Break a neck

It is apparent to most people that a broken neck may be life-threatening. Concern for this is a main feature in the ABCDE patient management approach as cervical spine protection is performed simultaneously with airway assessment. While there is general agreement among health care professionals on the importance of this topic, there is less agreement as to which measures are optimal in order to protect the cervical spine, and consequently the unconscious patient. In an unconscious patient with spontaneous breathing, maintaining an adequate airway without compromising spine positioning is a challenge, when endotracheal intubation is not performed. The study by Hyldmo et al. in this issue of Acta Anaesthesiologica Scandinavica aimed to determine the amount of motion created by four different lateral positions in an unstable cervical spine in five cadavers. The unstable cervical spine was surgically created by cutting several ligaments and the disc between the C5 and C6 vertebrae. The authors hypothesized that the lateral trauma position would reduce spinal motion compared to the standard recovery position, and two different versions of the High Arm IN Endangered Spine (HAINES) position. The authors found overall less range of spinal motion with the lateral trauma positioning compared to the recovery position, and a similar motion compared to the HAINES. The analysis was rather complicated as they assessed cervical spine motion with six different endpoints using an electromagnetic device. Of the 18 comparisons, only three were significant, although there was a general trend favouring the HAINES and lateral trauma position. The authors might have used a global score incorporating the six variables instead of assessing six individual parameters among four different positions. The authors refer to their study as exploratory, and did not perform a post hoc power estimation of the number of cadavers needed to provide smaller confidence intervals and potentially more significant comparisons. Although the cadavers were fresh, it is probable that the turning of cadavers is performed with more effort due to rigor mortis and an altered stiffness of the tissue than in persons still alive. Performing these procedures on cadavers could very well induce more motion of the neck than in persons alive. It is difficult to say if range of motions should be expressed in absolute numbers or as relative differences between different positions. Additionally, it is uncertain if a decreased lateral bending motion of 2.6° in the lateral trauma position compared to recovery position translates into an increased risk of spinal cord injury. The authors claim that the European Resuscitation Council does not provide recommendations whether the recovery position offers an