Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXXIII: Wounds and Injuries of the Spinal Column and Cord

Management Considerations in the Combat Environment

United States Department of Defense

The medical officer must realize that there are certain fundamental differences between the civilian practice of medicine and the compelling realities of the battlefield. If this were not the case, handbooks such as this one, dealing with military surgery, would be redundant and unnecessary. One such difference is exemplified in the initial management of the casualty with a possible spinal column or cord injury where there is an ongoing and immediate threat to the life of both the casualty and combat medic who comes to his aid.*

Current Advanced Trauma Life Support (ATLS) guidelines concerning spinal column and cord injury or potential injury state that "any patient sustaining injury above the clavicles or a head injury resulting in an unconscious state should be suspected of having an associated cervical spinal column injury which should be immobilized with a properly applied spine board, and a semirigid cervical collar." U.S. Army field manuals present similar guidelines with regard to, neck injuries and suspected fractures of the neck. Proper immobilization of the spine and movement of the casualty requires two or more people, a spine board and semirigid cervical collar. These guidelines are appropriate for the civilian sector, the peacetime military, and for secure military areas, but not for battlefields. The realities of war can make the ideal management of casualties unrealistic. If ATLS guidelines were strictly adhered to, one could envision the first day of a NATOWarsaw Pact conflict with thousands of casualties strapped to long boards and wearing cervical collars while waiting to have their spines "cleared" Simple logistics would preclude idealized management of this number of potential spinal injuries. Common sense must prevail.

On the active battlefield, during a fire fight or when one leaves his hole during an artillery or mortar barrage, the objective is to bring the casualty out of the line of fire, into a hole, or behind cover, where the basic fundamentals of casualty care (the ABCs) can be applied. The longer the casualty and the medic remain exposed, the greater the likelihood of additional wounds and additional casualties. Under conditions such as these, the prime consideration is preservation of the lives of both the wounded and the rescuers.

Additional insights regarding immediate battlefield management of the casualty with possible cervical injury is provided by the WDMET (Wound Data and Munitions Effectiveness Team) data from the Vietnam experience. Only 1.4% of all casualties with penetrating wounds of the neck, who survived long enough to become candidates for cervical immobilization, might have benefitted from such treatment. These data do not support the use of cervical collars and spine boards for penetrating and perforating neck wounds on the battlefield. Also noteworthy in the WDMET data on cervical injuries is that 13 of those killed in action, and 7 of those wounded in action, were providing battlefield care for others when they were hit. The conclusion from the WDMET data is that battlefield splinting of the cervical spine was of very little value in preventing neurological injury, while it materially increased the risks to the casualty and the provider.

*The reader should bear in mind that the differences which follow apply only to the active battlefield where there is immediate and ongoing threat to the life of the casualty and those who come to his aid.

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Operational Medicine 2001

Health Care in Military Settings

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