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Unstable cervical spine without spinal cord injury in penetrating neck trauma
Brief Reports
Unstable Cervical Spine Without Spinal Cord Injury in Penetrating Neck Trauma JONATHAN D. APFELBAUM, MD,*::I: STEPHEN V. CANTRILL, MD, AND NElL WALDMAN, MDt Cervical spine instability in the neurologically intact patient following penetrating neck trauma has been considered rare or non-existant. We present a case of a woman with an unstable C5 fracture without spinal cord injury after a gunshot wound to the neck. Considerations regarding the risk of cervical spine instability are discussed, as well as suggestions for a prudent approach to such patients. (Am J Emerg ied 1999; 18:55-57. Copyright © 2000 by W.B. Saunders Company) Previous publications stated gunshot wounds cause spinal cord injury from direct trauma rather than from movement of an unstable spinal column after the initial injury, i-4 Based upon the current literature, the risk of an unstable cervical spine following penetrating trauma is felt to be "minimal." 1,5 We present here a case of a woman who sustained a gunshot wound to her neck, resulting in an unstable cervical spine without neurological deficit. Although small, the risk of iatrogenic injury in a patient without neurological deficit after sustaining penetrating trauma to the neck is real and should be a consideration in guiding the treatment of the patient.
CASE REPORT A 48-year-old white woman presented via ambulance to a rural emergency department (ED) approximately 45 minutes after sustaining a gunshot wound to the right side of her neck. The patient was shot with a handgun loaded with .22 long rifle ammunition at close range (less than 10 feet) while standing upright. En route to the ED, the patient was initially placed in a cervical collar for immobilization and was noted by emergency medical services personnel to have no neurological deficits. However, due to ongoing blood loss, after radio consultation with the attending physician at the ED, the cervical collar was removed to allow better access to the wound site for hemostasis and wound tamponade. On arrival in the ED, the patient was complaining of a "lump" in her throat and neck pain. Her vital signs included a blood pressure
From the *Denver Health Medical Center, Department of Emergency Medicine, Denver, CO; tMontrose Memorial Hospital, Department of Emergency Medicine, Montrose, CO, and McLeod Regional Medical Center, Florence, SC. Manuscript received May 6, 1998, returned May 22, 1998; revision received July 1, 1998, accepted August 9, 1998. Address reprint requests to Jonathan Apfelbaum0 MD, McLeod Regional Medical Center, 555 Cheves St, Florence, SC 29501. Key Words: Cervical spine, gunshot wound, GSW, spinal instability, neurological deficit. Copyright © 2000 by W.B. Saunders Company 0735-6757/00/1801-0012510.00/0
of 100/67 mm Hg, pulse of 103 beats/rain, and a respiratory rate of 22 breaths/min. She appeared to have lost a significant amount of blood. She was noted to have a "puncture" gunshot wound in the mid-region of her right sternocleidomastoid muscle with a large hematoma. During the secondary survey, the patient was log-rolled and a second 1 cm gunshot wound was identified 2 cm superior and posterior to the pinnae of her right ear with significant ongoing hemorrhage. It was felt that these were entrance and exit wounds, respectively. The patient's mid-cervical spine, in the area of C3 to C6, was tender to palpation. The patient's neurological examination was without focal findings. She was alert and oriented to person, place, time, and situation. Cranial nerves 2 through 12 were intact although the patient had a somewhat muffled voice, and motor and sensory function were grossly normal. Deep tendon reflexes (DTRs) were within normal limits and symmetrical bilaterally at biceps, wrists, patella, and ankle. Due to the serious nature of her injury, a more detailed motor and sensory examination was deferred at this time. Her physical examination was otherwise unremarkable. A lateral cervical spine radiograph was performed (Figure 1) in the ED. A comminuted fracture of the body of C5, a 2 mm step-off of C5 on C6, an increased C5 to C6 interspinons space, and a prevertebral soft tissue swelling of 3.5 cm were noted. Because of the grossly abnormal cervical radiograph, the patient was placed in a hard cervical collar, backboarded, and secured in rigid cervical spine precautions. Given the progressive sensation of a lump in the patient's throat, her muffled voice, and the large retropharyngeal hematoma, the decision was made to intubate the patient. Oral rapid sequence intubation with a 7.5 mm endotracheal tube was performed with ketamine and rocuronium without difficulty. During intubation, additional personnel were utilized to hold in-line stabilization to assure continued cervical spine immobilization. After intubation the patient received longer-acting chemical paralysis with vecuronium and additional sedation for transportation to another facility. Since the neurological examination was impaired because of chemical paralysis, high-dose methylprednisolone was administered to cover for possible spinal cord injury. She also received antibiotic coverage with cefazolin. The patient was transferred by helicopter to another facility where she was admitted to the neurosurgery service. Subsequently, the patient underwent computed tomography (CT) and magnetic resonance imaging (MRI) scans of her neck which showed an unstable cervical spine at the C5-C6 level. The bullet appeared to have transversed the body of C5, exiting at the right neuroforanlenal and transverse foramen area, disrupting both anterior and posterior ligamentous columns. There was no cervical spinal cord injury. An arteriogram showed that both vertebral arteries were completely disrupted and occluded but that there was distal reconstitution by collateral vascular branches with adequate 55
56
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 18, Number 1 • January 2000
DISCUSSION
FIGURE 1. Portable, cross table, lateral cervical spine radiograph of a 48-year-old female after sustaining a .22 caliber gunshot wound to her neck. Findings include a burst fracture of C5, 2 mm subluxation of C5 on C6, increased C5 to C6 interspinous space, bullet fragments, and retropharyngeal hematoma.
circulation. After extubation several days later, the patient noted pain in her right upper extremity, which was felt to be a causalgia-type pain secondary to C6 nerve root injury either from bony fragments or the initial bullet, which was felt to be consistent with the observed bullet exit point in C5. On reconstruction of the bullet's trajectory, it was felt that the projectile entered the patient's mid-fight sternocleidomastoid muscle in a level or slightly upward plane, transversed lateral to medial as it went anterior to posterior. The bullet struck the body of C5 and made a acute superior/lateral angle change as it penetrated the vertebral body, exiting through the right neuroforamenal and transverse foramen area of C5. It proceeded laterally and superiorly to exit the body approximately 2 cm superior and posterior to the right ear. The patient underwent C5 anterior cervical decompression, C5 vertebrectomy, and C4 to C6 fusion with an iliac crest graft and an Orion plate. Postoperatively the patient continued to have a C6 radicnlopathy with causalgia-type pain. She was treated with tricyclic antidepressants and a stellate ganglion block with good results. At her 6 week follow-up appointment, the patient was doing well. She had minimal weakness (5 minus out of 5, using a standard 0 to 5 motor strength scale) of her right hand grip, and right wrist flexor and extensor muscles. She has some decreased sensation over her right shoulder and some "burning" dysesthesias in her right hand, both of which were improved.
Gunshot wounds (GSWs) to the neck can be devastating injuries with significant associated morbidity and mortality, and have been reported to cause 13% of spinal injuries, third only to falls and motor vehicle accidents. 6 Most of the literature regarding penetrating neck trauma has focused on the care of vascular, esophageal, tracheal, pharyngeal, or soft tissue injuries. 7-12 Neurological deficit, when present, is considered an indication for emergent operative exploration. 79,12 Only one study has looked specifically at the frequency of cervical spine instability, with the conclusion that "spinal stability following a gunshot wound is not guaranteed, especially in the cervical spine, and each case should be assessed individually for the presence of instability. ''4 Cervical spine immobilization is recommended in penetrating neck trauma. 5,13However, an unsafe prehospital environment, 5 priority of the ABCs of advanced trauma life support (ATLS), 13,14 or need for direct wound treatment 15 may preclude immobilization. The attendant risk ofiatrogenic cervical spinal cord injury has previously been considered minimal to nonexistent. 1-4 The primary concern in managing such injuries has been control of bleeding 7,9,1a and airway management. 16,17 One reason that spinal instability has been underestimated is the article by Arishta et al,5 which noted no benefit from prehospital neck stabilization. However, this article was a retrospective review of data from the Vietnam- conflict. In the review of their data, they concluded that possibly 4 of 472 patients (0.8%) might have benefited from cervical spine immobilization in the field. Of their patient population, 69 of 472 casualties had cervical spine injuries, with 11 of these surviving long enough to receive treatment. Seven of the 11 had stable spinal fractures not requiring immobilization, and the remaining died from other injuries without clear benefit or detriment from lack of stabilization. The authors concluded that 1 or 2 out of 100 patients with penetrating neck injuries might benefit from immobilization in the prehospital setting. In reviewing this article, Sumchai 15 pointed out that 29% of the casualties who had wounds compatible with life had cervical spinal column injuries. Isiklar and Lindsey 4 retrospectively evaluated patients presenting with low-velocity gunshot wounds to the spine. Their patient population was composed of patients presenting to their facility over a 4-year period with spinal injuries. Of their 12 cases of GSWs involving the cervical spine, 3 (25%) were unstable, 11 (92%) had neurological deficits, and 8 (67%) had related vascular injuries. Three of their cases had incomplete data, and spinal stability was not able to be assessed. Of their patients, only 1 (8%) had an unstable cervical spine without a neurological deficit. Other articles have noted a frequency of spinal column injury in gunshot wounds to the neck from 2.7% 8 to 22%, 9 with neurologic deficits present in 1.9% 8 to 12%. 9 Whereas the stability of the fractures without spinal cord involvement is not known, clearly the frequency of spinal column fractures without neurological impairment is higher than previously suspected. The frequency of traumatic spinal cord injuries is estimated at 2.8 to 5.3 such injuries per 100,000 persons, ~8 and
APFELBAUM ET AL • UNSTABLE CERVICAL SPINE IN NECK TRAUMA
13% of spinal cord injuries are secondary to gunshot wounds. 6 While exact comparison is not possible, given the current data available, gunshot wounds would account for approximately 0.36 to 0.69 spinal injuries per 100,000 persons. Since significantly more people are injured in motor vehicle accidents per year than are shot, it is not unreasonable to consider that a higher percentage of patients shot are at risk for a spinal cord injury. As emergency physicians, we approach every victim of blunt trauma as if they had a spinal column injury. Perhaps a similar approach is warranted for patients sustaining penetrating trauma as well. Another observation is the association of lower velocity smaller caliber handguns 4,11,19with different injury patterns than previously seen in military studies, 5 including an increased frequency of fractures without neurological impairment and increased associated vascular injuries. One theory for the increased incidence of cervical spine instability with low-velocity GSWs is the decreased amount of surrounding soft tissue, compared to the thoracic or lumbar spine, such that an increased amount of the bullet's kinetic energy is conveyed to the spinal column with increased skeletal injuries. 4 In the care of this patient, the decision to remove the cervical collar in the ambulance was not unreasonable, given the significant ongoing blood loss. It is unclear what, if any, additional measures were taken at that time to stabilize the patient's neck that may have been of benefit. The caution exercised in the ED, including log-rolling of the patient with concordant cervical immobilization and careful technique in airway management, were prudent and appropriate for the circumstance. If spinal immobilization is unable to be maintained in the prehospital setting, such as in this case, alternatives should be considered. These could include using the posterior portion of a 2-piece (Philadelphia-type) cervical spine collar, sandbags or the equivalent, log-rolling, and usual spinal precautionary techniques as used with blunt trauma. Current teachings states that the risk of occult spinal instability is minimal, 1-4 and the risk of cervical manipulation for intubation is "nonexistent."~ Based upon the low but finite risk of spinal instability, it would behoove the prudent practitioner to be aware of the possibility of vertebral column involvement without neurological symptoms and exercise appropriate caution when caring for these
57
patients. As with blunt neck trauma, prehospital cervical spine immobilization should be performed whenever possible, and ED care and treatment should presume an unstable cervical spine until proven conclusively otherwise.
REFERENCES 1. Jorden RC: Neck Trauma, in Rosen P, Barkin R (eds): Emergency Medicine: Concepts and Clinical Practice, ed 4. St. Louis, Mosby-Year Book, 1998, pp 505-514 2. Waters RL, Hu SS: Penetrating Injuries of the Spinal Canal. Stab and Gunshot Injuries, in Frymoyer JW (ed): The Adult Spine. New York, Raven Press, 1991, pp 815-826 3. Gordon K: Head and Neck Trauma, in Hamilton GC, Sander AB, Strange GR, et al (eds): Emergency Medicine. An Approach to Clinical Problem-Solving. Philadelphia, Saunders, 1991, pp 894-923 4. Isiklar ZU, Lindsey RW: Low-velocity civilian gunshot wounds of the spine. Orthopedics 1997;20:967-972 5. Arishita GI, Vayer JS, Bellamy RF: Cervical spine immobilization of penetrating neck wounds in a hostile environment. J Trauma 1989;29:332-337 6. Waiters RL, Adkins RH: The effects of removal of bullet fragments retained in the spinal canal: A collaborative study by the National Spinal Cord Injury Model System. Spine 1991;16:934-939 7. Roon AJ, Christensen N: Evaluation and treatment of penetrating cervical injuries. J Trauma 1979;19:391-397 8. Carducci B, Lowe RA, Dalsey W: Penetrating neck trauma: Consensus and controversies. Ann Emerg Med 1986;15:208-215 9. Ordog GJ, Albin D, Wasserberger J, et al: Bullet wounds to the neck. J Trauma 1985;25:238-246 10. Saletta JD, Lowe RJ, Lim LT, et al: Penetrating trauma of the neck. J Trauma 1976;16:579-587 11. Heiden JS, Weiss MH, Rosenberg AW, et al: Penetrating gunshot wounds of the cervical spine in civilians. J Neurosurg 1975;42:575-579 12. Asensio JA, ValenzianoCP, Falcone RE, et al: Management of penetrating neck injuries: The controversy surrounding Zone II injuries. Surg Clin North Am 1991;71:267-297 13. Alexander RH, Proctor HJ: Spine and Spinal Cord Trauma, in Advanced Trauma Life Support Course for Physicians. Chicago, American College of Surgeons, 1993, pp 191-203 14. Pepe PE, Wyatt CH, Bickell WH, et ak The relationship between total pre-hospital time and outcome in hypotensive victims of penetrating injuries. Ann Emerg Med 1987;16:293-297 15. Sumchai AP: Letters to the editor. J Trauma 1989;29:1453 16. Walls RM, Wolfe R, Rosen P: Fools rush in? Airway management in penetrating neck trauma (ed). J Emerg Med 1993;11:479-480 17. Eggen JT, Jorden RC: Airway management, penetrating neck trauma. J Emerg Med 1993; 11:381-385 18. Relethford JH, Standfast SJ, Morse DL: Trends in traumatic spinal cord injury--New York, 1982-1988. MMWR 1991 ;40:535-543 19. Kupcha PC, An HS, Cotler JM: Gunshot wounds to the cervical spine. Spine 1990; 15:1058-1063
Unstable Cervical Spine Without Spinal Cord Injury in Penetrating Neck Trauma JONATHAN D. APFELBAUM, MD,*::I: STEPHEN V. CANTRILL, MD, AND NElL WALDMAN, MDt Cervical spine instability in the neurologically intact patient following penetrating neck trauma has been considered rare or non-existant. We present a case of a woman with an unstable C5 fracture without spinal cord injury after a gunshot wound to the neck. Considerations regarding the risk of cervical spine instability are discussed, as well as suggestions for a prudent approach to such patients. (Am J Emerg ied 1999; 18:55-57. Copyright © 2000 by W.B. Saunders Company) Previous publications stated gunshot wounds cause spinal cord injury from direct trauma rather than from movement of an unstable spinal column after the initial injury, i-4 Based upon the current literature, the risk of an unstable cervical spine following penetrating trauma is felt to be "minimal." 1,5 We present here a case of a woman who sustained a gunshot wound to her neck, resulting in an unstable cervical spine without neurological deficit. Although small, the risk of iatrogenic injury in a patient without neurological deficit after sustaining penetrating trauma to the neck is real and should be a consideration in guiding the treatment of the patient.
CASE REPORT A 48-year-old white woman presented via ambulance to a rural emergency department (ED) approximately 45 minutes after sustaining a gunshot wound to the right side of her neck. The patient was shot with a handgun loaded with .22 long rifle ammunition at close range (less than 10 feet) while standing upright. En route to the ED, the patient was initially placed in a cervical collar for immobilization and was noted by emergency medical services personnel to have no neurological deficits. However, due to ongoing blood loss, after radio consultation with the attending physician at the ED, the cervical collar was removed to allow better access to the wound site for hemostasis and wound tamponade. On arrival in the ED, the patient was complaining of a "lump" in her throat and neck pain. Her vital signs included a blood pressure
From the *Denver Health Medical Center, Department of Emergency Medicine, Denver, CO; tMontrose Memorial Hospital, Department of Emergency Medicine, Montrose, CO, and McLeod Regional Medical Center, Florence, SC. Manuscript received May 6, 1998, returned May 22, 1998; revision received July 1, 1998, accepted August 9, 1998. Address reprint requests to Jonathan Apfelbaum0 MD, McLeod Regional Medical Center, 555 Cheves St, Florence, SC 29501. Key Words: Cervical spine, gunshot wound, GSW, spinal instability, neurological deficit. Copyright © 2000 by W.B. Saunders Company 0735-6757/00/1801-0012510.00/0
of 100/67 mm Hg, pulse of 103 beats/rain, and a respiratory rate of 22 breaths/min. She appeared to have lost a significant amount of blood. She was noted to have a "puncture" gunshot wound in the mid-region of her right sternocleidomastoid muscle with a large hematoma. During the secondary survey, the patient was log-rolled and a second 1 cm gunshot wound was identified 2 cm superior and posterior to the pinnae of her right ear with significant ongoing hemorrhage. It was felt that these were entrance and exit wounds, respectively. The patient's mid-cervical spine, in the area of C3 to C6, was tender to palpation. The patient's neurological examination was without focal findings. She was alert and oriented to person, place, time, and situation. Cranial nerves 2 through 12 were intact although the patient had a somewhat muffled voice, and motor and sensory function were grossly normal. Deep tendon reflexes (DTRs) were within normal limits and symmetrical bilaterally at biceps, wrists, patella, and ankle. Due to the serious nature of her injury, a more detailed motor and sensory examination was deferred at this time. Her physical examination was otherwise unremarkable. A lateral cervical spine radiograph was performed (Figure 1) in the ED. A comminuted fracture of the body of C5, a 2 mm step-off of C5 on C6, an increased C5 to C6 interspinons space, and a prevertebral soft tissue swelling of 3.5 cm were noted. Because of the grossly abnormal cervical radiograph, the patient was placed in a hard cervical collar, backboarded, and secured in rigid cervical spine precautions. Given the progressive sensation of a lump in the patient's throat, her muffled voice, and the large retropharyngeal hematoma, the decision was made to intubate the patient. Oral rapid sequence intubation with a 7.5 mm endotracheal tube was performed with ketamine and rocuronium without difficulty. During intubation, additional personnel were utilized to hold in-line stabilization to assure continued cervical spine immobilization. After intubation the patient received longer-acting chemical paralysis with vecuronium and additional sedation for transportation to another facility. Since the neurological examination was impaired because of chemical paralysis, high-dose methylprednisolone was administered to cover for possible spinal cord injury. She also received antibiotic coverage with cefazolin. The patient was transferred by helicopter to another facility where she was admitted to the neurosurgery service. Subsequently, the patient underwent computed tomography (CT) and magnetic resonance imaging (MRI) scans of her neck which showed an unstable cervical spine at the C5-C6 level. The bullet appeared to have transversed the body of C5, exiting at the right neuroforanlenal and transverse foramen area, disrupting both anterior and posterior ligamentous columns. There was no cervical spinal cord injury. An arteriogram showed that both vertebral arteries were completely disrupted and occluded but that there was distal reconstitution by collateral vascular branches with adequate 55
56
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 18, Number 1 • January 2000
DISCUSSION
FIGURE 1. Portable, cross table, lateral cervical spine radiograph of a 48-year-old female after sustaining a .22 caliber gunshot wound to her neck. Findings include a burst fracture of C5, 2 mm subluxation of C5 on C6, increased C5 to C6 interspinous space, bullet fragments, and retropharyngeal hematoma.
circulation. After extubation several days later, the patient noted pain in her right upper extremity, which was felt to be a causalgia-type pain secondary to C6 nerve root injury either from bony fragments or the initial bullet, which was felt to be consistent with the observed bullet exit point in C5. On reconstruction of the bullet's trajectory, it was felt that the projectile entered the patient's mid-fight sternocleidomastoid muscle in a level or slightly upward plane, transversed lateral to medial as it went anterior to posterior. The bullet struck the body of C5 and made a acute superior/lateral angle change as it penetrated the vertebral body, exiting through the right neuroforamenal and transverse foramen area of C5. It proceeded laterally and superiorly to exit the body approximately 2 cm superior and posterior to the right ear. The patient underwent C5 anterior cervical decompression, C5 vertebrectomy, and C4 to C6 fusion with an iliac crest graft and an Orion plate. Postoperatively the patient continued to have a C6 radicnlopathy with causalgia-type pain. She was treated with tricyclic antidepressants and a stellate ganglion block with good results. At her 6 week follow-up appointment, the patient was doing well. She had minimal weakness (5 minus out of 5, using a standard 0 to 5 motor strength scale) of her right hand grip, and right wrist flexor and extensor muscles. She has some decreased sensation over her right shoulder and some "burning" dysesthesias in her right hand, both of which were improved.
Gunshot wounds (GSWs) to the neck can be devastating injuries with significant associated morbidity and mortality, and have been reported to cause 13% of spinal injuries, third only to falls and motor vehicle accidents. 6 Most of the literature regarding penetrating neck trauma has focused on the care of vascular, esophageal, tracheal, pharyngeal, or soft tissue injuries. 7-12 Neurological deficit, when present, is considered an indication for emergent operative exploration. 79,12 Only one study has looked specifically at the frequency of cervical spine instability, with the conclusion that "spinal stability following a gunshot wound is not guaranteed, especially in the cervical spine, and each case should be assessed individually for the presence of instability. ''4 Cervical spine immobilization is recommended in penetrating neck trauma. 5,13However, an unsafe prehospital environment, 5 priority of the ABCs of advanced trauma life support (ATLS), 13,14 or need for direct wound treatment 15 may preclude immobilization. The attendant risk ofiatrogenic cervical spinal cord injury has previously been considered minimal to nonexistent. 1-4 The primary concern in managing such injuries has been control of bleeding 7,9,1a and airway management. 16,17 One reason that spinal instability has been underestimated is the article by Arishta et al,5 which noted no benefit from prehospital neck stabilization. However, this article was a retrospective review of data from the Vietnam- conflict. In the review of their data, they concluded that possibly 4 of 472 patients (0.8%) might have benefited from cervical spine immobilization in the field. Of their patient population, 69 of 472 casualties had cervical spine injuries, with 11 of these surviving long enough to receive treatment. Seven of the 11 had stable spinal fractures not requiring immobilization, and the remaining died from other injuries without clear benefit or detriment from lack of stabilization. The authors concluded that 1 or 2 out of 100 patients with penetrating neck injuries might benefit from immobilization in the prehospital setting. In reviewing this article, Sumchai 15 pointed out that 29% of the casualties who had wounds compatible with life had cervical spinal column injuries. Isiklar and Lindsey 4 retrospectively evaluated patients presenting with low-velocity gunshot wounds to the spine. Their patient population was composed of patients presenting to their facility over a 4-year period with spinal injuries. Of their 12 cases of GSWs involving the cervical spine, 3 (25%) were unstable, 11 (92%) had neurological deficits, and 8 (67%) had related vascular injuries. Three of their cases had incomplete data, and spinal stability was not able to be assessed. Of their patients, only 1 (8%) had an unstable cervical spine without a neurological deficit. Other articles have noted a frequency of spinal column injury in gunshot wounds to the neck from 2.7% 8 to 22%, 9 with neurologic deficits present in 1.9% 8 to 12%. 9 Whereas the stability of the fractures without spinal cord involvement is not known, clearly the frequency of spinal column fractures without neurological impairment is higher than previously suspected. The frequency of traumatic spinal cord injuries is estimated at 2.8 to 5.3 such injuries per 100,000 persons, ~8 and
APFELBAUM ET AL • UNSTABLE CERVICAL SPINE IN NECK TRAUMA
13% of spinal cord injuries are secondary to gunshot wounds. 6 While exact comparison is not possible, given the current data available, gunshot wounds would account for approximately 0.36 to 0.69 spinal injuries per 100,000 persons. Since significantly more people are injured in motor vehicle accidents per year than are shot, it is not unreasonable to consider that a higher percentage of patients shot are at risk for a spinal cord injury. As emergency physicians, we approach every victim of blunt trauma as if they had a spinal column injury. Perhaps a similar approach is warranted for patients sustaining penetrating trauma as well. Another observation is the association of lower velocity smaller caliber handguns 4,11,19with different injury patterns than previously seen in military studies, 5 including an increased frequency of fractures without neurological impairment and increased associated vascular injuries. One theory for the increased incidence of cervical spine instability with low-velocity GSWs is the decreased amount of surrounding soft tissue, compared to the thoracic or lumbar spine, such that an increased amount of the bullet's kinetic energy is conveyed to the spinal column with increased skeletal injuries. 4 In the care of this patient, the decision to remove the cervical collar in the ambulance was not unreasonable, given the significant ongoing blood loss. It is unclear what, if any, additional measures were taken at that time to stabilize the patient's neck that may have been of benefit. The caution exercised in the ED, including log-rolling of the patient with concordant cervical immobilization and careful technique in airway management, were prudent and appropriate for the circumstance. If spinal immobilization is unable to be maintained in the prehospital setting, such as in this case, alternatives should be considered. These could include using the posterior portion of a 2-piece (Philadelphia-type) cervical spine collar, sandbags or the equivalent, log-rolling, and usual spinal precautionary techniques as used with blunt trauma. Current teachings states that the risk of occult spinal instability is minimal, 1-4 and the risk of cervical manipulation for intubation is "nonexistent."~ Based upon the low but finite risk of spinal instability, it would behoove the prudent practitioner to be aware of the possibility of vertebral column involvement without neurological symptoms and exercise appropriate caution when caring for these
57
patients. As with blunt neck trauma, prehospital cervical spine immobilization should be performed whenever possible, and ED care and treatment should presume an unstable cervical spine until proven conclusively otherwise.
REFERENCES 1. Jorden RC: Neck Trauma, in Rosen P, Barkin R (eds): Emergency Medicine: Concepts and Clinical Practice, ed 4. St. Louis, Mosby-Year Book, 1998, pp 505-514 2. Waters RL, Hu SS: Penetrating Injuries of the Spinal Canal. Stab and Gunshot Injuries, in Frymoyer JW (ed): The Adult Spine. New York, Raven Press, 1991, pp 815-826 3. Gordon K: Head and Neck Trauma, in Hamilton GC, Sander AB, Strange GR, et al (eds): Emergency Medicine. An Approach to Clinical Problem-Solving. Philadelphia, Saunders, 1991, pp 894-923 4. Isiklar ZU, Lindsey RW: Low-velocity civilian gunshot wounds of the spine. Orthopedics 1997;20:967-972 5. Arishita GI, Vayer JS, Bellamy RF: Cervical spine immobilization of penetrating neck wounds in a hostile environment. J Trauma 1989;29:332-337 6. Waiters RL, Adkins RH: The effects of removal of bullet fragments retained in the spinal canal: A collaborative study by the National Spinal Cord Injury Model System. Spine 1991;16:934-939 7. Roon AJ, Christensen N: Evaluation and treatment of penetrating cervical injuries. J Trauma 1979;19:391-397 8. Carducci B, Lowe RA, Dalsey W: Penetrating neck trauma: Consensus and controversies. Ann Emerg Med 1986;15:208-215 9. Ordog GJ, Albin D, Wasserberger J, et al: Bullet wounds to the neck. J Trauma 1985;25:238-246 10. Saletta JD, Lowe RJ, Lim LT, et al: Penetrating trauma of the neck. J Trauma 1976;16:579-587 11. Heiden JS, Weiss MH, Rosenberg AW, et al: Penetrating gunshot wounds of the cervical spine in civilians. J Neurosurg 1975;42:575-579 12. Asensio JA, ValenzianoCP, Falcone RE, et al: Management of penetrating neck injuries: The controversy surrounding Zone II injuries. Surg Clin North Am 1991;71:267-297 13. Alexander RH, Proctor HJ: Spine and Spinal Cord Trauma, in Advanced Trauma Life Support Course for Physicians. Chicago, American College of Surgeons, 1993, pp 191-203 14. Pepe PE, Wyatt CH, Bickell WH, et ak The relationship between total pre-hospital time and outcome in hypotensive victims of penetrating injuries. Ann Emerg Med 1987;16:293-297 15. Sumchai AP: Letters to the editor. J Trauma 1989;29:1453 16. Walls RM, Wolfe R, Rosen P: Fools rush in? Airway management in penetrating neck trauma (ed). J Emerg Med 1993;11:479-480 17. Eggen JT, Jorden RC: Airway management, penetrating neck trauma. J Emerg Med 1993; 11:381-385 18. Relethford JH, Standfast SJ, Morse DL: Trends in traumatic spinal cord injury--New York, 1982-1988. MMWR 1991 ;40:535-543 19. Kupcha PC, An HS, Cotler JM: Gunshot wounds to the cervical spine. Spine 1990; 15:1058-1063