Immobilisation should not be discontinued in unconscious patients

Editor—Gupta and Clancy highlight a common management dilemma, which I have experienced myself, in requests to “clear the cervical spine” in unconscious patients with multiple injuries either in the resuscitation setting or, more commonly, after a period in intensive care.1 The request is often made after the three films recommended for advanced trauma life support have been obtained.2 A response that “the risk of potential for spinal cord injury cannot reasonably be ‘cleared’ until a patient is conscious, cooperative, and controlled in respect of distracting sources of pain and has a normal neurological and physical examination” is often met with a request for a consultant's opinion.

Even in a recent instructional article on the care of patients with multiple injuries, advice is unhelpful; it states that “when the neurological status cannot be verified (as in unconscious patients) a complete radiological assessment is necessary with anteroposterior and lateral views followed by [computed tomography] when this is indicated.”3 My understanding is that computed tomography will strongly reassure that bony injury or appreciable paraspinal haematoma is unlikely, but the ideal imaging modality would be magnetic resonance imaging,4 which at present is not practicable in patients with multiple injuries.

So what will I say next time I am asked to clear the cervical spine, even knowing that the incidence of isolated ligamentous disruption, putting the cord at risk, is low? I will continue to give the same reply as before, and a consultant's opinion will again be asked for and will usually be to clear the cervical spine and remove the immobilisation.

In children, cord injury may be present despite normal radiographic appearances

Editor—Gupta and Clancy found that in 19 of the 25 general intensive care units that they surveyed, spinal immobilisation was discontinued in unconscious patients with multiple injuries while the patient was unconscious provided that the cervical spine radiograph showed no abnormality.1 It must be emphasised that this study concerned only adult patients. In children, spinal cord injury without radiological abnormality is well documented.2 In my experience, three of 31 patients with cervical spine injury had cord injury despite the x ray film showing no abnormality.

In children who are at risk of cervical spine injury, adequate spinal immobilisation must be maintained even if the appearances of the x ray films are normal. It should be continued until the stability of the cervical spine and the absence of cord injury have been confirmed by clinical examination when the patient is conscious (supplemented if necessary with magnetic resonance imaging or computed tomography), even at the cost of occasional pressure sores.