title: Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck trauma.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK. arul49@doctors.org.uk
authors.forename: Arul
authors.initials: A
authors.lastname: Ramasamy
authors.forename: Mark
authors.initials: M
authors.lastname: Midwinter
authors.forename: Peter
authors.initials: P
authors.lastname: Mahoney
authors.forename: Jon
authors.initials: J
authors.lastname: Clasper
mesh_terms: D055826:Afghan Campaign 2001-; D000346:Afghanistan / Q000453:epidemiology; D001753:Blast Injuries / Q000150:complications / Q000453:epidemiology / Q000628:therapy; D002574:Cervical Vertebrae / Q000293:injuries*; D004632:Emergency Medical Services / Q000379:methods*; D006801:Humans; D007103:Immobilization / Q000379:methods; D054542:Iraq War, 2003-2011; D008887:Military Medicine; D008889:Military Personnel; D019838:Neck Injuries / Q000150:complications / Q000453:epidemiology* / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D013119:Spinal Cord Injuries / Q000150:complications / Q000453:epidemiology / Q000628:therapy; D023481:Terrorism; D006113:United Kingdom / Q000208:ethnology; D014950:Wounds, Penetrating / Q000150:complications / Q000453:epidemiology* / Q000628:therapy