Cervical spine immobilization in the elderly population

Immobilization of the cervical spine is a cornerstone of spinal injury management. In the context of suspected cervical spine injury, patients are immobilized in a 'neutral position' based on the head and trunk resting on a flat surface. It is hypothesized that the increased thoracic kyphosis and loss of cervical lordosis seen in elderly patients may require alternative cervical immobilization, compared with the 'neutral position'.

To investigate this, an audit of pan-scan CT performed on consecutive major trauma patients aged over 65 years was carried out over a 6-month period. Utilizing the pan-CT's localizing scout film, a novel measurement, the 'chin-brow horizontal' angle was independently measured by a senior spine surgeon (RJM) and a neurosurgeon (PJR) with the gantry used as a horizontal zero- degree reference. The benefit of the 'chin-brow horizontal' angle in the trauma setting is it can be assessed from the bedside whilst the patient is immobilized against a flat surface.

During the 6-month study period, 58 patients were identified (30 male, 28 female), with an average age of 77.6 years (minimum 65, maximum 97). Results showed that 'chin-brow horizontal' angles varied widely, between +15.8 degrees in flexion to -30.5 degrees in extension (mean -12.4 degrees in extension, standard deviation 9.31 degrees. The interobserver correlation was 0.997 (95% CI: 0.995-0.998).

These findings suggest that, due to degenerative changes commonly seen in elderly patients, the routine use of the 'neutral position' adopted for cervical spine immobilization may not be appropriate in this population. We suggest that consideration be taken in cervical spine immobilization, with patients assessed on an individual basis including the fracture morphology, to minimize the risk of fracture displacement and worsened neurological deficit.