This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formattedPDF and full text (HTML) versions will be made available soon.

Specialisation of spinal services: consequences for cervical traumamanagement in the district hospital

Journal of Trauma Management & Outcomes 2007, 1:6 doi:10.1186/1752-2897-1-6

Ulfin Rethnam (ulfinr@yahoo.com)James Cordell-Smith (jamescordellsmith@hotmail.com)

Amit Sinha (A.sinha@cd-tr.wales.nhs.uk)

ISSN 1752-2897

Article type Short Report

Submission date 17 April 2007

Acceptance date 30 November 2007

Publication date 30 November 2007

Article URL http://www.traumamanagement.org/content/1/1/6

This peer-reviewed article was published immediately upon acceptance. It can be downloaded,printed and distributed freely for any purposes (see copyright notice below).

Articles in Journal of Trauma Management & Outcomes are listed in PubMed and archived atPubMed Central.

For information about publishing your research in Journal of Trauma Management & Outcomes orany BioMed Central journal, go to

http://www.traumamanagement.org/info/instructions/

For information about other BioMed Central publications go to

http://www.biomedcentral.com/

Journal of TraumaManagement & Outcomes

2007 Rethnam et al., licensee BioMed Central Ltd.This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Specialisationofspinalservices:consequencesforcervicaltraumamanagementinthedistricthospital

UlfinRethnam(1),JamesCordell-Smith(2),AmitSinha(3)

1) DepartmentofOrthopaedics,GlanClwydHospital,Bodelwyddan,UnitedKingdom

2) DepartmentofOrthopaedics,MorristonHospital,Swansea,UnitedKingdom3) DepartmentofOrthopaedics,GlanClwydHospital,Bodelwyddan,United

Kingdom.

Emailaddresses

UR ulfinr@yahoo.comJCS jamescordellsmith@hotmail.comAS Amit.Sinha@cd-tr.wales.nhs.uk

Correspondenceto:

MrUlfinRethnam11FforddParcCastellBodelwyddan,Rhyl,UnitedKingdomLL185WD

Abstract

BackgroundSpecialisation in spinal services has lead to a low threshold for referral of cervicalspine injuries from district general hospitals. We aim to assess the capability of adistrictgeneralhospitalinprovidingthehalovestdeviceandtheexpertiseavailableinapplyingthedeviceforunstablecervicalspineinjuriespriortotransfertoareferralcentre.

MethodsThestudywasapostalquestionnairesurveyoftraumaconsultantsatdistrictgeneralhospitalswithouton-sitespinalunitsintheUnitedKingdom.SeventyinstitutionswereselectedrandomlyfromanelectronicNHSdirectory.Weposedsevenquestionsonthelocalavailability,expertiseandtrainingwithhalovestapplication,andtransferralpoliciesinpatientswithspinaltrauma.

ResultsTheresponseratewas51/70(73%).Nineteenofthehospitals(37%)didnotstockthe halo vest device. Also, one third of the participants (18 / 51, 35%, 95%confidence interval 22 50%) were not confident in application of the halo vestdevice and resorted to transfer of patients to referral centres without haloimmobilization.

ConclusionThe lack of equipment and expertise to apply the halo vest device for unstablecervicalspineinjuriesishighlightedinthisstudy.Trainingofall traumasurgeonsintheapplicationofthehalodevicewouldovercomethisdeficiency

Background

IntheUnitedKingdom(UK),mostspinaltraumapresentstodistrictgeneralhospitalswhereon-sitespinalunitsareunavailable.Patientsneedtobetransferredtotertiarycarecentresfordefinitivesurgicalmanagement.Unstable cervical spine injuries require adequate immobilisation to prevent or limitneurological sequelae during transport. Methods of immobilisation of the injuredcervicalspineincludecervicalorthotics(hardcervicalcollar),headcervicalorthotics(Philadelphia collar and Miami-J collar), cervical traction, and halo-vestimmobilisation. The halo vest is the most rigid of all cervical orthoses [1], andrepresentstheimmobilisationmethodofchoicewhenpreparingpatientsfortransferbetweenhospitals[2].

Althoughthisisaneffectiveandrelativelysafeprocedure[3],Kangandco-workersfeltthatfamiliaritywiththedesign,rationaleofusage,propermethodofapplication,and awareness of potential complications could minimize the morbidity associatedwiththeuseofthehalovestdevice[4].

WeinvestigatedthecapabilityofUKdistrictgeneralhospitalsregardingthefamiliarityandconfidenceofapplicationofthehalovesttractiondeviceamongtheorthopaedicstaff, availability of the device, and the implications this may have for training andservicedeliveryinlightoftheongoingrestructuringofspinalservicestowardstertiaryspinecentres.

Methods

A survey was conducted at 70 UK district general hospitals with designated acutetrauma admission status. Eligible centres were identified randomly using anelectronicNHSdirectory.Hospitals with on-site spinal units were excluded. Individual orthopaedic traumaconsultantswerecontactedbyapostalquestionnairetoassessthe levelofserviceprovisionwithregardtohalovestapplication.

Thequestionnairewas inasimple tick-boxstyle formatandassessedwhether thehospitals in which the consultants were employed stocked halo vest equipmentroutinely, their level of confidence to apply halo devices to adult and paediatrictraumapatients,andwhether theyhad receivedadequate training inapplicationorhadrecentexperienceinhalovestapplication.In addition, participants were asked about referral protocols and problemsencountered with referral of patients with cervical spine injuries to tertiary spinecentres.

Results are presented as absolute numbers and proportions together with 95%binomialexactconfidenceintervals(CI),whereappropriate.

Results

Altogether,51/70consultantsrespondedtothequestionnaire,foraresponserateof73%.Nineteen(37%)of51districthospitalsnolongerroutinelystockedemergencyhalo-vestequipment.Just33/51(65%,95%CI5078%)oftheconsultantsstatedthattheywouldfeelconfidenttoapplythisdeviceevenwhenavailablebothinadultsandchildren, while the remaining did not feel confident either because of inadequatetrainingorlackofrecentexperience.

Twenty consultants (39%, 95% CI 26 54%) did not receive adequate training inapplying thehalovestdevice.Only fifteen (29%,95%CI1744%)hadappliedahalovestinthepasttwoyears.Mostsurgeonshadalowthresholdinreferringpatientstotertiaryspinalunitsdespiteinherentrisksassociatedwithtransferofanunstablecervical injurywithsuboptimalimmobilisation (34 / 51,67%,95%CI5279%).Thiswasdespiteonequarterofclinicians(12/51,24%,95%CI1337%)encounteredreferraldifficultiessuchasinappropriatedelaysorproblemsobtainingspecialistadvice.

Discussion

Cervical spine injuries can have serious neurological consequences. Patients withthese injuries require adequate immobilisation to prevent or limit neurologicaldeteriorationduringtransfertotertiaryspinecentresanddefinitivesurgicalfixation.

Thekeyfactorinimmobilisingthecervicalspineistherigidityoftheapplieddevice.Cervical and head-cervical orthoses still allow for variable motion of the cervicalsegments and therefore are not suitable in patients with unstable cervical spineinjuries. Studies assessing the stabilising effects of different cervical orthosesshowedthehalo-vestdevicetobethemostrigid[5,6].

Thetreatmentofunstablecervicalspineinjurieswiththehalovestisanestablishedprocedure.ThehalotractiondevicewasfirstdevisedbyPerryandNickelin1959toovercome problems encountered while using the Minerva plaster for treatingunstablecervicalspinefractures[7].Thehalotractiondeviceprovidesgoodcontrolofflexion,extensionandrotationoftheuppercervicalspine[8,9].Thehalovestcanbeusedforbothintermediateanddefinitivetreatmentofcervicalspine injuries, as well as immobilisation after surgical fixation of cervical spinefractures [10]. It may even be used for treatment of unstable cervical and upperthoracicfracturesanddislocationsaslowasTh3.

Thehaloringismadeofgraphiteormetalwithpinfixationonthefrontalandparieto-occipitalareasoftheskull.Developmentoflightweightcompositematerialledtothedesignofradiolucentringscompatiblewithmagneticresonanceimaging.Restrictionin cervical motion dependson the fit of thehalo vest, since improper fit can allow31% of normal spine motion. The halo vest is the weak link in terms of motioncontrol. Compressive and distractive force can occur with variable fit of the vest.Motion restrictions provided by the halo include the following: limits flexion andextensionby90to96%,limitslateralbendingby92to96%,limitsrotationby98to99%[4].When compared to cervical traction using skull tongs the halo-vest device keepspatientsmobileandreducesrespiratoryproblems.Thisisspecificallyadvantageousinelderlypatientswhohaveahigherincidenceofuppercervicalspineinjuries[11].

Despite its efficacy in immobilising the cervical spine, the halo vest device has itsownproblems.Complications likepin loosening,pinsite infection,discomfortatpinsites, dysphagia, prolonged bleeding at pin sites, and dural puncture have beenreportedintheliterature[1].Thiscanbereducedbyfamiliaritywiththedesign,andawarenessofpropermethodofapplication.

Although in the UK most spinal trauma cases present initially to district generalhospitals,ourstudyshowsatrendnottostockthehalodeviceinonethirdofthesehospitals. This would mean immobilisation of potentially unstable cervical spineinjuries by other, less rigid cervical orthoses.When the halodevice was available,only two thirdsof the traumasurgeonswereconfident inapplyingone.Previously,this would have been considered a prerequisite trauma skill for practicingorthopaedicsurgeonsinhospitalsprovidingacuteservices.Therenowappearstobeawidevariation in theprovisionof thisessentialservice throughout theUK,withahighproportionoftraumaunitshavingneithertheresourcesnorclinicalexpertisetomanage these injuries. As the management of spinal trauma becomes morespecialised, this is likely to affect service delivery and training, and has importantsafetyimplications.

One limitation of our study is that, although the sample population was selectedrandomly,itmaystillnotberepresentativeofalldistrictgeneralhospitalsintheUK.Also, theoverall samplesizeand response ratemay further limit firmconclusions.Finally,wedidnotcollectdataondemographicandprofessionalbackgroundsoftherespondentsandtheirinstitutions.

Apartfromtheselimits,ourstudyhascreatedanawarenessoftheexistinglevelofapplicationskillandavailabilityofthehalovesttractiondevice.Nocomparablestudyisavailable in the literature,and itmaybeof interest toperformsimilarsurveys inothercountries.We recommend training all trauma surgeons in the indications, technique ofapplication,andpossiblecomplicationsofthehalovestdevice.

Conclusion

Specialisationofspinalserviceshasserious implicationson the initialmanagementofcervicalspinetraumaindistrictgeneralhospitalswithouton-sitespinalunits.Thelackofequipmentandexpertise toapply thehalovestdevice forunstablecervicalspine injuries in this set up is highlighted. We recommend training of all traumasurgeonsintheapplicationofahalovestdeviceandmakingthisdeviceavailableforuse.

CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.

Authors'contributionsURwas involved in reviewing the literature,drafting themanuscriptandproof readthemanuscript.JCSwasinvolvedincollectingdata,reviewingtheliterature,draftingthe manuscript and proof read the manuscript. AS is the senior author and wasresponsibleforfinalproofreadingofthearticle.Allauthorshavereadandapprovedthefinalmanuscript.

AcknowledgmentsFundingwasneithersoughtnorobtained.Wethankalltheorthopaedicconsultantswhoparticipatedinthisstudyandthemedicalsecretariesfortheirsupport.

References

1. BotteMJ,ByrneTP,AbramsRA,GarfinSR:Thehaloskeletalfixator:currentconceptsofapplicationandmaintenance.Orthopedics1995,18:463-471.

2. BirdJH,LukeDP,WardNJ,StewartMP,TempletonPA:ManagementofunstablecervicalspineinjuriesinsouthernIraqduringOPTELIC.JRArmyMedCorps2005,151:179-185.

3. ChanRC,SchweigelJF,ThompsonGB:Halo-thoracicbraceimmobilizationin188patientswithacutecervicalspineinjuries.JNeurosurg1983,58:508-515.

4. KulkarniSS,HoS:Spinalorthotics.[http://www.emedicinecom/PMR/topic173htm],2005.

5. ChandlerDR,NemejcC,AdkinsRH,WatersRL:Emergencycervical-spineimmobilization.AnnEmergMed1992,21:1185-1188.

6. RichterD,LattaLL,MilneEL,VarkarakisGM,BiedermannL,EkkernkampA,OstermannPA:Thestabilizingeffectsofdifferentorthosesintheintactandunstableuppercervicalspine:acadaverstudy.JTrauma2001,50:848-854.

7. THOMPSONH:The"halo"tractionapparatus.Amethodofexternalsplintingofthecervicalspineafterinjury.JBoneJointSurgBr1962,44-B:655-661.

8. RyanMD,TaylorTK:Odontoidfractures.Arationalapproachtotreatment.JBoneJointSurgBr1982,64:416-421.

9. THOMPSONH:The"halo"tractionapparatus.Amethodofexternalsplintingofthecervicalspineafterinjury.JBoneJointSurgBr1962,44-B:655-661.

10. KangM,VivesMJ,VaccaroAR:Thehalovest:principlesofapplicationandmanagementofcomplications.JSpinalCordMed2003,26:186-192.

11. LiebermanIH,WebbJK:Cervicalspineinjuriesintheelderly.JBoneJointSurgBr1994,76:877-881.

Start of article