Semirigid cervical spine collar and risk of missing significant soft tissue injuries

Abstract

We report the case of an initial misdiagnosis of significant scalp soft tissue hidden beneath a semirigid cervical collar. A 16-year-old unrestrained rear seat passenger was involved in an RTA sustaining a subdural haematoma, cervical spine fractures and what was initially diagnosed as a significant degloving scalp injury. The patient was admitted to the intensive care unit intubated sedated, and with a cervical collar. The scalp injury was dressed with a view that potential reconstructive surgery would be needed subsequently.

This case demonstrates that while cervical collars remain a fundamental aspect of initial prehospital care in trauma, they have potential drawbacks to their use, which need to be carefully noted. Some of these drawbacks have been reported extensively in the literature. This case outlines the necessity of a thorough secondary survey in the trauma patient as the cervical collar can obscure the assessment of significant head and neck soft tissue injuries.

Background

The application of a cervical collar has been considered a vital component of prehospital trauma care for the last three decades.¹ It is an integral part of the well-recognised ABCDE primary survey used for the trauma patient, with ‘A’ standing for ‘airway maintenance with cervical spine protection’.¹ The rationale for application of the cervical collar in the trauma setting has been to reduce the risk of secondary spinal cord injury by immobilising a potentially unstable cervical spine.²

Up until the turn of the century, spinal immobilisation was considered mandatory for almost all trauma patients until the spine could be cleared radiologically. This would include very uncomfortable measures including backboards, cervical collars, head restraints and strapping. This is significant considering there remains no evidence that spinal immobilisation has a direct effect on mortality, neurological injury or even spinal stability.^{3 4}

The issue is spinal immobilisation is not a benign procedure. Reported complications other than pain and discomfort include respiratory compromise, increased risk of aspiration from vomiting, decubitus ulceration and even increased intracranial pressure.⁵ In the absence of randomised clinical trials, which can identify the exact effect of spinal immobilisation on the risk of secondary spinal cord injury, the theoretical risk remains and the practise of immobilisation will understandably continue, especially in high-risk patients.

The challenge for the clinician then becomes how to avoid unnecessary spinal immobilisation in certain cases to avoid the aforementioned adverse effects. This can be done through following internationally recognised guidelines,^6–8 or well-defined protocols, such the NEXUS criteria or the Canadian C-Spine Rule.^{9 10} Certain patient subgroups are at higher risk of having concomitant cervical spine injuries in trauma. These include patients older than 50, presenting with a GCS of lower than nine or with concomitant spleen or lung injuries.¹¹

If spinal immobilisation is judged necessary, it then becomes essential that the clinician is aware of potential adverse effects to attempt to minimise them or avoid them altogether. It is also worth noting that types of cervical collars differ in terms of immobilisation they provide, perceived comfort and their effect on JVP.¹² The following case report outlines a significant restriction of cervical spine immobilisation, which is not widely recognised.

Case presentation

A 16-year-old girl presented to the emergency department with multiple trauma following a high-impact road traffic accident. She had been an unrestrained back seat passenger in a car travelling at 90 mph, which had collided with another car. The injuries she sustained included a significant degloving scalp injury extending from the right mastoid to the left temporal area and from the forehead anteriorly to the occiput posteriorly.

Rapid sequence intubation was performed at scene and the patient was placed in a cervical collar. A full trauma CT series was subsequently performed. This revealed a significant loss of tissue from the scalp, a small subdural haematoma, fractures to C5 and C6, transverse process fractures through L1 and L2, bilateral pulmonary contusions and an undisplaced fracture of the proximal right superior pubic ramus.

Initial assessment of the scalp had identified a soft tissue injury with what appeared to be total tissue loss covering a significant area of the scalp (figure 1). There was significant debris on the scalp including hair, hair extensions, plastic and glass. The patient was kept intubated in intensive care unit (ICU) overnight where she required sedation. Due to the cervical spine fractures, the patient remained in a cervical collar.

Figure 1.

Appearance suggestive of significant degloving scalp injury.

Following a review of the CT images on the morning ward round, 6 hours postinjury, a bulk of soft tissue appeared to be overlying the occiput including some foreign bodies. The patient was then reviewed and a log roll was performed to examine the patient with the cervical spine collar removed. The scalp soft tissue had been entrapped in the cervical collar but was still viable. On release, the tissue was clearly bleeding (figure 2). An adequate secondary survey had not been performed, exposing the neck, between the time of injury and the morning ward round.

Figure 2.

On release of scalp tissue from cervical collar, healthy tissue with evidence of bleeding.

A decision was made to take the patient to theatre for examination under anaesthesia, washout and primary closure. In theatre, the Pulse Lavage System was used to washout the scalp from a significant amount of debris (figure 3). Two significant defects were identified in the pericranium measuring around 5 cm in diameter each (figure 3). The pericranium was approximated and small burr holes were made by the neurosurgical team to promote bleeding aid the revascularisation of the scalp. Three large Vac drains were placed and the scalp was then closed in a layered approach (figure 4).

Figure 3.

Washout using the Pulse Lavage System.

Figure 4.

Primary closure of soft tissue achieved. Vac drains (white arrows) and intracranial pressure monitoring catheter (black arrow).

Outcome and follow-up

The patient returned to ICU postoperatively and was extubated the following day. The scalp tissue remained healthy and viable 5 days postoperatively. The skin clips and non-resorbable sutures were removed a week postoperatively.

Discussion

It has been claimed that 3%–25% of spinal cord injuries are secondary because of inappropriate immobilisation either in the prehospital or early hospital setting.² To what extent this is true and how effective cervical collars are in preventing secondary spinal injuries remains contentious. Still, cervical collars are considered essential to accomplish cervical spine immobilisation, especially in unconscious patients. However, this immobilisation is not without potential complications and there is also debate as to how this immobilisation should take place.

The prevalence of significant spinal cord injury following blunt trauma with significant injury is <2%.¹³ This means more than 50 patients will have their necks immobilised for every significant cervical spine injury. If there is concomitant moderate to severe head injury, the risk of cervical spine injury does increase to 7.8%.¹¹ Neck immobilisation is usually accompanied by the patient being placed on a rigid spinal board. Potential complications include increased difficulty in airway management, decubitus ulceration, aspiration from vomiting, respiratory compromise and possible increased intracranial pressure.

This case outlines another potential limitation of using a semirigid cervical collar, namely the hinderance of potential assessment of soft tissue injuries of the head and the neck. In this case, the soft tissue of the scalp was hidden behind the cervical collar. If the congested soft tissue had not been identified promptly, it would have no longer become viable and reconstructive surgery would have been needed.

The aim of this case is to highlight two main points. First, a thorough secondary survey assessing the patient from head to toe is of paramount importance and can identify significant hidden injuries. This process should not be hindered by the presence of a cervical spine injury as manual immobilisation and log roll can be performed while assessing the patient. Second, while cervical spine immobilisation is often necessary in the trauma setting, this process is not without potential limitations and complications. One of these potential limitations is missing significant soft tissue injuries of the occiput and neck that can be hidden beneath the cervical collar.

Learning points.

• Cervical spine immobilisation is not an entirely benign procedure and may cause respiratory compromise, risk of aspiration from vomiting, decubitus ulceration and even raised intracranial pressure.

• Significant soft tissue injuries of the occiput and the neck can be hidden beneath a semirigid cervical collar or other forms of cervical immobilisation.

• Cervical spine immobilisation should not hinder a thorough secondary survey assessing the patient from head to toe.

• If significant soft tissue injury is suspected, manual in-line stabilisation can be performed along with a log roll to adequately assess for significant soft tissue injuries.