Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In today’s global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties. We retrospectively reviewed hospital charts and autopsy reports of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention and cause of death was recorded. During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 (7%) actually survived to reach hospital. Four subsequently died from injuries within 72 hours. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation, however this patient died as result of a co-existing head injury. Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life threatening conditions

Aims. Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters. Methods. We searched PubMed, EMBASE, Scopus, and Web of Science databases using variations of the term “electric scooter”. We excluded studies conducted prior to 2015, studies with a population of less than 50, case reports, and studies not focused on electric scooters. Data were analyzed using t-tests and p-values < 0.05 were considered significant. Results. We studied 5,705 patients from 34 studies. The mean age was 33.3 years (SD 3.5), and 58.3% (n = 3,325) were male. The leading mechanism of injury was falling (n = 3,595, 74.4%). Injured patients were more likely to not wear a helmet (n = 2,114; 68.1%; p < 0.001). The most common type of injury incurred was bony injuries (n = 2,761, 39.2%), of which upper limb fractures dominated (n = 1,236, 44.8%). Head and neck injuries composed 22.2% (n = 1,565) of the reported injuries, including traumatic brain injuries (n = 455; 2.5%), lacerations/abrasions/contusions (n = 500; 7.1%), intracerebral brain haemorrhages (n = 131; 1.9%), and concussions (n = 255; 3.2%). Standard radiographs comprised most images (n = 2,153; 57.7%). Most patients were treated and released without admission (n = 2,895; 54.5%), and 17.2% (n = 911) of injured patients required surgery. Qualitative analyses of the cost of injury revealed that any intoxication was associated with higher billing costs. Conclusion. The leading injuries from e-scooters are upper limb fractures. Falling was the leading mechanism of injury, and most patients did not wear a helmet. Future research should focus on injury characterization, treatment, and cost. Cite this article: Bone Jt Open 2022;3(9):674–683

Personal injury claims following whiplash injury currently cost the British economy more than £3 billion a year, yet only a minority of patients have radiologically demonstrable pathology. Patients sustaining fractures of the cervical spine have been subjected to greater force and might reasonably be expected to have worse symptoms than those with whiplash injuries. Using the Neck Disability Index, we compared pain and functional disability in four groups of patients who had suffered cervical spine injuries. The four groups were: patients with stable cervical fractures treated conservatively, patients with unstable cervical fractures treated by internal fixation, patients with whiplash injuries seeking compensation, and patients with whiplash injuries not involved in litigation. After a mean follow-up of 3½ years, patients who had sustained cervical spine fractures had significantly lower levels of pain and disability than those who suffered whiplash injuries and were pursuing compensation (p< 0.01), but had similar level to those whiplash sufferers who had settled litigation or had never sought compensation. Functional recovery following neck injury is unrelated to the physical insult. The increased morbidity in whiplash patients is likely to be psychological and is associated with litigation

Introduction. Catastrophic neck injury is rare in rugby, however the consequences are invariably devastating. Schoolboys have previously been identified as a group at risk. This study came about as a result of a recent increase in admissions of schoolboy rugby players to the National spinal injuries unit in Glasgow. Aim. To audit schoolboy rugby admissions to spinal injury units throughout the United Kingdom and Ireland, in doing so to appraise the current state of data collection. To obtain estimates of playing numbers from the Home unions. Method. Retrospective review of all 12 spinal injury units for records of cases subsequent to 1996. Representatives of each of the four home unions were contacted to confirm cases and establish playing numbers. Results. Records were available from 1996 in Scotland and Ireland and from 2000 in England and Wales. Two units collect prospective data, two had easily retrievable data. In the absence of any register data retrieval was challenging elsewhere. Of the 36 cases 24 would be classified as catastrophic 12 as near misses. The median age for injury was 17. 51% of injuries occurred in the tackle, 35% in the scrum. 92% of scrum injuries involved neurological damage, 61% with complete neurological loss at presentation, 8% with no neurological injury. Tackle injuries were associated with neurological damage in 42%, 26% with complete lesions and no neurological injury in 57%. Estimates for playing numbers (U18 inclusive) approximate to Scotland 19,000, Wales 30,000, Ireland 40,000 and England 1,200,00. Conclusion. •. A persistent number of schoolboys were injured through the study period. •. Recording of serious neck injuries is inconsistent through the United Kingdom and Ireland. •. The numbers injured in Scotland were disproportionate in view of the relative playing populations. •. Whilst less frequent, scrum injuries were more often associated with spinal cord injury

Background. A cautious outlook towards neck injuries is the norm to avoid missing cervical spine injuries. Consequently there has been an increased use of cervical spine radiography. The Canadian Cervical Spine rule was proposed to reduce the unnecessary use of cervical spine radiography in alert and stable patients. Our aim was to see whether applying the Canadian Cervical Spine rule reduced the need for cervical spine radiography without missing significant cervical spine injuries. Methods. This was a retrospective study conducted in 2 hospitals. 114 alert and stable patients who had cervical spine radiographs done for suspected neck injuries were included in the study. Data on patient demographics, Canadian Cervical Spine rule, cervical spine radiography results and further visits after discharge were recorded. Results. 14 patients were included in the high risk category according to the Canadian Cervical Spine rule. 100 patients were assessed according to the low risk category. If the Canadian Cervical Spine rule was applied, there was a significant reduction in cervical spine radiographs (p<0.001) as 86/100 patients (86%) in the low risk category would not have needed cervical spine radiograph. 2/100 patients who had significant cervical spine injuries would have been identified when the Canadian Cervical Spine rule was applied. Conclusion. Applying the Canadian Cervical Spine rule for neck injuries in alert and stable patients reduced the use of cervical spine radiographs without missing out significant cervical spine injuries. This relates to reduction in radiation exposure to patients and cost benefits

Background: A cautious outlook towards neck injuries has been the norm to avoid missing cervical spine injuries. Consequently there has been an increased use of cervical spine radiography. The Canadian Cervical Spine rule was proposed to reduce the unnecessary use of cervical spine radiography in alert and stable patients. Our aim was to see whether applying the Canadian Cervical Spine rule reduced the need for cervical spine radiography without missing significant cervical spine injuries. Methods: This was a retrospective study conducted in 2 hospitals. 114 alert and stable patients who had cervical spine radiographs done for suspected neck injuries were included in the study. Data on patient demographics, Canadian Cervical Spine rule, cervical spine radiography results and further visits after discharge were recorded. Results: 14 patients were included in the high risk category according to the Canadian Cervical Spine rule. 100 patients were assessed according to the low risk category. If the Canadian Cervical Spine rule was applied, there was a significant reduction in cervical spine radiographs (p< 0.001) as 86/100 patients (86%) in the low risk category would not have needed cervical spine radiograph. 2/100 patients who had significant cervical spine injuries would have been identified when the Canadian Cervical Spine rule was applied. Conclusion: Applying the Canadian Cervical Spine rule for neck injuries in alert and stable patients reduced the use of cervical spine radiographs without missing out significant cervical spine injuries. This relates to reduction in radiation exposure to patients and cost benefits

Objectives. To evaluate the neck strength of school-aged rugby players, and to define the relationship with proxy physical measures with a view to predicting neck strength. Methods. Cross-sectional cohort study involving 382 rugby playing schoolchildren at three Scottish schools (all male, aged between 12 and 18 years). Outcome measures included maximal isometric neck extension, weight, height, grip strength, cervical range of movement and neck circumference. Results. Mean neck extension strength increased with age (p = 0.001), although a wide inter-age range variation was evident, with the result that some of the oldest children presented with the same neck strength as the mean of the youngest group. Grip strength explained the most variation in neck strength (R. 2. = 0.53), while cervical range of movement and neck girth demonstrated no relationship. Multivariable analysis demonstrated the independent effects of age, weight and grip strength, and the resultant model explained 62.1% of the variance in neck strength. This model predicted actual neck strength well for the majority of players, although there was a tendency towards overestimation at the lowest range and underestimation at the highest. Conclusion. A wide variation was evident in neck strength across the range of the schoolchild-playing population, with a surprisingly large number of senior players demonstrating the same mean strength as the 12-year-old mean value. This may suggest that current training regimes address limb strength but not neck strength, which may be significant for future neck injury prevention strategies. Age, weight and grip strength can predict around two thirds of the variation in neck strength, however specific assessment is required if precise data is sought

Abstract. Objectives. Catastrophic neck injuries in rugby tackling are rare (2 per 100,000 players per year) with 38% of these injuries occurring in the tackle. The aim of this study was to determine the primary mechanism of cervical spine injury during rugby tackling and to highlight the effect of tackling technique on intervertebral joint loads. Methods. In vivo and in vitro experimental data were integrated to generate realistic computer simulations representative of misdirected tackles. MRI images were used to inform the creation of a musculoskeletal model. In vivo kinematics and neck muscle excitations were collected during lab-based staged tackling of the player. Impact forces were collected in vitro using an instrumented anthropometric test device during experimental simulations of rugby collisions. Experimental kinematics and muscle excitations were prescribed to the model and impact forces applied to seven skull locations (three cranial and four lateral). To examine the effects of technique on intervertebral joint loads the model's neck angle was altered in steps of 5° about each rotational axis resulting in a total of 1,623 experimentally informed simulations of misdirected tackles. Results. Neck flexion angles and cranial impact locations had the largest effects on maximal compression, anterior shear and flexion moment loads. During posterior cranial impacts compression forces and flexion moments increased from 1500 to 3200 N and 30 to 60 Nm respectively between neck angles of 30° extension and 30° flexion. This was more evident at the C5-C6 and C6-C7 joints. Anterior shear loads remained stable throughout neck angle ranges however during anterior impacts they were directed posteriorly when the neck was flexed. Conclusions. The combination of estimated joint loads in the lower cervical spine support buckling as the primary injury mechanism of anterior bilateral facet dislocations observed in misdirected rugby tackles and highlights the importance of adopting a correct tackling technique. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction A tertiary referral centre for spinal injuries will receive referrals from many different centres. The format and quality of imaging that accompanies these patients varies considerably. Methods Two cases are reported where initial imaging demonstrated unstable cervical spine injuries that were subsequently found to be normal. The cases and images are presented. Results A 19-year old female was transferred to our unit having fallen off a wall and sustaining a neck injury. The accompanying CT scan showed a C6 vertebral body fracture with bilateral fracture-subluxations of the facet joints. As there was a discrepancy with the clinical findings, a repeat fine cut CT scan was performed which was completely normal. The previous appearances were entirely due to artifact throughout the scan. A 46-year old male fell down stairs sustaining a neck injury and loss of consciousness. A CT scan of his cervical spine demonstrated an odontoid peg fracture (type II). Subsequent imaging showed the odontoid peg was completely normal. The initial CT appearances were entirely due to artifact caused by the patients’ tongue piercing!. Discussion CT scans are used with increasing frequency in the assessment of cervical spine injuries. In both these case the abnormalities present on the initial scans were entirely due to artifact that was reciprocated through the entire CT scans. Reporting these cases reinforces the importance of careful clinical examination and correlation with appropriate investigations. If there is a discrepancy between the clinical and radiological findings then it is essential that further imaging is performed

Introduction: Injuries to the urinary tract are a well known complication in patients with pelvic trauma. A severe urological injury frequently results in adverse long term outcome and prolonged disability. We present a review of the results of management of urological injury and the impact on final outcome in patients with pelvic fractures. Patients: Out of 554 patients admitted to our center with pelvic fracture, 39 with injury to the urinary tract were identified – 8 females and 31 males (study group). The mean age of the patients was 30.9 yrs (range 15 to 71 yrs) and the mean ISS was 12.9 (range 9 to 22). Two patients had a skin wound communicating with fracture hematoma. Seven (18 %) had upper tract injury, 6 (15.4 %) had extraperitoneal bladder rupture, 9 (23.1 %) had intraperitoneal rupture, 3 (7.6 %) had bladder neck injury and 14 (35.9 %) had urethral injury. The mechanism and type of injury, initial management, timing of urological intervention, orthopaedic procedure complications and long term result in terms of incontinence, stricture and sexual dysfunction were assessed. All patients were assessed based on Orthopaedic, urological and the Euroqol (EQ5D) generic health questionnaire and compared to age and sex matched control group of 47 patients with similar pelvic injuries and ISS but no urological injury. The mean follow up period was 2.3 years. Results: Upper urinary tract injuries: All were managed nonoperatively and had a uniformly good outcome except one patient who had a traumatic renal vein thrombosis and required nephrectomy. Three had acetabular fractures (one ant column and 2 both column fractures) and 4 had pelvic ring injuries (2 AP, 2 LC). Six were operated with av. time delay between injury and surgery being 7.1 days. We consider the urological injury related to the general trauma rather than the specific pelvic injury. Lower tract injuries: 14 out of 15 patients with bladder rupture had a repair of bladder within 24 hours of arrival at our center. One with a small extra-peritoneal tear was managed nonoperatively. Seven had LC injury, 6 had ARC and 2 had acetabular fractures (both column). One of the acetabulum fractures was managed by fixation and bladder repair on the day of arrival and the other had secondary congruence, which was not operated. Pelvic ring injuries were managed by internal and/or external fixation as appropriate. The average time delay between injury and surgery was 1.8 days. One patient with AP2 fracture died after 3 weeks due to severity of associated visceral injuries. Three patients reported failure of erection. All three patients with bladder neck injury had an APC fracture. Two were managed by immediate repair (day 1 and day 2) and had normal continence. One repair was delayed due to delay in transfer and was done on the 4th day. He developed faecal and urinary incontinence and loss of sexual function. Thirteen males had urethral injury – average age 37 yrs (range 19 to 70 years). Five had APC and five LC pelvic ring injuries, three had acetabular fractures. Three patients had a primary urethrostomy for a gap defect and two of these developed erectile dysfunction. Two were referred late to our center and were managed by continent urinary diversion. The rest had a catheter railroaded to maintain alignment of the two urethral ends and delayed repair was done for three patients. One patient in this group had sexual dysfunction while 5 developed a stricture. The only female patient with urethral injury had an open tilt fracture associated with urethral tear. The control group had 7 acetabular fractures, 19 AP compression, 17 lateral compression injuries and 4 vertical shear injuries. Four were managed nonoperatively. None of these had an open fracture. The average time delay between injury and surgery was 2.2 days. We found no significant difference between the study and the control group in the outcome on comparing patients with upper tract and bladder injuries but the urethral injury group had a poorer result in all 5 parameters of the EQ5D. Conclusions: Upper tract and bladder injuries in the context of pelvic trauma can be successfully managed as described, they do not add significant morbidity compared to the control group. In contrast urethral injuries significantly affected the outcome after pelvic fracture in terms of general health and return to normal function. Early management with primary alignment at the time of pelvic stabilisation and a delayed repair if required produced good results. A high index of suspicion and routine retrograde urethrograms would reduce risk of missed or iatrogenic injury. A team approach is required to achieve optimum results

The cervical spine exhibits the greatest range of motion amongst the spinal segments due to its tri-planar components of movement. As a result, measurement of movements has proved difficult. A variety of methods have been used in an attempt to measure these movements but none have provided satisfactory triplanar data. This paper uses the Zebris ultrasonic 3-D motion analysis system to measure flexion, extension, range of lateral bending and range of axial rotation in five similar male and five similar female subjects with no history of neck injuries. The subjects were tested unrestrained and in soft and hard collars, as well as in Philadelphia, Miami J and Minerva orthoses. Results show that the Minerva is the most stable construct for restriction of movement in all planes in both groups (p< 0.001 vs. all groups (p=0.01 vs. Philadelphia in female extension), ANOVA). In the male group, the standard hard collar provides the second best resistance to flexion, lateral bending and axial rotation. The female group showed no one orthosis in second place overall. Looking at these results allows ranking of the measured orthoses in order of their three-dimensional stability. Furthermore, they validate the Zebris as a reliable and safe method of measurement of the complex movements of the cervical spine with low intersubject variability. In conclusion, this paper, for the first time presents reproducible data incorporating the composite triplanar movements of the cervical spine thus allowing comparative analysis of the three-dimensional construct stability of the studied orthoses. In addition, these results validate the use of the Zebris system for measurement of cervical spine motion

The aim of the study was to highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury. We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol. This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application. Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative. We would like to emphasise the disastrous consequences of applying a rigid collar in patients with ankylosed cervical spine. The survey demonstrates the lack of awareness (∼ 50%) amongst A&E and T&O doctors regarding pitfalls to collar application. We recommend the ATLS manual highlight a pitfall for application of rigid collars in patients with ankylosed spines and suspected cervical spine injuries

Aim of Study. To highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury. Study Method. We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol. This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application. Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative. Conclusion. We would like to emphasise the disastrous consequences of applying a rigid collar in patients with ankylosed cervical spine. The survey demonstrates the lack of awareness (∼50%) amongst A&E and T&O doctors regarding pitfalls to collar application. We recommend the ATLS manual highlight a pitfall for application of rigid collars in patients with ankylosed spines and suspected cervical spine injuries

Introduction: Loss of the cervical lordosis is a common finding on the emergency department in patients who have been involved in a car accident as well as in those who have suffered head and neck injury. The difficult circumstances, under which the plain films are usually taken, make the use of CT indispensable. Our study presents the CT findings from the cervical spine in patients with loss of the cervical lordosis. Method-Patients We studied 120 patients from February 2003 to January 2004. Their mean age was 37 years old. Our protocol included the lateral-AP view, while in the absence of findings, except loss of cervical lordosis, from the plain films, the patients underwent spiral CT within 24 h. Results: Fractures of the cervical spine were found in 7 patients (5,8%). In 5 of them these involved the A1–A2 level. In two patients fractures of the occipital condyles were found. One A7 fracture coexisted with an A2 fracture. No patient had neurological symptoms. Conclusions: The complete investigation of the cervical spine at the emergency department is often quite difficult. The possible underlying injuries can be potentially life threatening. The percentage of positive findings in our study is quite high to justify the routine use of spiral CT for the detailed investigation of such patients

Study Design: A prospective randomised controlled trial. Objective: The early management of acute soft tissue injuries of the neck remains controversial. The aim of this study was to compare an early mobilisation regime versus with treatment with a soft collar for recovery of function and activity levels after soft tissue injuries of the neck. Subjects: Over a one year period, 108 patients presenting with a soft tissue neck injury were enrolled in a prospective trial. Each patient was randomised to either early mobilisation using an exercise regime (55 patients) or 3 weeks treatment in a soft collar followed by the same exercise regime (53 patients). Patients were followed up at 3, 12 and 52 week intervals from injury. Outcome Measures: Visual Analogue Scores for pain, range of neck movements, activities of daily living and time taken to return to work. Results: No differences were found between the two groups for pain, range of neck movements or for activities of daily living at any of the follow up intervals. The collar treatment group took significantly longer to return to work after injury (21 days) compared to the early mobilisation group (9 days), p< 0.05. Conclusions: Treatment in a soft collar had no clinical benefit compared to early mobilisation in terms of recovery of function, pain or range of neck movements, but was associated with an increased time to return to work

Introduction: Impingement syndrome has been reported to occur in a proportion of patients (9%) following whiplash injuries to the neck. In this study we aim to examine this finding to establish the association and incidence of subacromial impingement following whiplash injuries to the cervical spine. Method and results: We examined 219 patients who had presented to a single surgeon for a medico-legal report, at an average of 13.8 months (range 1–52) following a whiplash injury to the neck. All patients were assessed for clinical evidence of subacromial impingement. The patients were asked if the symptoms had developed following their neck injury and those with past history of shoulder pain were identified and excluded. 56 patients (26%) had shoulder pain following the injury; of these, 11 (5%) had clinical evidence of impingement syndrome, however in the majority other clinicians had overlooked this. The seatbelt shoulder (driver’s right and front passenger’s left) was involved in 9 (82%) of the cases (p< 0.001). The average age was 38.2 years compared with 57.8 years in those with subacromial impingement (p< 0.05). Impingement is therefore likely to be due to direct trauma from the seatbelt in the older age group with an already compromised subacromial space. Conclusion: It is now established that subacromial impingement occurs following whiplash injuries to the neck. This is however, frequently overlooked and shoulder pain is attributed to pain radiating from the neck. It is important that this is appreciated and patients are specifically examined for signs of impingement so that appropriate treatment can be instigated. Direct trauma from the seatbelt is one likely explanation for this association

Cervical spine collars are applied in trauma situations to immobilise patients' cervical spines. Whilst movement of the cervical spine following the application of a collar has been well documented, the movement in the cervical spine during the application of a collar has not been. There is universal agreement that C-spine collars should be applied to patients involved in high speed trauma, but there is no consensus as to the best method of application. The clinical authors have been shown two different techniques on how to apply the C-spine collars in their Advanced Life Support Training (ATLS). One technique is the same as that recommended by the Laerdal Company (Laerdal Medical Ltd, Kent) that manufactures the cervical spine collar that we looked at. The other technique was refined by a Neurosurgeon with an interest in pre-hospital care. In both techniques the subjects' head is immobilised by an assistant whilst the collar is applied. We aimed to quantify which of these techniques caused the least movement to the cervical spine. There is no evidence in the literature quantifying how much movement in any plane in the unstable cervical spine is safe. Therefore, we worked on the principle: the less movement the better. The Qualisys Motion Capture System (Qualisys AB, Gothenburg, Sweden) was used to create an environment that would measure movement on the neck during collar application. This system consisted of cameras that were pre-positioned in a set order determined by trial and error initially. These cameras captured reflected infra-red light from markers placed on anatomically defined points on the subject's body. As the position of the cameras was fixed then as the patients moved the markers through space, a software package could deduce the relative movement of the markers to each camera with 6 degrees of freedom (6DOF). Six healthy volunteers (3 M, 3 F; age 21-29) with no prior neck injuries acted as subjects. The collar was always applied by the same person. Each technique was used 3 times on each subject. To replicate the clinical situation another volunteer would hold the head for each test. The movements we measured were along the x, y, and z axes, thus acting as an approximation to flexion, extension and rotation occurring at the C-spine during collar application. The average movement in each axis (x, y and z) was 8 degrees, 8 degrees and 5 degrees respectively for both techniques. No further data analysis was attempted on this small data set. However this pilot study shows that our method enables researchers to reproducibly collect data about cervical spine movement whilst applying a cervical collar

Introduction Cervical spine fractures and dislocations are uncommon injuries that can have serious neurological consequences. These injuries require adequate stabilisation to prevent further spinal cord injury during transfer between hospitals. Evacuation is often requires a combination of road ambulance, helicopter and fixed wing aircraft from military hospitals. This paper outlines the neck injuries sustained during Op Telic and discusses the need for Halo vests to be available at Role 3. Methodology The MND(SE) Hospital databases were used to identify all casualties admitted with either a “cervical” or “Neck” injury. The databases covered the period from March 2003 until February 2004. The diagnoses were categorised into minor and serious cervical spine injuries. We defined a serious cervical spine injury as either a fracture or dislocation. We looked at the discharge letters of all casualties evacuated to a Role 4 hospital to confirm whether the casualties had serious cervical spine injuries. Results 46 casualties were admitted and all were British except 2, who were Iraqi. 33 casualties were returned to their unit for duty or discharged at the airhead on return to the UK. Twelve casualties required hospital treatment. There were 3 serious cervical spine injuries over the study period which included one Hangman’s fracture of C2, one flexion compression injury of C5 and one unifacetal dislocation. All casualties were neurologically intact. Conclusions 3 casualties were treated at MND(SE) Hospital for serious injuries to the cervical spine. Two patients were transferred without Halo stabilisation after failing to obtain halos in Iraq. One casualty was kept until a halo was flown out from the UK. Recommendations All unstable cervical spine fractures should be stabilised with a halo vest prior to transfer from Role 3. Halo rings and vests should be available at Role 3 facilities

Introduction: Regular review [. 1. , . 2. ] of cervical injuries occurring in rugby players is an important step toward maximising the safety of the players. It is hoped that the recognition of recurring patterns of injury would lead to appropriate rule modification by the regulatory bodies of the sport. Serious cervical injuries in rugby have been reported to occur by a range of mechanisms, including those involved with scrummaging, tackling, rucking and mauling. Spinal flexion is the commonest mechanism of injury and has been associated with scrum engagement, scrum collapse, rucking or mauling, and mistimed tackling. The second most common mechanism of cervical spinal injury is hyper-extension. This commonly occurs during tackling, particularly the ‘gang tackle’ involving several participants simultaneously, where sudden deceleration of a player’s head may lead to cervical hyperextension, focal spinal stenosis and potential damage to the spinal cord by a “pincer” mechanism. The most commonly reported levels of injury are C5/6 and C4/5 [. 3. ]. Methods: A retrospective review of neck injuries presenting to a major spinal injuries facility and resulting from all codes of football (rugby union, rugby league, soccer, indoor soccer and touch) was conducted and 38 cases identified. Results: Of the 38 patients 14 were injured playing rugby union, 15 rugby league, 3 soccer, 1 indoor soccer, 1 touch football and 4 were playing an unidentified code. 6 players were injured while scrummaging, 5 rugby union and 1 rugby league. 21 people were injured as tacklees, 4 as tacklers and 2 with unspecified involvement in a tackle. 1 person was injured whilst “heading” the ball, and 3 people were injured in a non-contact or unspecified action. At final follow-up, 4 people were found to be quadriplegic (ASIA A), 10 quadriparetic (ASIA B – 0 C −1 and D –9) and 24 recovered completely (ASIA E)

INTRODUCTION: Regular review [. 1. , . 2. ] of cervical injuries occurring in rugby players is an important step toward maximising the safety of the players. It is hoped that the recognition of recurring patterns of injury would lead to appropriate rule modification by the regulatory bodies of the sport. Serious cervical injuries in rugby have been reported to occur by a range of mechanisms, including those involved with scrummaging, tackling, rucking and mauling. Spinal flexion is the commonest mechanism of injury and has been associated with scrum engagement, scrum collapse, rucking or mauling, and mistimed tackling. The second most common mechanism of cervical spinal injury is hyper-extension. This commonly occurs during tackling, particularly the ‘gang tackle’ involving several participants simultaneously, where sudden deceleration of a player’s head may lead to cervical hyperextension, focal spinal stenosis and potential damage to the spinal cord by a “pincer” mechanism. The most commonly reported levels of injury are C5/6 and C4/5 [. 3. ]. METHODS: A retrospective review of neck injuries presenting to a major spinal injuries facility and resulting from all codes of football (rugby union, rugby league, soccer, indoor soccer and touch) was conducted and 38 cases identified. RESULTS: Of the 38 patients, 14 were injured playing rugby union, 15 rugby league, three soccer, one indoor soccer, one touch football and four were playing an unidentified code. Six players were injured while scrummaging, five rugby union and one rugby league. 21 people were injured as tacklees, four as tacklers and two with unspecified involvement in a tackle. One person was injured whilst “heading” the ball, and three people were injured in a non-contact or unspecified action. At final follow-up, four people were found to be quadriplegic (ASIA A), 10 quadriparetic (ASIA B – 0 C –1 and D –9) and 24 recovered completely (ASIA E)