Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
Injury. 2009 Dec;40(12):1342-5. doi: 10.1016/j.injury.2009.06.168. Epub 2009 Jul 17.
Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In today's global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties.
We retrospectively reviewed the medical records of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention was recorded.
During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 of these (7%) actually survived to reach hospital. Four of this six subsequently died from injuries within 72 h. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury.
Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life-threatening conditions.
目前的 ATLS 协议规定，当伤员因可能损伤颈椎的重大创伤机制而遭受创伤时，应采取脊柱预防措施。在敌对环境中，应用这些预防措施会使院前医疗团队面临相当大的个人风险。它也可能会妨碍或延迟识别气道问题。在当今全球恐怖主义的威胁下，这种敌对环境不再仅限于冲突地区。本研究的目的是确定穿透性弹道颈部创伤后颈椎损伤的发生率，以评估这些伤员在院前进行颈椎固定的必要性。
我们回顾性地审查了过去 5.5 年中在伊拉克和阿富汗作战的英国军人伤亡人员的医疗记录，这些伤员因穿透性颈部创伤就诊。记录了每位患者的创伤机制、入院时的神经状态、医疗和手术干预情况。
在研究期间，90 名伤员发生穿透性颈部创伤。创伤机制为爆炸伤 66 例（73%），枪伤 24 例（27%）。90 名伤员中，20 名（22%）有颈椎损伤（颈椎骨折或颈脊髓损伤），但仅有 6 名（7%）实际存活到达医院。这 6 名幸存者中有 4 名在 72 小时内因伤死亡。在到达外科手术设施的 56 名幸存者中，只有 1 名（1.8%）发生不稳定颈椎损伤，需要手术稳定。该患者后来因并发头部损伤而死亡。
穿透性弹道颈部创伤死亡率很高。我们的数据表明，穿透性弹道颈部创伤幸存者颈椎不稳定的可能性非常小。在危险环境中（如枪击事件或恐怖爆炸），强制性脊柱固定的风险/收益比不利，可能会使医疗团队长期面临风险。此外，颈托可能会掩盖潜在的危及生命的情况。
