Protect Ya Neck (Wu Tang Clan, 1992)

When Wu-Tang Clan released "Protect Ya Neck" 30 years ago, they knew that the philosophy of managing cervical spine injuries would eventually change from "cervical spine immobilization," to "cervical spine protection." I wonder what other sage and prescient medical predictions are hidden away in the titles of late '90's rap...

Okay, so, I went off on a tangent before I even started to discuss the topic at hand, but that's what happens when I'm on my 3rd cup of coffee. My real goal with this article was to discuss cervical spine injuries and the implications that can have on managing someone in the woods.

Unstable C2 fracture.

Statistically speaking, you're far more likely to be involved in a motor vehicle accident that results in a cervical spine (C-spine) injury in the car on the way to the trail than you are on the trail itself. That being said, the risk of C-spine injury goes up with your speed and/or height before falling.

The fact that you've got an approximately 10lb head that can be whipped around is part of the problem too.

As another tangent, I started going down the rabbit hole looking for equations to calculate the forces involved in a crash, with a distant memory that force equalled mass times velocity (f=m*v), but it seems that force equals mass times acceleration (f=m*a), and momentum equals mass times velocity (p=m*v). Then I learned that P=MV is a musical artist and I decided that I needed to stop there.

Back to the subject at hand, looking at the people who are at most risk of a cervical spine injury, there's a fair amount of overlap for people who are out on the trails potentially doing dangerous things, as most C-spine injuries occur in young men. Despite that, even simple falls can be dangerous, and even more so as we get older.

Protecting the cervical spine
initially is prudent.

As you probably know, the big concern with C-spine injuries is that the spinal cord can be damaged, and as of now, there are no proven therapies to restore neurologic function. 

There are two phases of C-spine injuries, primary and secondary, and the only option for dealing with the primary injury is to not fall. Once it's done, it's done. Preventing secondary injury (which occurs from inflammation, cellular damage, low oxygen, and/or low blood pressure) is where healthcare providers can intervene. But first, the injury needs to be identified and in between the time of injury and the time where a C-spine injury is definitively found or excluded, is where some controversy lies.

What do you, or EMS providers need to do when considering the possibility of a C-spine injury?

As described by the 2019 Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection:

"...it is important to recognize and/or attempt to differentiate 5 types of spinal injury scenarios: 1) an uninjured spine, 2) a stable spine injury without existing or potential neurological compromise, 3) an unstable, or potentially unstable, spine injury without apparent neurologic compromise, 4) an unstable spine injury with neurologic compromise, and 5) an injured patient with unknown spinal injury status."

Really, what is this doing?

Historically, once there was concern for a C-spine injury, some type of "immobilization" was needed. 

C-spine "immobilization," is often done by using hard cervical collars. I put the word in immobilization in quotes, because the collars only limit motion to a degree, but it's a far cry from "immobilization." Many pre-hospital emergency medical services have protocols that require these hard collars if there's even a whiff of C-spine injury. On the surface, that sounds good, but there's really no good data that says these collars actually do anything to prevent further injury, and there's plenty of data that says the collars can cause harm. Additionally, these protocols that still enforce some type of spinal immobilization often result in patients coming in via EMS with towels loosely wrapped around the neck, as if this farce of a scarf is doing anything.

But okay, I can see a misguided rationale to continue the use of cervical collars in an urban setting as presumably we (healthcare providers) can relatively quickly evaluate a patient to really determine the possibility of a spinal injury. 

What about when you're a mile (or more) in the woods, and the application of a cervical collar (in whatever form that is), changes the situation from someone walking out on their own or having to be carried out by six or eight rescuers?

Back to the Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection, the question of "whether spinal immobilization is actually helpful in the wilderness out-of-hospital environment for any of these types of patients" is explored. I encourage you to read the article yourself, but the TL:DR summary is that spinal immobilization is "out" but spinal protection is "in." 

(by the way, while the data supporting cervical collars is lacking, fear of litigation is still one of the primary drivers in their use, and I'm not immune. Anything discussed here is purely conjecture.)

From that article, it seems that protection can come in many forms, and *may* mean slowly and cautiously walking out of the woods. Let's face it, might a person being carried over rough terrain be jostled more in a litter than he/she would by walking out slowly with some assistance? Maybe.

This was scientifically studied as it pertained to accident victims being removed from car accidents, with options including patients being immobilized and extricated, and "they concluded that self-extraction with verbal instructions and no assistive devices was the most stable extraction method."

And, because time can be of the essence in managing secondary injury, might it not be more protective to get a person out quickly under his/her own power rather than waiting for a rescue team to carry someone out? Maybe.

Bottom line is that every person and every accident is different. Every scenario is different.

"Judgment regarding the likelihood of associated spinal injury should be individualized, as no reasonable guidelines are practical given the wide and disparate combinations of trauma and injury. As previously discussed, in appropriate circumstances, severe spine trauma can result from minimal trauma (particularly in the elderly), yet patients can often escape serious injury following the most dramatic trauma and do not appear to require any more aggressive intervention than passive motion restriction with soft interventions like padding or encouragement of conscious patients not to move in any way that is painful, all of which should be intuitive interventions anyway."

Because of the WIDE variation in considering spinal cord injuries in the woods, I think of the following:

• If someone has midline neck pain immediately after a fall--that's suspicious for a bony injury (and possible spinal cord injury).
• If someone has an altered mental status/confusion or other symptoms suggestive of a head injury, it's possible that the person also has a cervical spine injury.
• If someone has an accident that could have caused a cervical spine injury AND has any weakness, numbness, tingling or other weird neurologic sensation (or lack of sensation), that's a cord injury until proven otherwise. 

With that in mind, a person with a neurologic symptom or confusion or severe neck pain probably won't be walking out the woods on his/her own, so some type of cervical spine protection should be used (whether that's a soft collar or other supportive device) while awaiting assistance.

In the absence of those red flags, there's a grey area and the need for some judgment.

"the routine use of spinal immobilization in the wilderness environment not only increases the financial cost of rescue operations, it also greatly increases the time, logistics, danger, and complexity of the operation, thereby also exacting a cost in terms of increased morbidity and mortality to not only the patient but to rescue personnel as well."

A windbreaker or other wrapped clothing may be enough to protect the cervical spine.

Ultimately, more research is needed to determine the BEST method for protecting an injured cervical spine, until then, be careful and Protect Ya Neck.

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