Tag Archives: Cervical spine

General

Dysphagia and Cervical Spine Injury

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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

Normal soft tissue (<6mm at C2, <22mm at C6)

A study in the Jan 2011 Journal of Trauma outlined 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. We don’t use halo vests very often any more, but cervical collars can exacerbate the problem by keeping the neck in an unaccustomed position. 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.

General

Is Applying Or Removing That Cervical Collar Dangerous?

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Cervical collars are applied to blunt trauma patients all the time. And most of the time, the neck is fine. It’s just those few patients that have fracture or ligamentous injury that really need it.

I’ve previously written about how good some of the various types of immobilization are at limiting movement (click here). But what happens when you are actually putting them on or taking them off? Could there be dangerous amounts of movement then?

Several orthopaedics departments studied this issue using an electromagnetic motion detector on “fresh, lightly embalmed cadavers” (!) to determine how much movement occurred when applying and removing 1- and 2-piece collars. Specifically, they used an Aspen 2-piece collar, and an Ambu 1-piece. They were able to measure flexion/extension, rotation and lateral bending.

Here are the factoids:

  • There were no significant differences in rotation (2 degrees) and lateral bending (3 degrees) when applying either collar type or removing them (both about 1 degree)
  • There was a significant difference (of 0.8 degrees) in flexion/extension between the two types (2-piece flexed more). Really? 0.8 degrees?
  • Movement was similarly small and not significantly different in either collar when removing them

Bottom line: Movement in any plane is less than 3-4 degrees with either a 1-piece or 2-piece collar. This is probably not clinically significant at all. Just look at my related post below, which showed that once your patient is in the rigid collar, they can still flex (8 degrees), rotate (2 degrees) and move laterally (18 degrees) quite a bit! So be careful when using any collar, but don’t worry about doing damage if you use it correctly.

Related post:

Reference: Motion generated in the unstable cervical spine during the application and removal of cervical immobilization collars. J Trauma 72(6):1609-1613, 2012.

General

Dysphagia and Cervical Spine Injury

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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.

General

Inline Stabilization vs Inline Traction of the Cervical Spine

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Members of the trauma team must frequently protect the cervical spine when moving the patient or performing certain procedures. In most cases, a cervical collar is placed which does a fine job of this. Occasionally, though, the collar must be removed to provide access to areas near or under the collar.

When the collar is off, someone must be charged with immobilizing the cervical spine. Sometimes this is incorrectly referred to as providing inline traction and not inline stabilization.There is a big difference!

Inline traction is used to try to realign cervical vertebra that are malpositioned due to fracture or ligamentous injury. This should only be performed under the guidance of a neurosurgeon!

Inline stabilization merely means that the patient (or trauma professional) is restrained from moving the cervical spine. This is commonly needed while intubating the patient, so that the intubator does not extend the neck when trying to visualize the cords.

Why is this important? Check out the images below. If a severe injury has already occurred, traction on the neck may have devastating consequences! Inline stabilization is the only way to go.

Spine injury AO dissociation