DTIC ADA629616: Evaluation and Management of Combat-Related Spinal injuries: A Review Based on Recent Experiences

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TheSpineJournal12(2012)817 823
Review Article
Evaluation and management of combat-related spinal injuries: a review
based on recent experiences
Andrew J. Schoenfeld, MDa,*, Ronald A. Lehman, Jr., MDb, Joseph R. Hsu, MDc
aDepartmentofOrthopaedicSurgery,115thCombatSupportHospitalandWilliamBeaumontArmyMedicalCenter,5005N.PiedrasSt,ElPaso,TX79920,USA
bIntegratedDepartmentofOrthopaedicSurgeryandRehabilitation,WalterReedNationalMilitaryMedicalCenter,8901RockvillePike,
Bethesda,MD20889,USA
cDepartmentofOrthopaedicSurgery,UnitedStatesArmyInstituteofSurgicalResearch,SanAntonioMilitaryMedicalCenter,3851RogerBrookeDr,
SanAntonio,TX78234,USA
Received10February2011;revised30March2011;accepted28April2011
Abstract BACKGROUND CONTEXT: The current approach to the evaluation and treatment of military
casualties in the Global War on Terror is informed by medical experience from prior conflicts
andcombatencountersfromthelast10years.Inanefforttostandardizethecareprovidedtomil
itarycasualtiesintheongoingconflicts,theDepartmentofDefense(DoD)haspublishedClinical
Practice Guidelines (CPGs) that deal specifically with the combat casualty sustaining a spinal in
jury. However, the combat experiencewith spine injuries in the present conflicts remains incom
pletely described.
PURPOSE: TodescribetheCPGsforthecareofthecombatcasualtywithsuspectedspineinjuries
anddiscuss them inlightofthepublished militaryexperiencewithcombatrelated spinaltrauma.
STUDYDESIGN: Literature review.
METHODS: A literature review was conducted regarding published works that discussed the
incidence,epidemiology,andmanagementofcombatrelatedspinaltrauma.TheCPGs,established
bytheDoD,arediscussedinlightofactualmilitaryexperienceswithspinetrauma,thepresentsit
uationintheforwardsurgicalteamsandcombatsupporthospitalstreatingcasualtiesintheater,and
recentpublications inthefieldof spinesurgery.
RESULTS: IntheconventionalwarsfoughtbytheUnitedStatesbetween1950and1991(Korea,
Vietnam,GulfWarI),theincidenceofspineinjuriesremainedcloseto1%ofallcombatcasual
ties. However, in the GlobalWar on Terror,the enemy has relied on implements of asymmetric
warfare, including sniper attacks, ambush, roadside bombs, and improvised explosive devices.
The increase in explosivemechanisms of injury has elevated the number of soldiers exposed to
blunt force trauma and, consequently, recent publications reported the highest incidence of
combat relatedspinalinjuries inAmericanmilitary history. Woundedsoldiers are expeditiously
evacuatedthroughtheechelonsofcarebuttypicallydonotreceivesurgicalmanagementintheater.
The current CPGs for the care of soldiers with combat related spinal injuries should be re
examinedinlightofdataregardingtheincreasingnumberofspineinjuries,newinjurypatterns,
suchaslumbosacraldissociationandlowlumbarburstfractures,andrecentreportswithinthefield
ofspinesurgeryasawhole.
CONCLUSIONS: Americanandcoalitionforces are sustainingthe highestspine combatcasu
altyratesinrecordedhistoryandpreviouslyunseeninjuriesarebeingencounteredwithincreased
frequency.WhiletheCPGsprovideusefuldirectionin terms of theevaluation andmanagement
FDAdevice/drugstatus:Notapplicable. containedhereinaretheprivateviewsoftheauthorsandarenottobecon
Authordisclosures:AJS:Nothingtodisclose;RAL:Grants:DARPA struedasofficialorreflectingtheviewsoftheDepartmentofDefense,the
(I, Paid directly to institution/employer), DMRDP (H, Paid directly to USgovernment,ortheUSArmy.
institution/employer);JRH:Nothingtodisclose. * Corresponding author. Department of Orthopaedic Surgery, 115th
ThedisclosurekeycanbefoundontheTableofContentsandatwww. CombatSupportHospitalandWilliamBeaumontArmyMedicalCenter,
TheSpineJournalOnline.com. 5005N.PiedrasSt,ElPaso,TX79920,USA.Tel.:[phone].
Disclaimer:TheauthorsofthismanuscriptaremembersoftheUSmil Email address: [email protected] (A.J. Schoenfeld)
itary and employees of the US government. The opinions or assertions
15299430/$ seefrontmatterPublishedbyElsevierInc.
http://dx.doi.org/10.1016/j.spinee.2011.04.028
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Evaluation and management of combat-related spinal injuries: a review
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based on recent experiences
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Schoenfeld A. J., Lehman Jr. R. A., Hsu J. R.,
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818 A.J.Schoenfeldetal./TheSpineJournal12(2012)817 823
of combat casualties with spine injuries, such recommendations may warrant periodic
re evaluation in light of recent combat experiences and evolving scientific evidence within the
spine literature. Published by Elsevier Inc.
Keywords: Spineinjuries;Combat;UnitedStatesmilitary;Spinaltrauma
Introduction The DoD CPGs for cervical spine evaluation and the
treatment of casualties with spine injuries
Combat-related injuries to the spinal column have been
documented in the historical record since the fifth century The guidelines for the evaluation and management of
BCE [1]. The ancient Greeks accurately described cervical patients with spinal injuries are presently influenced by
spinewoundssustainedduringcombat,andtheEgyptiansde- the echelons of care system used by the US and coalition
vised means to attempt reduction of fractures and disloca- forces to evacuate injured personnel from the battlefield
tions [1]. Until the age of gunpowder, however, mostspine to treatment centers in Europe or the United States where
injuriessustainedasaresultofwarwereeitherimmediately definitive care is administered [6,11]. Treatment for
fataloruntreatable.Withtheadventofballistictechnology, a wounded soldier begins at Echelon I, where combat
and the development of modern medicine, combat-related medics deliver first aid at the point of injury and/or trans-
spineinjurieshavebecomemoresurvivableevenastheirin- portthecasualtytoaBattalionAidStation.EchelonIIcon-
cidence has increased [2]. For example, during Korea and sists of the forward surgical team, where wounded
Vietnam, spine injuries were encountered among 1% of all personnel can be evaluated by general surgeons and ortho-
soldiers injured in combat [3,4]. This number increased to pedic surgeons. If necessary, surgery to save life or limb
approximately 6% in the American air assault operation in may be performed in this setting.
Panama (1989) [5], and recent investigations regarding the EchelonIIIfacilitiesconsistofcombatsupporthospitals
modernbattlefieldsintheGlobalWaronTerrorhavedocu- that are still present within the theater of operations. Com-
menteda7.4%incidenceofspinetraumaamongallcombat bat support hospitals generally have advanced imaging
casualties[2,6]. capability with computed tomographic (CT) scanners at
The current approach to the evaluation and treatment of their site and also possess the capability of performing
military casualties in Operation Iraqi Freedom (OIF) and emergentsurgicalandorthopedicprocedures[11].Onocca-
Operation Enduring Freedom (OEF) is informed by medi- sion, a neurosurgeon may be assigned to a combat support
cal experience from prior conflicts as well as the first hospital,butdoctrinally,dedicatedspinesurgeonsandneu-
decade of the Global War on Terror. In an effort to stan- rosurgeons are not part of the standard surgical staff [11].
dardizethecareprovidedtomilitarycasualtiesintheongo- However, typically there is at least one fellowship-trained
ing conflicts, the Department of Defense (DoD) has orthopedic spine surgeon and one neurosurgeon in each
published more than 25 Clinical Practice Guidelines combattheateratanyonetime.Thatbeingsaid,orthopedic
(CPGs),twoofwhichdealspecificallywiththecombatca- spinesurgeonsareassigned toEchelon IIIfacilitiestopro-
sualty sustaining a spinal injury. These are the CPGs for vide general orthopedic care, with the administration of
cervical spine evaluation [7] and the CPG on spine injury expertspinalcareasanadjunctduty.Itisimportanttorec-
surgical management and transport [8]. ognizethat,atthepresenttime,spinesurgicalinstrumenta-
At the present time, enemy tactics in both Iraq and tion is not readily available at each Echelon III facility
Afghanistancontinuetoevolve;yet,anincreasedreliance within the combat zone and, by doctrine, wounded
on unconventional warfare has been observed, including American or coalition soldiers do not receive surgical
theheavyuseofimprovisedexplosivedevices,landmines, implantsofanykinduntiltheyarriveatLandstuhlRegional
and suicide bombers [6,9,10]. This approach to combat, MedicalCenterinGermany(EchelonIV)oramilitarytreat-
combined with the personnel protective equipment (army ment facility within the United States (Echelon V) [11].
combat helmet and improved outer tactical vest) and up- Additionally, the potential for injured soldiers to be evalu-
armored vehicles deployed in supportof US and coalition ated by magnetic resonance imaging (MRI) is not realized
forces, has culminated in an increased prevalence of spi- untilEchelonIVorV[11].Itshouldbenoted,however,that
nal injuries among service members in OIF and OEF the medical evacuation process is so efficient that injured
[2,6].ThegoalofthisreviewistodescribetheDoDCPGs soldiers can arrive at Echelon IVor V facilities within 24
for the care of the combat casualty with suspected spine to 48 hours of a traumatic event.
injuries and discuss the guidelines in light of the pub- The cervical spine evaluation CPG follows advanced
lished military experience with combat-related spinal trauma life support protocols in advocating a high level
trauma. of suspicion for those individuals sustaining major
A.J.Schoenfeldetal./TheSpineJournal12(2012)817 823 819
explosive or blast injuries, falls from a height, or ejection individuals whose presentation is consistent with spinal
from a motor vehicle [7]. Wounded service members, and cord compression from a traumatic disc herniation or epi-
those complaining of neck pain or demonstrating obvious duralhematoma[8].Theguidelinealsodeclaresthattreat-
neurologiccompromise,shouldbeimmobilizedinthefield ment with high-dose methylprednisolone per the National
with a cervical collar. Individuals with penetrating injuries AcuteSpinalCordInjuryStudyprotocols[13]isnotindi-
fromanexplosionshouldalsohaveacollarplaced,butthe cated in soldiers with combat-related spinal cord injuries.
CPG specifies that soldiers with isolated penetrating cervi- This is especially important in those soldiers who have
calinjurieswhoareconsciousandexhibitnoneurologicin- open wounds, as the immunosuppression and side effects
volvement do not necessitate cervical immobilization [7]. caused by the steroids can have deleterious consequences
The concern for a penetrating injury to the neck, with the on wound healing. Additionally, the consensus opinion
absence of neurologic deficit, is that by applying external by the American Association of Neurological Surgeons
cervical immobilization, there may be an increased risk in2002concludedthatthereisinsufficientevidencetorec-
of unrecognized airway compromise during the evacuation ommend for or against the use of the steroid protocol for
process.Moreover,theCPGemphasizesthatthelivesofthe spinal cord injuries [14].
casualty and those providing first aid on the battlefield are TheCPGadvocatesthatacervicalcollarissufficientfor
oftheutmostimportance,andmovementofthecasualtyto transportinmostpatients withacervicalinjury[8].Incer-
asecureareaoutsidethefieldoffiretakesprecedenceover tain situations, although these are not elaborated in the
cervical immobilization. guideline, a halothoracic brace is also deemed acceptable.
Once the wounded soldier reaches a hospital environ- However, halo braces are not available at all Echelon III
ment, the CPG provides cervical spine evaluation algo- facilities. Soldiers with thoracic or lumbar injuries are to
rithms for both the conscious and unreliable/obtunded be immobilized in a vacuum spine board (VSB) and evac-
patient. The algorithm for the conscious patient applies uated from theater by a critical care air transport team
the National Emergency X-Radiography Utilization Study [8,11]. The VSB is similar to the ‘‘bean bag’’ device that
criteria [12] for cervical evaluation and recommends CT is used for positioning in the operating room environment
imaging if the patient has positive examination findings. inthatitwrapsaroundthepatientandcanbeinflatedtode-
IntheeventthataCTscannerisunavailable,thealgorithm crease the motion occurring during the transfer/transport
allowsforthreeviewsofthecervicalspine(anteroposterior, process. It does have some limitations although as there
lateral, and odontoid views) as the primary means to facil- have been observed areas of superficial skin breakdown
itatecollarremoval.TheCPGnotonlyadvisesthatthecol- as well as patient anxiety and claustrophobia that some-
lar be retained in the event of radiographic abnormalities times necessitates intubation for transport. To date, there
but also provides for continued immobilization in the face is no Level I evidence on the efficacy of the VSB.
of normal imaging if the patient continues to complain of The CPG is vague with regard to the possibility of sur-
neck pain, limited range of motion, or paresthesias [7]. gical intervention ‘‘in theater.’’ Concerns regarding the
Fortheobtundedorunreliablepatient,theCPGmaintains long-term complications associated with infected implants
thataCTstudyofthecervicalspinemustbeperformed.If and operating room resource utilization have generally
theCTimageisreadasnormal,thealgorithmcallsforcollar led practitioners to refrain from instrumenting the spine
removal [7]. The guideline allows for continued collar use or decompressing an unstable spine injury until the
only in situations where the CT scan is positive for injury wounded soldier reaches Echelon IVor V [11]. The CPG,
or the study is deemed inadequate. The CPG declares that however, declares that optimizing the patient’s final neuro-
because of the lack of sufficient evidence regarding the ef- logicresultshouldbetheprimarygoalandprovidesforthe
fectivenessofMRIrelativetoCTforidentifyingoccultcer- possibility of decompression and instrumentation in select
vicalinjuries,MRIisnotconsideredanecessaryadjunctin situations, such as a hemodynamically stable patient with-
theclearanceprocessforobtundedpatientsinjuredincom- outotherwounds,nocontaminatedspinalinjury,andapro-
bat[7].Furthermore,inallinstances,theCPGproposesthat gressiveneurologicdeficit[8].Suchasituationcouldarise,
the determination of cervical clearance be made within for example, in a helicopter pilot with progressive neuro-
24hoursofinjury[7].Shouldprolongedcervicalimmobili- logic deficits from a closed lumbar burstfracture sustained
zationbedeemednecessary,the trauma(extrication)collar inacrash(Fig.1).Inthecaseofpenetratingspinaltrauma,
shouldbereplaced with anorthosisthatprovidessufficient the CPGallows for surgicaldebridementand emergentde-
paddingandpreventstheformationofdecubitusulcers. compression in the case of cauda equina syndrome, pro-
Thespineinjurymanagementandtransportprotocolin- gressive neurologic deterioration, incomplete spinal cord
corporates the CPG for cervical evaluation and also adds lesion when fragments are present within the spinal canal,
that CT imaging or orthogonal views of the thoracic and and cerebrospinal fluid leak [8]. The guideline, however,
lumbar spine should be obtained for patients with sus- also cautions that decompression in theater without the
pected injuries in those zones [8]. As MR evaluation is potential for instrumented stabilization should only be per-
notavailableintheater,theCPGforspineinjurymanage- formed after great consideration and possibly only follow-
ment posits that a CT myelogram may be necessary for ingagreementbetweenthetreatingsurgeonandthechiefof
820 A.J.Schoenfeldetal./TheSpineJournal12(2012)817 823
force trauma, and the use of enhanced vehicular and body
armor has allowed soldiers to survive blasts that would
have proven fatal in prior conflicts [2].
Both these factors have contributed to the rise of
combat-related spinal injuries as appreciated in the work
of Kelly et al. among others. These authors compared in-
juries sustained by 486 soldiers killed in combat in OIF
and OEF in 2003 to 2004 to 487 killed during 2006 [9].
Explosions were the predominant mechanism of injury
for both time periods, but there was a statistically signifi-
cant increase in the number of individuals killed because
ofexplosionbetween2003 2004and2006[9].Spinalcord
injury was documented as the cause of death in 1% of the
cohortkilledduring2003to2004and2%ofthosekilledin
2006. Similar findings were also presented in the work of
Bell et al. [16], who examined the cases of 408 patients
with neurologic injuries incurred during combat in OIF
(2003 2008).Onceagain,explosionswerethepredominant
injurymechanismwith56%ofthecohortinjuredbyblasts.
In this series, 40 individuals (9.8% of the cohort) were
foundtohavesustainedinjuriestothespinalcordorverte-
bral column [16].
Two studies have specifically targeted cervical injuries
resulting from penetrating wounds caused by combat
[17,18].Driscolletal.[17]examinedtherecordsof52sol-
diers evacuated to Walter Reed Army Medical Center as
Fig.1. Sagittal computedtomographicreconstructiondemonstratingT11
andlowlumbarL5burstfractureinanactivedutyservicememberinjured a result of penetrating cervical injury from 2003 to 2005.
incombat. Spinal column involvement was evident in only 6% of
the cohort, but neurologic compromise was documented
trauma at an Echelon III facility [8]. Should surgical inter-
in 17%. Sixty-five percent had received emergent neck ex-
vention be considered and undertaken, communication be-
plorationintheater.Ultimately,8%ofsoldiersinthisstudy
tween the Echelon III and IV/V facility is paramount for
were found to have permanent neurologic deficits, and 2%
continuityofthecareplan.Onoccasion,patientswithapro-
died as a result of their injuries [17].
gressiveincompleteneurologicdeficitcanbedecompressed
In the work of Ramasamy et al. [18], the cases of 90
and instrumented posteriorly in theater; however, there is
casualties with penetrating cervical trauma were reviewed.
no anterior reconstruction capability at Echelon III hospi-
Thecauseofinjurywasexplosionin73%ofthecohortand
tals, and access surgeons are not always available because
gunshotwoundsin27%.Thecervicalspinewasinvolvedin
of the surgical case load and casualty flow.
22% of cases, and 90% of soldiers with spinal injury asso-
ciatedwiththeirpenetratingwoundsdied[18].Only3%of
the casualties considered to have unstable spine injuries
Combat-related spinal injuries in OIF and OEF
were able to reach a hospital facility alive, and ultimately
As indicated above, for the better part of military med- onlytwoindividualssurvived.Bothpatients,however,were
ical history, spinal injuries sustained during warfare either found to have some degree of neurologic impairment, and
resulted in immediate demise or could not be effectively one patient was tetraplegic. In light of their findings,
managed [1,2]. Although considered rare relative to other Ramasamy et al. maintained that few soldiers with pene-
combat-related injuries, the incidence of war-related spine trating neck trauma would benefit from cervical immobili-
trauma has continued to increase over the course of the zation and advocated instead for expeditious evacuation
20th century [2]. In the conventional wars fought by the claiming that it is ‘‘. neither prudent nor practical to
United States between 1950 and 1991 (Korea, Vietnam, immobilize (sic) all patients with penetrating injury to the
Gulf WarI), the incidence ofspineinjuriesremained close neck under battlefield conditions’’ [18].
to 1% of all combat casualties [3,4,15]. However, in both Recently, Schoenfeld et al. [2] conducted an analysis of
OIFandOEF,theenemyhasreliedonimplementsofasym- spine wounds among the soldiers of a US Army Brigade
metric warfare, including sniper attacks, ambush, roadside Combat Team assigned to OIF during the Iraq War Troop
bombs, and improvised explosive devices [2,6,9 11]. This Surge of 2007. As the Brigade Combat Team is presently
increaseinexplosivemechanismsofinjuryrelativetogun- themilitary’sbasicdeployableunit,theseauthorshypothe-
shot has elevated the number of soldiers exposed to blunt sizedthattheirdatarepresentedthebestavailableevidence
A.J.Schoenfeldetal./TheSpineJournal12(2012)817 823 821
regarding the incidence and epidemiology of spine injuries injury) [2]. However, recent experience from Walter Reed
in the current conflicts. In this cohort of 4,122 soldiers de- ArmyMedicalCenterhasshownanincreaseinunusualspi-
ployedtoacombatzone,Schoenfeldetal.[2]documented nalwoundingpatterns,includinglowlumbarburstfractures
a spine combat casualty rate of 7.4%. This represents the (Fig. 1) and lumbosacral dissociations (Fig. 2) [19]. These
highest documented figure for the incidence of combat- injuriesresultfromtheforceofblastmechanismsimparted
related spinal injuries in American military history. The to the axial skeleton of soldiers as theyare securely seated
cervical spine was the most commonly injured segment in uparmored vehicles.
(48% of cases), whereas lumbar injuries occurred in 45%
[2]. Closed fractures were present in 21% of those with
spine wounds, whereas open fractures were documented
Current challenges and opportunities for the future
in 7%. Explosive mechanisms were responsible for 83%
of all spine injuries in the series [2]. RecentpublicationsregardingtheexperiencesofUSand
It is important to note that most service members with coalitionforcesonthebattlefieldsoftheGlobalWaronTer-
survivable spine wounds presented with injuries similar to rornecessitatenewevaluationoftheCPGsregardingcervical
thoseencounteredinaciviliantraumasetting(ie,compres- spine clearance and the management of combat casualties
sion fracture, lumbar burst fracture, flexion-distraction with spinal injuries. Foremost, it should be recognizedthat
because of a combination of enemy tactics and heightened
personnelprotectivemeasures,agreaternumberofspinein-
juriesarebeingwitnessedinthepresentconflictsthanever
before [2].Rather than beingrelegated toarareeventover
thecourseofadeployment,practitionersandmedicalunits
operating in combat theaters should expect to see patients
withcomplexspineinjuriesandbeproperlyequippedtodeal
withsuchcasualties.Thepossibilityofsuccessfulsurgicalin-
terventionforpersonnelwithprogressiveneurologicdeficits,
forexample,wouldbeenhancedbytheavailabilityofspinal
instrumentationsetswithintheater.Indeed,thespineinjury
management CPG alludes to this, stating ‘‘Improvements
in spinal instrumentation systems available in theater may
broadenthesurgicaloptionsavailabletothespinesurgeon’’
[8].Additionally,itisimperativetostandardizeinstrumenta-
tionandimplantsets,sothatifemergentsurgerydoesoccur
intheater,theEchelonIVandVfacilitieshavethemeansto
revisecomponents,ifnecessary.
Second,someconsiderationshouldbegiventotheproto-
colsinherentinthecervicalevaluationCPGinlightofrecent
publicationswithinthespineliterature.Atpresent,theguide-
linecallsforcervicalspineclearanceintheobtundedorun-
reliablepatientafteranegativeCTstudy[7].Severalrecent
reports, however, have called such recommendations into
question[20 22].Althoughmultipleinvestigationssupport
thenotionthatasinglenegativeCTstudyissufficienttoclear
thecervicalspine[7],otherauthorscontendthatMRIrepre-
sents the true ‘‘gold standard’’ for the evaluation of occult
cervicalinjuryintheobtundedpatient[22].Moreover,inare-
cent meta-analysis representing 1,550 patients injured by
blunttrauma,Schoenfeldetal.[21]demonstratedthatCTim-
agingofthecervicalspinealonewasincapableofdetecting
all clinically significant injuries. In this study, 6% of clini-
callymeaningfulinjuriesweremissedonCTevaluationwith
1%necessitatingsurgicalintervention[21].Additionally,it
should be recognized that most modern studies endorsing
the use of stand-alone CT for cervical clearance are per-
formedwithhelicalmultidetectorscanningequipment[20],
Fig.2. (Top) Axialcomputedtomographic(CT)imageofalumbosacraldis
thelikes ofwhich arenottypicallyavailable inthecombat
sociationsustainedduringcombat.(Bottom)SagittalCTimageofthesame
servicememberdepictedinTopdemonstratingalumbosacraldissociation. zone,evenatEchelonIIIfacilities.
822 A.J.Schoenfeldetal./TheSpineJournal12(2012)817 823
Inlightofthesefindings,itmaybemoreprudenttoincor- lumbosacral dissociation and low lumbar burst fractures,
poratethetreatmentapproachadvocatedbyAndersonetal. are being encountered with increased frequency. Although
[20] in the cervical spine CPG. Instead of dividing patients theDoDCPGsprovideusefuldirectionintermsoftheeval-
intoconsciousandunreliable/obtunded,Andersonetal.[20] uationandmanagementofthecombatcasualtywithaspine
recommendedthecategoriesofasymptomatic,symptomatic, injury, these guidelines may warrant periodic re-evaluation
temporarily unassessable, and obtunded. Asymptomatic inlightoftherecent experienceswith spineinjuries onthe
patients may be cleared using the National Emergency battlefieldsofOIFandOEFandcontinuallyevolvingscien-
X-Radiography Utilization Study protocol [12,20]. Symp- tificevidence.Ultimately,moresubstantialresearchmustbe
tomatic patients are examined usingplain film radiographs, conducted, particularly with respect to the global military
CT,and/orMRIasdeemednecessary.Temporarilyunassess- experience with spine casualties in the last decade, before
able patients are those with short-term cognitive deficits or definitive conclusions can be reached and appropriate rec-
distractinginjurieswhoareexpectedtobeconsciousandable ommendationsmade.
toco-operatewithanexaminationwithin24to48hours[20].
Thesepatientsareleftinacollarforthe24to48-hourperiod
whiletheirotherinjuriesaretreatedand/orcognitivefunction Supplementary data
returns.Theymaythenbeevaluatedasasymptomatic/symp-
This article will have an accompanying commentary.
tomaticpatientsorreverttotheobtundedcategoryiftheyare
Please visit the online version of The Spine Journal at
stillunassessableafter48hours.
www.TheSpineJournalOnline.com, and at 10.1016/j.
Individuals in the obtunded category require CTand/or
spinee.2011.04.028.
MRI before the determination of cervical clearance [20].
In these situations, the need to remove the cervical collar
is driven by concerns regarding the potential for elevated References
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