Cervical Spinal Cord Injury: Who Needs A Tracheostomy?

The sad truth is that patients with cervical spine injury may need a tracheostomy. In very high lesions (C1-2) the need may be permanent. Lower injuries (C3-5) frequently need a trach for a limited period of time while they develop enough reserve to compensate for the lost of chest wall muscle power.

It’s not always easy to tell which patient is likely to need intubation upon arrival in the ED. I’ve seen occasional patients fail while getting their CT scans, which is poor planning. Is there a way to predict who might fail, thus benefiting from early intubation and an early plan for tracheostomy?

The trauma group at LAC + USC Medical Center undertook a National Trauma Databank review to try to answer this question. They identified 5256 patients with cervical spinal cord injuries without a severe traumatic brain injury that would otherwise require intubation. About 21% received tracheostomies, and the common predictors were:

  • Intubation at the scene by EMS (they’ve done the job of deciding for us!)
  • Intubation in the ED
  • Complete cord injury at any level
  • Facial fractures
  • Chest trauma
  • Injury Severity Score >=16

Patients who received a tracheostomy generally spent more days on the vent, in the ICU and in the hospital than those who did not. However, their mortality was lower.

It’s generally recognized that patients with complete injuries from C1-C5 routinely require tracheostomy. The surprising thing about this study was that complete injuries at C6 or C7 did as well.

Bottom line: If you have a patient with a spinal cord injury who meets any of the criteria above, stand ready to intubate. I tell my trainees that, if at any time they see something that makes them think about intubating, they should have already done it. Likewise, the surgical ICU team should have a low threshold to performing an early tracheostomy on these patients.

Reference: Incidence of clinical predictors for tracheostomy after cervical spinal cord injury: a National Trauma Databank review. J Trauma 70(1): 111-115, 2011.

Picture: crossbow bolt through the mouth and cervical spinal cord.

Dysphagia and Cervical Spine Injury

Cervical spine injury presents a host of problems, but one of the least appreciated ones is dysphagia. Many clinicians don’t even think of it, but it is a relatively common problem, especially in the elderly. Swallowing difficulties may arise for several reasons:

  • Prevertebral soft tissue swelling may occur with high cervical spine injuries, leading to changes in the architecture of the posterior pharynx
  • Rigid cervical collars, such as the Miami J and Aspen, and halo vests all force the neck into a neutral position. Elderly patients may have a natural kyphosis, and this change in positioning may interfere with swallowing. Try extending your neck by about 30 degrees and see how much more difficult it is to swallow.
  • Patients with cervical fractures more commonly need a tracheostomy for ventilatory support and/or have a head injury, and these are well known culprits in dysphagia

A study in the Jan 2011 Journal of Trauma outlines the dysphagia problem seen with placement of a halo vest. They studied a series of 79 of their patients who were treated with a halo. A full 66% had problems with their swallowing evaluation. This problem was associated with a significantly longer ICU stay and a somewhat longer overall hospital stay.

Bottom line: Suspect dysphagia in all patients with cervical fractures, especially the elderly. Carry out a formal swallowing evaluation, and adjust the collar or halo if appropriate. 

Reference: Swallowing dysfunction in trauma patients with cervical spine fractures treated with halo-vest fixation. J Trauma 70(1):46-50, 2011.