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Introduction
Spinal injuries are thankfully relatively uncommon but have the potential to cause very significant morbidity and mortality. It is reported that between 0.5% and 3% of patients presenting with blunt trauma suffer spinal cord injury (SCI). 1 2 The incidence varies globally and time has yielded increased numbers of injuries annually. American figures estimate an incidence in the region of 40 cases per million per year. 3 In the UK, the majority of traumatic SCI are attributable to land transport (50%), followed by falls (43%), then sport (7%). 4 Of those fractures causing SCI, half involve fractures of the cervical spine, with 37% due to thoracic spine injury and 11% due to lumbar spine injury. Of the C-spine, 50% occur at the C6/7 junction and a third at C2. 5 Data show a crossover rate in the region of 10%-15% of patients with a confirmed cervical fracture also having a thoracolumbar fracture. 6 It is well recognised that immobilisation is not without harm but the 'number needed to treat' in order to include one actual injury is high.
SCI occurs when unstable spinal fractures (only diagnosed by imaging in hospital) cause direct mechanical damage as a result of traction and compression, following which ischaemia and cord swelling ensues. Unstable fractures are those where there is disruption of two or three vertebral columns. The anterior column is formed by the anterior longitudinal ligament and the anterior half of the vertebral body, disc and annulus, the middle column by the posterior half of the vertebral body, disc and annulus and the posterior longitudinal ligament and the posterior column by the facet joints, ligamentum flavum, the posterior elements and the interconnecting ligaments. Immobilisation is based on the logical premise that preventing movement should decrease the incidence of SCI or further deterioration of existing damage. This is undertaken by, in effect, adding external supports to the body, preventing secondary injury during extrication, resuscitation, transport and evaluation.
Immobilisation is a routinely performed procedure in the prehospital environment. Its potentially serious adverse sequelae and the litigious nature of modern medicine have seen the development of an extraordinarily conservative approach to immobilisation where it is applied in many cases in which neither the mechanism of injury nor the clinical findings would...