Cervical spine immobilization is a routine precaution taken by both EMS and Emergency Departments for patient who experience oftentimes minimal trauma. The purpose of maintaining immobilization of the cervical spine with suspected bony injury is to prevent secondary injury. Other than patient discomfort, maintaining cervical spine immobilization is oftentimes resource-heavy and can complicate essential procedures and tasks such as intubation or central line insertion. So why are we doing it?
C-spine immobilization came into heavy use around the 1960’s after there were case reports of such secondary spinal cord injuries. The common theme that one hears is “that one patient who moved their head the wrong way and suddenly collapsed due to sudden paralysis.” Since that time, there have been no randomized controlled trials to test the theory of secondary injury and it became standard of practice.
A recent review article in Academic Emergency Medicine explored the question on the necessity of c-spine immobilization by performing a literature review on these case reports of secondary injuries. 12 studies were identified describing 41 different cases of secondary neurological injury. Of these, 24 described cervical spine injuries and only 7 of those described injuries above C5. In addition, there were several factors which made it unclear as to whether or not injury occurred as a result of faulty immobilization or due to worsening localized swelling from the initial incident.
The review article concluded there were no high quality data sufficient enough to recommend cervical spine immobilization. Conversely, there was also not enough high quality data to not recommend immobilization. Common risk factors for deterioration includes conditions such as ankylosing spondylitis, mental status abnormalities, or manipulation for imaging (flexion and extension views for c-spine x-rays). As such, the search for the randomized clinical trial will continue, although it is unlikely to gain IRB approval as it goes against our current standard of practice.
Oh, and as for the sudden onset paralysis during neck movement? There has never been a single case report describing this phenomenon. We could file that one under “urban legends.”
Oto B, Corey DJ II, Oswald J, Sifford D, Walsh B. Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature. Academic Emergency Medicine. 2015; 22:00-00.