Clinical Review

Spinal immobilisation for unconscious patients with multiple injuries

BMJ 2004; 329 doi: (Published 26 August 2004) Cite this as: BMJ 2004;329:495

This article has corrections. Please see:

  1. C G Morris, specialist registrar (,
  2. E P McCoy, consultant1,
  3. G G Lavery, consultant1
  1. 1 Regional Intensive Care Unit, Royal Victoria Hospital, Belfast BT12 6BA, Northern Ireland
  1. Correspondence to: C G Morris
  • Accepted 29 June 2004


After blunt polytrauma the cervical spine may be injured in 2-12% of patients,13 and injuries of the head and neck are associated in up to one third of cases.4 5 The presence of a head injury is important as it is the strongest independent risk factor for injury of the cervical spine (relative risk 8.56) and may also prevent meaningful clinical evaluation and exclusion of cervical injury.

Before the advanced trauma life support guidelines7 it had been suggested that among patients with a cervical spine injury, a delayed or missed diagnosis was associated with 10 times the rates of permanent neurological sequelae.8 Modern trauma care appropriately assumes that injury is present until it is excluded. Conscious trauma patients who are able to report symptoms and meet the criteria detailed in box 1 may generally be regarded as having a stable cervical spine. The strict application of such criteria may be more sensitive than routine screening radiographs.911

These criteria will not allow clinical exclusion of injury among most patients with multiple injuries. Patients rendered unconscious and requiring intubation, receiving analgesia or sedation, or with a serious head injury are not appropriate for the clinical exclusion of cervical spine injury. The strategy for the evaluation of such patients may lie anywhere between the following two modalities.

Firstly, prolonged immobilisation and a semirigid cervical collar may be used, with clinical evaluation on the return of an “adequate” level of consciousness (many clinicians believe that this is the only reliable way to exclude occult ligamentous injury). This is often associated with serious complications of prolonged immobilisation and application of the cervical collar, detailed in figure 1 and box 2. In addition, this form of evaluation in a previously unconscious patient has not been studied …

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