Case Report
Trauma
Self-extrication and selective spinal
immobilisation in a polytrauma patient
with spinal injuries
Aidan Brown1 and Adam Low2
Abstract
Methods of extrication and spinal immobilisation following trauma remains controversial. There is a consensus shift
towards encouraging patients to self-extricate from vehicles after collisions and reduced use of hard cervical collars.
Difficulties in conducting randomised controlled trials in this area means that case reports are important in adding to the
existing evidence base. This case of an 81-year-old female polytrauma patient suggests that self-extrication, and not using
hard cervical collars is safe practice, even in the context of significant multi-level spinal injuries.
Keywords
Extrication, polytrauma, spinal immobilisation
Introduction
Spinal immobilisation at the scene of trauma remains
an area of ongoing controversy, with consensus shifting
away from the use of hard spinal collars and controlled
extrications.1,2 A pre-hospital consensus statement
aimed to address this with a pragmatic approach
based upon the literature and expert consensus, but
an updated statement is yet to be published in the
United Kingdom (UK).3
Norwegian pre-hospital guidelines for adult trauma
patients make 10 recommendations based on thorough
review of available evidence that include a minimal
handling strategy, cervical stabilisation including
manual in-line immobilisation/hard cervical collars/
head blocks or a combination thereof (acknowledging
controversy surrounding rigid cervical collars), and
invitation to self-extricate under certain circumstances.4
The ethical barriers to conducting randomised con-
trolled trials in this area of practice means that the evi-
dence base will be limited to case reports and expert
opinion. As such, we present a case that we feel will
add to the existing evidence base surrounding pre-hos-
pital spinal immobilisation and extrication.
Case report
An 81-year-old female was involved in a head on road
traffic collision (RTC) on a single carriageway national
0(0) 1–4
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DOI: 10.1177/1460408620910845
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speed limit road in the UK. The Ambulance Service
was called at 16:47, triggering immediate dispatch of
the regional Medical Emergency Response and
Incident Team (MERIT). The crew consists of a critical
care paramedic (CCP) and pre-hospital emergency
medicine physician; at 16:52, the MERIT team arrived
on scene, shortly after the first ambulance.
Two patients were on scene: a male driver had self-
extricated and was uninjured, stating that the other car
had slowly veered into his lane resulting in head on
collision. Both vehicles had sustained damage to the
front crumple zones and engine block, without intru-
sion into the cabins and airbags had deployed. There
was one occupant in the second vehicle, an elderly
female, still inside the cabin. A passing doctor, who
had stopped to render aid, had lowered the backrest
of her seat, and was manually immobilising her cervical
spine.
On assessment by the MERIT team, the patient was
alert, explaining how she ‘woke up’ whilst driving down
1
West Midlands Ambulance Service NHS Foundation Trust, Midlands Air
Ambulance Charity, Brierley Hill, UK
2
Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham
NHS Foundation Trust, Birmingham, UK
Corresponding author:
Adam Low, Queen Elizabeth Hospital Birmingham, Mindelsohn Way,
Edgbaston, Birmingham, West Midlands B15 2 GW, UK.
Email: aelow@doctors.org.uk
2 Trauma 0(0)

the road and realised she was in the wrong lane just
before impact. She denied significant pain but had some
non-specific lumbar ache, was moving all four limbs
normally, with intact sensation. She confirmed she
had been restrained. A precipitant medical event was
suspected, with apparent recovery. Following a risk–
benefit analysis, the team invited that patient to self-
extricate from the vehicle. The damaged driver door
was removed by the Fire and Rescue Service and she
was asked to self-extricate slowly via the driver’s door.
She was instructed to stop if pain increased or she
experienced any altered sensation in arms or legs. She
was able to get out of the car, walk two metres holding
onto the CCP’s arm, and position herself on the ambu-
lance trolley. The extrication took less than 2 min.
A primary survey was repeated in the ambulance. She
had a raised respiratory rate, and began complaining of
chest pain, with seatbelt pattern bruising noted across
the chest wall. She had no crepitus or surgical emphy-
sema and had bilateral air entry, although reduced at
Figure 1. Three-dimensional reconstruction showing
the bases. There was no abdominal or pelvic pain. She right-sided rib fractures and flail segment. There were
was able to independently move all four limbs, with a bilateral rib fractures and sternal fracture in this case leading
Medical Research Council motor score of 5/5, had to ventilatory insufficiency.
normal sensation to touch in all dermatomes, and com-
plained of a painful, deformed left wrist with suspected
underlying closed fracture. and cryostat trial intervention). Bedside transthoracic
The team immobilised her with head blocks and echocardiogram revealed a small pericardial effusion
tape, on a scoop stretcher. She was initially normoten- with preserved left ventricular systolic function.
sive, and the trolley tilted head up to try to improve After transfer to the Intensive Care Unit (ICU), she
ventilatory efficacy. She became increasingly hypoten- was nursed on a spinal bed with Miami-J cervical collar
sive, tachycardic and tachypnoeic and was triaged to and log rolled for ongoing care needs. Magnetic reson-
the nearest Major Trauma Centre (MTC) which was ance imaging at 12 h revealed impingement at C6, epi-
a 40-min blue light transfer by road. Total on scene dural haematoma from C3 to T6, and signal changes
time was 30 min. The pre-hospital interventions were between T6 and T7 (Figure 2(b)). She underwent emer-
application of pelvic splint, 750 ml intravenous crystal- gency posterior C4–T10 decompression and fixation in
loid titrated to a radial pulse as the service was not the prone position to facilitate nursing care and poten-
carrying blood/blood products, 1 g tranexamic acid, tial rehabilitation followed by extensive rib fixation 36 h
analgesia, and heat loss prevention. post-admission.
At the MTC, she remained clinically shocked but Early percutaneous tracheostomy on ICU facilitated
Glasgow Coma Score (GCS) 15, moving all four weaning, whilst sedation holds revealed residual motor
limbs and with chest injury-associated ventilatory insuf- function bilaterally in the upper limbs, but paralysis of
ficiency. Trauma protocol computed tomography (CT) the lower limbs. There were notable brady-arrhythmias
scan revealed sternal fractures with associated flail seg- on ICU requiring permanent pacemaker insertion. She
ment (Figure 1), right haemothorax for which an inter- unfortunately developed multi-organ dysfunction fol-
costal chest drain was inserted, C6/7 subluxation lowing sequential ventilator-associated pneumonias
with transverse process bony injury, a Chance fracture and died 22 days after injury.
at T6/T7 with gross displacement and deformity
(Figure 2(a)), multiple thoraco-lumbar transverse pro-
cess fractures, fracture of the sacrum and retroperiton-
Discussion
eal haematoma. Her GCS deteriorated after scanning, We present a polytrauma case of an elderly patient who
secondary to respiratory failure with a PaCO2 of had significant primary unstable cervical and thoracic
16.99 kPa. She had a rapid sequence induction with spinal injuries, but safely self-extricated without caus-
manual in-line immobilisation in the emergency depart- ing immediate neurological decline or deficit. It is not
ment and resuscitation with blood products (six packed clear when the neurological deficit occurred, as the
red cells/six fresh frozen plasma, one unit of platelets whole time she was awake she was moving all four
Brown and Low
Figure 2. (a) Sagittal magnetic resonance image illustrating bone injury at thoracic vertebral level T6/7 with significant vertebral
body deformity. (b) Sagittal magnetic resonance image illustrating the subluxation and cord impingement at C6/C7, above the
cervical–thoracic junction. There is an epidural haematoma present extending from C3 to T6 with associated signal change in the cord.
limbs. Possible causes of this deterioration may include:
the evolving epidural haematoma expansion, com-
pounded by coagulopathy of trauma (admission core
body temperature 34.9 C and international normalised
ratio: 1.3), or oedema around the vulnerable cord from
the primary injury, compounded by hypotension, or
worsened by movement during self-extrication.
Focussing specifically on the spinal immobilisation
and extrication strategy used in this case, there are
some areas to consider in further depth. Options for
extraction were extrication by health care profes-
sionals/fire and rescue service in a controlled manner
utilising specific equipment, rapid extrication in the
context of physiological instability or patient self-
extrication. Dixon et al.’s study utilised biomechanical
sensors and high-speed infra-red cameras to analyse
movement during nine different extrication techniques5
and found that conventional extrication techniques rec-
orded up to four times more movement (relative to the
midline) in a simulated patient than controlled self-
extrication. On this basis, self-extrication is a reason-
able option in a conscious and co-operative patient.
This case suggests that this is possible even in a patient
with unstable bony spinal injuries without causing
immediate neurological deterioration, supporting the
hypothesis that spinal muscle spasm and pain will pre-
vent excessive, damaging motion resulting in neuro-
logical decline, adding evidence to consensus opinion
and guidance.3,4 Whilst neurological decline was noted
3
on ICU during sedation holds, the fact that she had no
neurological decline during her transfer into hospital
and initial resuscitation suggests that this was not the
immediate result of self-extricating. Any secondary
oedema could equally have occurred with a controlled
extrication, though her period of hypotension and wor-
sening hypothermia could equally have made this worse.
Retrospective analysis has demonstrated an increase
in time to extrication associated with professional rescue
from a vehicle when compared with self-extrication.6,7
In this case, had the patient remained in the vehicle
when she began to physiologically deteriorate, manage-
ment may have been challenging and controlled extri-
cation added to time on scene, increased hypothermia
and delaying time to hospital in the context of signifi-
cant polytrauma.
In hindsight, with full knowledge via CT of the inju-
ries suffered, it could be argued that this patient should
not have been asked to self-extricate due to the presence
of distracting injuries; however, at that time the patient
was only complaining of moderate lumbar back pain.
There is no consensus over what defines a distracting
injury,8 and our case suggests that even in the presence
of significant injury, patients who are GCS 15
with intact neurology can still safely self-extricate.
The impact of drugs or alcohol may alter clinicians’
risk:benefit analyses.
The ability of pre-hospital practitioners to accurately
predict the presence of bony spinal injuries is
4 Trauma 0(0)
inconsistent,9 so a high index of suspicion based upon
mechanism of injury/co-morbidity/age should be main-
tained over decisions regarding immobilisation/triage.
Conclusion
Despite the eventual fatal outcome, this case adds to
the limited evidence base for self-extrication of con-
scious patients after RTCs, even in the presence of
spinal and distracting injuries.
Acknowledgements
We would like to thank Dr Alex James to his agreement for
publishing this interesting and challenging case, and Dr Han
Seng Chew for assisting in selection of appropriate accom-
panying images for the case report.
Contributorship
AB and AL reviewed the existing literature and wrote the case
report. AB was directly involved in the pre-hospital care of
the patient and AL in the hospital care. Both wrote and
reviewed the case report pre-submission.
Declaration of conflicting interests
The author(s) disclosed no conflict of interest with regards to
the research, authorship, and/or publication of this article.
Ethical approval
Ethical approval was not sought for this case report.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Guarantor
AL.
Informed consent
Written informed consent was obtained from the patient’s
next of kin while they were still alive on intensive care, for
their anonymised information to be published in this article.
The patient was aware of the case report but unable to sign a
consent form due to their injuries and clinical condition.
ORCID iD
Adam Low https://orcid.org/0000-0001-5035-3267
Provenance and peer review
Not commissioned, externally peer reviewed.
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