UNSTABLE SPINAL FRACTURES IN SNOWDONIA MOUNTAIN CASUALTIES
Authors: Hunt J , Dykes L , Walford T 
Published: November 2016

Objectives & Background

For decades, spinal immobilisation has been a cornerstone of pre-hospital trauma care, driven by fears that unstable spinal fractures without spinal cord injury (SCI) initially may convert to SCI unless the casualty is fully immobilised. For mountain casualties in environments requiring Search & Rescue assistance, conventional spinal packaging may be impossible.

We analysed unstable spinal fracture cases from our database of mountain casualties with specific regard for handling/packaging & neurological outcome.

Methods

Live mountain casualties with unstable spinal fractures C1-L5 were identified from our database of Snowdonia mountain casualties (1/1/04–4/6/16). Contemporaneous mountain rescue, SAR helicopter & ED records were scrutinised to determine whether spinal precautions were undertaken, and if not, why not. Hospital notes were examined to determine the nature/level of spinal fracture (instability of C3-L5 estimated using the Denis 3-column model) and neurological findings, if any.

Results

From 1328 casualties in our database (82% trauma) 64 had spinal fracture(s): one in nine casualties with non-trivial mechanism of injury.

25/64 (40%) had at least oneunstablevertebral fracture (4% of casualties with significant MOI), of which 23/25 (92%) had fallen from height, one was injured by a quad bike rollover & one fell from a mountain-bike.

Only 10/25 casualties with unstable fractures were immobilised from the location where injury occurred through to fracture diagnosis. The remaining 15 (60%) were moved either at scene or in hospital. Terrain precluded packaging in 4/15. 8/15 were moved at scene, either from perilous positions by passer-bys (e.g. in a stream, not breathing in a ditch) or they were ambulatory. In two cases, the unstable fracture was missed in the ED and spinal immobilisation removed, and in one case spinal injury was simply not suspected at scene.

4/25 had neurological findings related to their unstable fractures: see table.

Conclusion

60% of our unstable fractures cases were not immobilised at some point from scene of injury to fracture diagnosis. Two cases suffered serious permanent neurological injury but their SCIs (one complete, one partial) were immediately apparent at scene. One patient was left with mild triceps weakness. No patients–immobilised or not–deteriorated neurologically from status at scene.

These findings may reassure SAR personnel when it is logistically impossible to immobilise a casualty.Table 1

Cases with neurological symptoms or signs

AgeSexMOILevel of unstable #Other spinal #NeurologyImmobilisation63MMountain biking, fell head-first into ditchC3/4n/aComplete SCI obvious at scene by time rescuers arrivedAfter being pulled from ditch by friend who did CPR65FHill-walking, fell 2.5 m into rocky streamC3C2/4Obvious immediate severe left arm weakness+mild left leg weakness. Recovered to power 3+ to 4/5 in left arm.After being helped from stream by friends60M6 m tumbling fallC7n/aPatch forearm paresthesia found in ED when rotating neck to left during attempt to clear neck clinically. Mild triceps weakness 3 to 4/5 found later.Patient mobile at scene & did not report neck pain (but was immobilised during transport to hospital)57M18 m tumbling fall, rocky groundC1C7, T1Intermittent tingling thumb/index finger (but did not concur with level of the unstable #). Settled by discharge.Immobilised from scene, neck thought clear in ED, C1# found next day