What is the recommended technique for manual inline stabilization in patients with potential neck injuries?

Manual Inline Stabilization Technique for Suspected Neck Injuries

For patients with suspected cervical spine injury requiring airway management, apply manual in-line stabilization (MILS) with simultaneous removal of the anterior portion of the cervical collar to optimize glottic visualization while minimizing cervical spine movement. 1

Core Technique Components

Hand Positioning and Stabilization Method

• Position one hand on each side of the patient's head, maintaining the cervical spine in neutral alignment without applying axial traction. 1
• Hold the head firmly to prevent flexion, extension, and rotation during airway procedures. 2, 3
• Critical caveat: Avoid axial traction, as it can cause distraction at fracture sites (mean 7.75 mm) and may produce subluxation in unstable injuries. 4

Cervical Collar Management During Intubation

• Remove the anterior portion of the cervical collar before intubation attempts while maintaining MILS. 1, 2
• This modification is essential because cervical collars reduce interincisor distance to approximately 10 mm (compared to 19 mm with MILS alone), which is insufficient for most laryngoscope blades and significantly increases intubation failure rates (30% vs 3.3%). 5
• Collar immobilization also causes greater extension of the occipitoatlantal joint (14° vs 10°) compared to MILS alone. 5

Intubation Approach

• Use rapid sequence induction with direct laryngoscopy and a gum elastic bougie, maintaining cervical spine axis without Sellick maneuver. 1, 2
• Head extension of approximately 10-15° is typically required for adequate glottic visualization even with optimal technique. 6
• Be prepared to discontinue MILS if intubation difficulties arise, as MILS degrades laryngoscopic view and may cause hypoxia in patients with traumatic brain injury. 7

Evidence Quality and Practical Considerations

Strength of Recommendation

The recommendation for MILS is based on historical case series showing major reduction in complications when MILS is applied, though the level of evidence remains low. 1 No randomized controlled trials exist due to ethical constraints. 7

Important Limitations

• MILS may not effectively immobilize injured cervical segments and can make intubation more difficult. 7
• Recent evidence suggests direct laryngoscopy and intubation are unlikely to cause clinically significant cervical movement in most cases. 7
• The technique requires education, training, and teamwork to perform correctly. 1

Alternative Positioning for Non-Intubation Scenarios

Recovery Position for Unconscious Patients

• If an unconscious patient with suspected neck injury requires positioning for airway protection, use the HAINES (High Arm IN Endangered Spine) modified recovery position. 8
• This involves raising one arm above the head in full abduction to support the head and neck during lateral positioning. 8
• HAINES produces less than half the lateral cervical flexion compared to standard lateral recovery position. 8

Common Pitfalls to Avoid

• Never apply axial traction during stabilization—this can worsen unstable injuries. 4
• Do not leave the cervical collar fully in place during intubation attempts—this dramatically reduces mouth opening and increases failure rates. 5
• Avoid prolonged rigid collar immobilization beyond 48-72 hours, as complications rapidly escalate after this timeframe. 2
• Do not rely on MILS as absolute protection—have a low threshold to modify technique if intubation difficulties arise, as hypoxia poses greater immediate risk than cervical movement in most cases. 7