Abstract
Confirmation of cervical stability in multiple trauma patients is often difficult. Prolonged collar immobilization of these patients is often required. Missed injuries can be catastrophic. Since January 2000, the senior author has regularly applied a modification of the classical White & Panjabi stretch test in the operating room as a method of assessing cervical stability in qualifying trauma patients. Review of the first thirty cases finds two cases of stable ligamentous injury identified which would have otherwise been missed, a mean of almost two weeks’ collar immobilization eliminated and no missed instabilities, with no complications or assessment failures to date.
The purpose of this study was to present the protocol and preliminary results of a modified White & Panjabi cervical stretch test in the assessment of cervical instability in multiple trauma patients.
Multiple trauma patients having no radiographic evidence of cervical instability on static imaging are routinely protected in hard collars until able to cooperate with clinical assessment and/or undergo flexion/extension radiographs for concern to possible discoligame-nous instability in the neck. Beginning in January 2000, such patients who were going to the operating room were routinely assessed with a stress test incorporating fluoroscopically-controlled axial distraction to tensile limit of the neck followed by maximum passive flexion and extension stressing. In the absence of intersegmental hypermobility, cervical precautions and immobilization were considered unnecessary and discarded. Chart documentation was reviewed for outcome and complications after discharge from the hospital.
To date thirty-two tests have been performed and twenty-six cases had complete chart documentation available for review. No complications of the procedure and no missed instabilities have been identified. An average of thirteen days’ collar immobilization were eliminated by this protocol. Two cases of ligamentous hypermobility without instability were identified, one at O/C1 and the other at C5/6; both patients were treated observationally and have done well. One case of an undisplaced C2 pedicle fracture in a massively traumatized geriatric case was confirmed as stable on the day of injury, eliminating the need for collar support until the patient died of multiple organ failure twenty-one days later. Two patients went on to have neck pain complaints on regaining consciousness, but could be reassured that there was no instability.
The operating-room cervical stress test is a practical and safe maneuver that can eliminate the requirement for collar immobilization in obtunded trauma patients, safely identify subtle ligamentous injuries without frank instability, and confirm stability in cases of undisplaced fracture.
The operating-room cervical stress test is an effective tool in screening trauma patients for such injuries. It does not require access to MRI technology and can be used in any hospital with an operating room.
Prolonged cervical collar immobilization and missed discoligamentous injuries of the neck in multiple trauma patients can be eliminated with the application of this test.
Correspondence should be addressed to Cynthia Vezina, Communications Manager, COA, 4150-360 Ste. Catherine St. West, Westmount, QC H3Z 2Y5, Canada
