Elsevier

Injury

Volume 34, Issue 12, December 2003, Pages 912-914
Injury

Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma?

https://doi.org/10.1016/S0020-1383(03)00070-6Get rights and content

Abstract

Introduction: Previous work suggests that patients with isolated penetrating trauma rarely require spinal immobilisation. This study aimed to identify the incidence of mechanically unstable, or potentially mechanically unstable, spinal column injuries in penetrating trauma patients. The study also aimed to identify the incidence of spinal cord injury as a result of penetrating trauma in Scotland.

Design: Retrospective analysis of prospectively collected data from the Scottish Trauma Audit Group (STAG).

Methods: Study patients were identified from the period 1992–1999. Patients coded for both penetrating trauma and spinal column or spinal cord injury were included. Case records, theatre notes and post mortem information were also examined.

Results: 34,903 patients were available for study. Twenty-seven patients were coded as having had penetrating trauma and concurrent spinal injury. 15 were excluded as they also had a major blunt mechanism of injury or had no actual injury to the spinal cord or column. In the remaining 12 patients, four cervical, one combined cervical and thoracic and seven thoracic spinal cord injuries were identified. 11 were male and 11 were assaulted. One assault was due to a gunshot wound; 10 resulted from sharp weapons. Four complete cord transections and nine partial cord lesions were identified. All 12 patients with spinal cord injury associated with isolated penetrating trauma either had obvious clinical evidence of a spinal cord injury on initial assessment or were in traumatic cardiac arrest. All had spinal immobilisation.

Conclusion: Fully conscious patients (GCS=15) with isolated penetrating trauma and no neurological deficit do not require spinal immobilisation.

Introduction

It has been suggested that full spinal immobilisation is rarely, if ever, required for patients with isolated penetrating trauma [2], [6]. The advanced trauma life support (ATLS®) student manual does not make the distinction between blunt and penetrating trauma with regard to spinal injury [1]. It emphasises the need for full and continuous spinal immobilisation in any patient with a suspected spinal cord or column injury until a fracture has been excluded radiologically. This refers predominantly to blunt trauma of the spinal cord and spinal column.

This approach has significant implications for pre-hospital care. Time may be a crucial factor in determining outcome in severe penetrating trauma. In critically injured patients, it has been estimated that for every 10 min of delay in definitive treatment, survival drops by 10% [7]. Therefore, in this study we aimed to determine if there were any mechanically unstable or potentially mechanically unstable spinal column injuries requiring formal spinal immobilisation in isolated penetrating trauma patients in Scotland. We also examined the incidence of spinal cord injury due to penetrating trauma in Scotland.

Section snippets

Methods

The Scottish Trauma Audit Group (STAG) was established in 1991 to evaluate the management of major trauma in individual Scottish hospitals [3]. It utilises TRISS methodology, which combines the injury severity score (ISS) and the revised trauma score (RTS) in addition to the patient’s age, to generate a probability of survival for each patient. [4] Currently 25 hospitals contribute to the national database. At the time of writing, data had been collected prospectively on more than 35,000

Results

There were 34,903 trauma patients available for study; 32,974 (94.5%) had sustained blunt trauma and 1929 (5.5%) penetrating trauma. Twenty-seven patients were coded as having penetrating trauma and concurrent spinal injury. Fifteen patients were excluded either because initial review clearly showed that there was a major blunt mechanism of injury also coded which unequivocally caused the spinal trauma, or because the spinal component of the injury was trivial. Patients were also excluded if

Discussion

In 1929 cases of penetrating trauma, the only patients with spinal cord lesions had clear evidence of this at initial presentation or were in cardiorespiratory arrest. This suggests that spinal column or spinal cord injury resulting from isolated penetrating trauma can be excluded in fully conscious patients without neurological symptoms or signs at presentation.

Contemporary teaching on trauma does not make any distinction between blunt and penetrating trauma in terms of the need for full

Acknowledgements

We sincerely thank Diana Beard, Project Director, Scottish Trauma Audit Group, and Rik Smith, Statistician, Scottish Trauma Audit Group for their help in gathering and analysing the data for this study.

References (12)

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