sets out conditions of low risk injury when a primary care provider can reasonably exclude potentially dangerous injury to the spinal column on clinical grounds.6

How should you deal with someone walking into your consulting room with neck pain some time after the injury? A clear understanding of the mechanism of injury is the most important step in the assessment of any injury. “Hurt neck in road traffic accident” is not good enough since such a history could be obtained from a patient involved in a minor rear end collision or from the unbelted occupant of a car that has rolled over. Note the patient's symptoms, especially any numbness or paraesthesia or limb weakness. Patient related factors such as age over 65 years, previous disorders such as ankylosing spondylitis, rheumatoid arthritis, and osteoporosis all indicate a higher risk.

Patients younger than 65 years of age who have not suffered a “dangerous mechanism of injury” (box 2), have no neurological symptoms or signs, and can rotate the neck to 45 degrees to the left and right, do not require x rays of the cervical spine.3

Advice for the immediate care of patients with neck pain who have been the occupants of a car that has been shunted in the rear by another car at low speed, can be derived from guidance by the National Institute for Clinical Excellence5 and the Canadian C-spine rule.3 Briefly, radiology and probably immobilisation are not needed if the patient is alert, mobile, younger than 65 years and has no neurological signs or symptoms, no other injuries, and can rotate the neck by 45 degrees to the left and right (see box 2 for “high risk” rear end shunts).

No such clear evidence base for back pain following clinically significant trauma exists, but the application of similar principles should help the doctor identify a population at low risk of having a spinal fracture.

The management of patients with low risk injuries of the neck and back is now well defined. Explanation of the injury, reassurance that the injury is not serious, early mobilisation, and early return to function is the best initial strategy. Advice about physiotherapy can be given to all and formal physiotherapy arranged early for those with more severe limitation in movement.

Patients who have had an accident need to have the risks of a spinal injury assessed. A group of patients at low risk of having an unstable spinal injury can be identified. These patients do not need spinal immobilisation. Patients with neck symptoms after minor injury meeting all the criteria for low risk are unlikely to need routine radiological evaluation.