Secondary survey - Thoracic/lumbar spine

If a decision is made to immobilise the patient, you will need help from appropriately trained and experienced staff. Consider the resources available, for example support may be obtained from trauma teams, orthopaedic doctors, outreach teams or paramedics in the community.

1. When immobilising the spine, tailor the approach to the person’s specific circumstances.
2. When carrying out full inline spinal immobilisation in adults, manually stabilise the head with the spine inline using the following stepwise approach:
   • Fit an appropriately sized semirigid collar unless contraindicated by: 
     • a compromised airway
     • known spinal deformities, such as ankylosing spondylitis (in these cases, keep the spine in the person’s current position).
   • Reassess the airway after applying the collar.
   • Using a log-rolling technique, place and secure the person onto a scoop stretcher.
   • Secure the person with head blocks and tape.
   • Using local manual handling recommendations, move the patient from the floor to a bed or trolley.
   • Patients should not be kept on a scoop stretcher for prolonged periods of time, but consideration is also needed about how to transport the patient to radiology and on and off the scanning table.
     
     
3. The use of spinal immobilisation devices may be difficult (for example in people with short or wide necks, or people with a pre-existing deformity) and could be counterproductive (for example increasing pain, worsening neurological signs and symptoms). In uncooperative, agitated or distressed people, think about letting them find a position where they are comfortable with soft padding and tape, eg rolled-up towels. A senior decision maker should be involved and should consider the following (15):
   • Check appropriately fitting collar, consider fitting a soft, padded collar (eg Miami-J)
   • Appropriate analgesia has been given
   • Delirium management strategies and triggers have been addressed
   • Balance of risk/benefits of immobilisation, imaging and sedation following local policies, with careful documentation of decision-making.

Please note, immobilisation practices are becoming increasingly more nuanced and patient-centred. Until any new formal guidance is issued, the advice stated here is from NICE and the London Major Trauma System (10,12,15). To immobilise a patient safely requires up-to-date and regularly practised skills that are not readily available to ward staff, do escalate for help before attempting to do so, keeping movement to a minimum in the interim.

If the patient is immobilised, consideration should be given to how the patient can be transferred to the radiology department and moved on and off the CT scanning table. Once again, appropriate equipment and expertise will be needed.

Assessment, imaging and imaging reporting should be completed within 2 hours of the decision to immobilise. If continued immobilisation is required, rigid collars should be switched to soft, padded collars (such as Miami-J) at the earliest opportunity and movement restrictions should be clearly documented within 1 hour of imaging reporting (15). This will require appropriate involvement of neurosurgical and/or orthopaedic specialists, depending on local pathways. 

Current practice for older, frail patients is to carefully consider the risks and benefits of prolonged immobilisation in the context of a diagnosed C-spine fracture (15). Risks of dysphagia, pressure ulcers and raised intracranial pressure are associated with prolonged immobilisation (16). A senior decision maker, in conjunction with the wider MDT, should lead shared decision making with the patient and family. 

• Perform an X-ray as the first‑line investigation for people with suspected spinal column injury without abnormal neurological signs or symptoms in the thoracic or lumbosacral regions (T1–L3).
• Perform a CT scan if the X‑ray is abnormal or there are clinical signs or symptoms of a spinal column injury.
• If a new spinal column fracture is confirmed, image the rest of the spinal column.
• If there is a neurological abnormality that could be attributable to spinal cord injury, perform MRI after CT, regardless of whether the abnormality is evident on CT (10).

In the case of spinal fractures, be aware that:

• approximately 10% of patients with C-spine fracture have a second, non-contiguous vertebral column fracture, therefore imaging of the entire spine is recommended
• in the context of spinal injury, the ASIA spinal cord injury chart can be used to document the motor and sensory examination
• neurogenic shock: injury to T6 or above can impair descending sympathetic pathways causing hypotension, bradycardia
• spinal shock refers to flaccidity and loss of reflexes that occur immediately after spinal cord injury
• hypoventilation can occur from injury to C3–C5
• the inability to feel pain from a spinal cord injury can mask other significant injuries, such as from a pelvic fracture
• central cord syndrome can occur without bony injury – commonly as a result of a forward fall resulting in facial impact, especially in those with underlying spinal stenosis, common in older fallers (6).