The practice of skeletal traction for cervical spine dislocations in district hospitals in the Western Cape

Abstract

Background: Cervical spinal cord injuries are common worldwide, and early intervention improves neurological outcomes. Not only is emergent closed cervical reduction best medical practice for these injuries, particularly facet dislocations, but South Africa has a unique situation where the apex court requires low energy cervical dislocations to be reduced within four hours of injury. As a result, district hospitals have a vital role in acute management of these injuries, especially where there are great distances to tertiary hospital referral centres and expected delays in patient transfers. This study aimed to assess the knowledge, resources and practice of closed cervical reduction in district hospitals in the Western Cape province of South Africa, and change in practice since the court ruling.

Methods: This was a retrospective comparative study. District hospitals were identified using the Western Cape public hospital listings. A survey was prepared using Google Forms, and emergency room clinicians were emailed the online survey in 2023. Responses were compared to a similar survey conducted in 2015. The attitude and competence of healthcare providers to perform cervical spine reductions in district level hospitals, as well as the availability of resources, were assessed.

Results: Availability of protocols improved by 20% from 2015 to 2023. Conversely, in 2023, 67% reported having no access to Cones calipers, compared to 58% in 2015. Most of the 2023 participants (74%) reported availability of imaging, while 46% and 51% of participants in 2015 and 2023, respectively, denied formal training in cervical reductions. There was a 51% reduction in practitioners who correctly identified the highest priority for closed reduction (worsening neurological deficit), from 2015 to 2023. Only 44% would attempt a reduction in the 2015 survey, and this declined to 21% in 2023. More practitioners considered reduction safe from 9% in 2015 to 21% in 2023. Most participants would change their practice given adequate training and resources.

Conclusion: The Western Cape public health sector remains ill-prepared for emergency reduction of cervical spine dislocations. There was no improvement in acute management of cervical spine injuries over the past decade, and the lack of resources, clinical skills and misperceptions around this are concerning and need addressing at provincial managerial level.

Level of evidence: 2