Although in ED we cannot prevent the primary injury, our objective is to recognise and prevent secondary injury. Through the use of the agreed standards

Standards:

1. Spinal protection must remain in place if an injury is suspected/identified, or until it is excluded via an established protocol.
   • Unless a senior clinician has clearly documented a decision, immobilisation not in the patients best interest.
2. Assessment of the whole spine should be performed and documented where injury is suspected.
3. If abnormal clinical signs are found, complete neurological examination must be performed and documented.
4. If spinal injury identified OR abnormal neurological signs consistent with spinal cord injury are found, immediate discussion with and referral to a centre capable of emergency spinal surgery must occur.
5. Significant spinal injury is excluded following either:
   • Normal clinical examination in an awake and orientated patient with no clinically significant distracting injury OR illness is present; the patient can concentrate on and reliably report neck findings. (in line with Canadian C-Spine rules)
   • Completion of spinal imaging protocols (standard 6).
6. Imaging protocols:
   • Thoracic and lumbar spine scans should be obtained according to major trauma protocols.If a cervical spine injury is suspected, thin slice CT scanning from occiput to T4, including sagittal and coronal reconstructions should be performed without delay.If whole-body CT (WBCT) for trauma is necessary, this should include the cervical spine if injury is suspected.
   • An initial report of spine clearance imaging should be available before the patient leaves the Emergency Department.

Option	Scenario		Action
1	This investigation demonstrates an injury that may affect spinal stability. (see Notes)		Continue spinal protection and seek advice from an appropriate clinical team.
2	This scan is of good quality and there are no comorbidities confounding its interpretation. No features of instability, such as fracture, haematoma or joint disruption are seen.	Patients with NO acute neurological symptoms/signs on examination or mobilisation.	Spinal protection may be removed.
		Patient who HAS acute neurological symptoms/signs on examination or mobilisation.	Continue spinal protection and seek advice from an appropriate clinical team.
		Unconscious OR unable to Co-Operate with examination (see Notes)	Spinal protection can be removed with caution providingConsultant Radiology report & No evidence of acute neurological deficitIt must be recognised there is a <1% chance of unrecognised injury. ANY evidence of neurological deterioration should be re-immobilised pending MRI
3	Whilst there are no obvious features of spinal instability, the CT scan is either not of good quality and/or there are comorbidities confounding its interpretation.		Continue spinal protection until MRI is performed and report available.

Magnetic Resonance Imaging is necessary when the following are present:

• Suspected cord injury
• Ambiguous CT scans, as per option 3 of standard 6
• Inability to assess patient, as per option 2 standard 6 
• Ankylosed spines with negative or indeterminate CT appearances for fracture
• Contraindications to ionising radiation, for example in pregnancy

Notes:

• Option 1 Standard 6: Certain Spinal injuries may be combatable with removal of protection on agreement of the base speciality consultant:
  • Facet joint fractures of the thoracic and lumbar spine
  • Spinous process fractures
  • Wedge compression fracture with loss of vertebral body height of less than 25%
  • Type 1 odontoid fracture
  • End-plate fracture
  • Transverse process fracture
  • Trabecular bone injury
  • Osteophyte fracture, excluding corner or teardrop fractures
  • Isolated avulsion fractures
• Option 2 Standard 6: Management of Unconscious or patients unable to fully co-operate with clinical exanimation is recognised as significant challenge. With advances in CT the number of significant injuries missed is very low <1%. However, there are significant risks associated with prolonged immobilisation, especially for frail patients who are more likely to fall into this group. 

This pragmatic approach is in line with BOA-Standards, however, it must be recognised there is a chance of deterioration. If ANY evidence of neurological deficit the patient should be re-immobilised and reassessed for further imaging. 

Complications of prolonged use of Immobilisation:

• Impaired venous drainage and increased intracranial pressure
• Difficult laryngoscopy and intubation
• Increased risk of aspiration and ventilator-associated pneumonia
• Difficult central venous cannula insertion
• Increased risk of central venous cannula associated blood stream infections
• Increased risk of pulmonary thromboembolism
• Pressure necrosis leading to ulceration
• Inability to provide good oral care
• Failed enteral nutrition, gastrostasis and reflux
• Restricted physiotherapy

Reference:

• NICE Spinal Injury – https://www.nice.org.uk/guidance/ng41
• BOA Standard C-Spine Clearance- https://www.boa.ac.uk/static/1e3aff2a-576f-484b-ab21ec91300678cf/BOAST-Cervical-Spine-Clearance.pdf
• C-Spine Clearance Unconscious patient UHW – https://www.rightdecisions.scot.nhs.uk/media/2106/clearance-of-the-cervical-spine-in-the-unconscious-adult-patient.pdf
• Morris CG, McCoy EP, Lavery GG. Spinal immobilisation for unconscious patients with multiple injuries. BMJ. 2004 Aug 28;329(7464):495-9. doi: 10.1136/bmj.329.7464.495. Erratum in: BMJ. 2004 Oct 2;329(7469):773. McCoy, E P [corrected to McCoy, E]. Erratum in: BMJ. 2004 Sep 18;329(7467):673. PMID: 15331475; PMCID: PMC515204.