Spinal Immobilization: Are we doing more harm than good ?

[Dustdevil]

Nah, you couldn't do take downs or extrications on it, but you can scoop them off of the LBB once the takedown or extrication is completed. Then the LBB becomes a tool, not an immobilization device, which it was never really meant to be and does so very poorly.

[Ace844]

Here's a great review and more info on this topic for everyone to gander at...

Systematic Review Source

This is a systematic review abstract, a regular feature of the Annals' Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area.

The source for this systematic review abstract is: Kwan I, Bunn F, Roberts I, on behalf of the WHO Pre-Hospital Trauma Care Steering Committee. Spinal immobilisation for trauma patients (Cochrane Review). In: The Cochrane Library, Issue 1, 2005. Chichester, UK: John Wiley & Sons, Ltd.

Objective

The objective of this systematic review is to quantify the effect of different methods of spinal immobilization (including immobilization versus no immobilization) on mortality, neurologic disability, spinal stability, and adverse effects in trauma patients.

Data Sources

The authors searched the Cochrane Controlled Trial Register (CCTR), the specialized register of the Cochrane Injuries Group, MEDLINE, EMBASE, CINAHL, PubMed, and the National Research Register. They subsequently checked reference lists of all articles and contacted experts in the field to identify eligible trials. Eight manufacturers of spinal immobilization devices were also contacted for information. There was no language restriction in any of the searches.

Study Selection

The review was limited to randomized controlled trials comparing spinal immobilization strategies in trauma patients with suspected spinal cord injury. All trials performed in healthy volunteers were excluded.

Data Extraction

One reviewer performed screening of the electronic searches for possibly relevant trials (10% second reviewer assessment); the full text of all potentially relevant trials was retrieved, and 2 reviewers applied the selection criteria independently to the trial reports. Disagreements were resolved by a third reviewer. Two reviewers independently extracted data. The reviewers were not blinded to the authors or journal when performing these tasks.

Main Results

The authors identified 4,438 potentially eligible reports; none of these met the inclusion criteria. The authors failed to find any randomized controlled trial performed on unhealthy volunteers that focused on spinal immobilization strategies and techniques in trauma patients. A number of randomized controlled trials were identified comparing different spinal immobilization strategies in healthy volunteers. The results of randomized controlled trials on healthy volunteers may provide some useful insights into their relative effectiveness in trauma patients. For this reason, although trials of healthy volunteers did not meet the inclusion criteria, the authors summarized them in the additional tables section of the review.

Conclusions

The authors of this Cochrane review failed to identify any randomized controlled trials that met their inclusion criteria. The effect of spinal immobilization on mortality, neurologic injury, spinal stability, and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilization, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilization may increase mortality and morbidity cannot be excluded. Large prospective studies are needed to validate the decision criteria for spinal immobilization in trauma patients with high risk of spinal injury. Randomized controlled trials in trauma patients are required to establish the relative effectiveness of alternative strategies for spinal immobilization.

Cochrane Systematic Review Author Contact

Irene Kwan

Public Health Intervention Research Unit London School of Hygiene & Tropical Medicine London, UK E-mailIrene.Kwan@lshtm.ac.uk.

Commentary: Clinical Implication

Spinal immobilization and spinal precautions are common practices in the out-of-hospital care of patients with trauma, especially those in whom spinal injury is suspected. Despite this practice, spinal cord injuries are rare, often obvious at the scene, and several validated decision rules exist that are designed to clinically clear the cervical spine and reduce the need for radiography.1,2 In the United States, out-of-hospital agency-specific protocols and national guidelines consider spinal immobilization as “the standard of care.†This systematic review concludes that there is no published or unpublished scientific evidence justifying the practice of spinal immobilization in the out-of-hospital setting, suggesting that a large randomized controlled trial is required to solve this problem. This lack of scientific evidence is potentially related to historical out-of-hospital practice factors or even perhaps fear of litigation by deviating from what is considered “standard of care.â€

The authors of this Cochrane systematic review also describe several studies that show how spinal immobilization has little or no effect on outcomes.3,4 The authors suggest that because significant forces are needed to produce an unstable spinal injury, there is a high likelihood that the spinal cord damage occurs at impact and subsequent movement will not cause further damage. Moreover, other studies have found associated risks related to the practice of spinal immobilization, such as airway difficulties, increased intracranial pressure, increased risk of aspiration, and restricted ventilation.5,6 Finally, spinal immobilization could lead to increased pain and potentially delay discharge, lead to patient flow problems, and contribute to emergency department (ED) crowding.

Several cervical spine clearance and radiology clinical decision rules exist1,2 and are used in ED practice. Various recent publications have recommended the development of out-of-hospital-specific rules and proposed the possibility of using existing NEXUS or Canadian criteria in the out-of-hospital setting.7-10 A recent report demonstrated that emergency medical services (EMS) personnel could safely (sensitivity of 92% and specificity of 40%) decide on spinal immobilization using a simple decision scheme based on the NEXUS criteria of altered mental status, evidence of intoxication, neurologic deficit, suspected extremity fracture, and spine pain or tenderness.9

We agree that large randomized prospective studies assessing the effectiveness of different immobilization devices and techniques are required to effectively validate the practice of spinal immobilization.

Take Home Message

There are no randomized controlled trials that support or refute the use of spinal immobilization in out-of-hospital trauma victims. Because of the potential complications associated with spinal immobilization, the validity of routine out-of-hospital spinal immobilization in trauma patients should be questioned. In the absence of any evidence, EMS services should evaluate the value of translating current decision rules and evaluating nonrandomized controlled trial research in an effort to mitigate negative outcomes that could result from a routine and unnecessary immobilization practice.

EBEM Commentator Contact

Amado Alejandro Báez, MD, MSc

Division of Trauma, Burns and Surgical Critical Care Department of Emergency Medicine Brigham and Women's Hospital/Harvard Medical School E-mailaabaez@partners.org

EBEM Teaching Point

Lack of evidence versus no difference. Many systematic reviews in emergency medicine consist of a small number of trials or small number of overall patients, often demonstrating no clear evidence of benefit (or harm). Lack of evidence of effectiveness does not prove ineffectiveness, nor does the absence of a statistical difference between 2 interventions represent equivalence. When no difference between 2 interventions is identified, many authors prematurely claim equivalence; however, in most cases the power of the systematic review is insufficient to draw such a conclusion. Under such circumstances, results should be described as demonstrating no evidence of a difference rather than being equivalent. Concluding that 2 interventions are equivalent should be limited to cases in which the 95% confidence intervals (CIs) are narrow and there is no possibility of a clinically meaningful difference.

Effectiveness is a measure of the benefit resulting from an intervention for a given health problem for a particular group. Using traditional effect measures such as relative risk or odds ratio, no effect is represented when the point estimate approximates 1.0. Even in large trials, the 95% CI of the point estimate may cross this vertical line of no effect. This CI may or may not include points corresponding to a clinically important difference between the interventions. Large samples will produce narrow CIs and therefore perhaps will provide adequate confidence that a minimally clinically important difference is absent. Small sample sizes generally provide wide CIs that may include values that, if true, would correspond to clinically important differences between the interventions.

References

1. 1Hoffman JR, Wolfson AB, Todd K, et al.. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998;32:461–469. Abstract | Full Text | PDF (49 KB) | MEDLINE | CrossRef

2. 2Stiell IG, Wells GA, Vandemheen KL, et al.. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286:1841–1848. MEDLINE | CrossRef

3. 3Barkana Y, Stein M, Scope A, et al.. Prehospital stabilization of the cervical spine for penetrating injuries of the neck: is it necessary?. Injury. 2000;31:305–309. Abstract | Full Text | PDF (99 KB) | MEDLINE | CrossRef

4. 4Hauswald M, Ong G, Tandberg D, et al.. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5:214–219. MEDLINE

5. 5Davies G, Deakin A, Wilson A. The effect of a rigid collar on intracranial pressure. Injury. 1996;27:647–649. Abstract | Abstract + References | PDF (464 KB) | MEDLINE | CrossRef

6. 6Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999;3:347–352. MEDLINE

7. 7Stroh G, Braude D. Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? an argument for selective immobilization. Ann Emerg Med. 2001;37:609–615. Abstract | Full Text | PDF (84 KB) | MEDLINE | CrossRef

8. 8Hankins DG, Rivera-Rivera EJ, Ornato JP, et al.. Turtle Creek Conference II: spinal immobilization in the field: clinical clearance criteria and implementation. Prehosp Emerg Care. 2001;5:88–93. MEDLINE | CrossRef

9. 9Meldon SW, Brant TA, Cydulka RK, et al.. Out-of-hospital cervical spine clearance: agreement between emergency medical technicians and emergency physicians. J Trauma. 1998;45:1058–1061. MEDLINE

10. 10Domeier RM, Frederiksen SM, Welch K. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann Emerg Med. 2005;46:123–131. Abstract | Full Text | PDF (191 KB) | CrossRef

From the Division of Trauma, Burns and Surgical Critical Care and Department of Emergency Medicine, Brigham and Women's Hospital/Harvard Medical School (Báez); and the Department of Emergency Medicine, Mayo Clinic College of Medicine (Schiebel), Boston, MA

PII: S0196-0644(05)01675-6 doi:10.1016/j.annemergmed.2005.09.008 © 2006 Published by Elsevier Inc. All rights reserved.

Abstract:

Background: The National Emergency X-Radiography Utilization Study defined five criteria for obtaining cervical spine radiographic investigations in blunt trauma patients. Distracting injury was given as the indication for more than 30% of all x-ray studies ordered. The hypothesis of this study was that upper and lower torso injuries would have different effects on clinical cervical spine assessment.

Methods: This is a single-center, prospective, observational study of admitted, alert, adult blunt-trauma patients. All patients underwent cervical spine plain-film radiography. Data were collected on all injuries, physical examination findings, narcotic administration, and radiograph results. Patients with upper and lower torso injuries were compared in their ability complain of pain or midline tenderness relative to a cervical spine fracture.

Results: In all, 406 patients participated. All patients received narcotic analgesics before examination. Forty patients (9.9%) had cervical spine fractures, of whom seven had a nontender neck examination. All seven patients with a nontender cervical spine and a neck fracture had at least one upper torso injury. None of the 99 patients with injuries isolated to the lower torso and a nontender neck had a cervical spine fracture (p < 0.05). The frequency of cervical spine fracture among patients with cervical spine tenderness was 19.8% (n = 33).

Conclusions: The National Emergency X-Radiography Utilization Study definition of a distracting injury may be narrowed. Upper torso injuries may be sufficiently painful to distract from a reliable cervical spine examination. Patients may detect spine tenderness in the presence of isolated painful lower torso injuries. Patients with spine tenderness warrant imaging.

Hope this helps,

ACE844

[JPINFV]

I figured that this would be the best thread to bump.

Dr. Bledsloe has a new column out where he sites a study that shows that using a LSB has no affect on spinal injuries at all.

[web:5118ab9e29]http://jems.com/Columnists/bledsoe/articles/111046/[/web:5118ab9e29]

Link to his 1994 article:

http://www.bryanbledsoe.com/pdf/mags/Spinal.pdf

[stcommodore]

we have the ability to clear C-Spine in my squad and it is listed in the PA BLS protocals. I think following those guidlines you can clear plenty of patients and save them alot of trouble. I heard it but really well at a CE class put on by our medical director. We have to remeber that by putting a pt on a LSB we are putting them in line for Cat Scan when they get to the hospital and an unknown amount of time on that board. If they don't need it it'll be a waste all around, but if you have any doubt board away!

[mediccjh]

Please post where in the PA BLS protocols they are.

[paramedicmike]

we have the ability to clear C-Spine in my squad and it is listed in the PA BLS protocals.

You can? Not the PA in which I live and work. Care to reference your source? And please don't say PA BLS protocols...I'm looking for specifics here.

I think following those guidlines you can clear plenty of patients and save them alot of trouble.

Can you please post these guidelines for us to see?

I heard it but really well at a CE class put on by our medical director. We have to remeber that by putting a pt on a LSB we are putting them in line for Cat Scan when they get to the hospital and an unknown amount of time on that board. If they don't need it it'll be a waste all around, but if you have any doubt board away!

Not in any hospital in three states to which I've transported patients. They'll get there, the doc will do his assessment. While the collar may stay, the patient is removed from the LSB fairly quickly. Sometimes I can even take the same board back with me before I leave the ER.

So, please enlighten us as to the source of your information. Please post that information here. Herbie's called you on it. I'm calling you on it. There are several other PA providers here who may just do the same.

-be safe.

[stcommodore]

Mabye its a county thing because I know we have and use it but Philly does not. Some of the guidlines include exclusion of the very young and very old, etoh, and MOI. But if you have a healthy adult patient that was rear ended at a low speed with no complaints, and overall nothing abnormal why are we going to board him if you are confident of your physical exam? Most of the time the ER doc will do the exact same thing under there NEXUS guidlines.

* No posterior midline cervical-spine tenderness.

* No evidence of intoxication.

* Normal alertness.

* No focal neurological deficit.

* No painful distracting injuries.

can I also say that the trauma team removing the patient from the backboard is critical for there assessment of the patients spine and the collar is the critical aspect in preventing motion by the patient that would cause injury. Hopefully we are all palpating the spine of patients before we place them on a backboard to...

[paramedicmike]

You are not clearing C-spine. What you're doing is called selective spinal immobilization. There is a difference between the two. If you don't know what that is there have been some excellent discussions on this forum about that very topic.

can I also say that the trauma team removing the patient from the backboard is critical for there assessment of the patients spine and the collar is the critical aspect in preventing motion by the patient that would cause injury. Hopefully we are all palpating the spine of patients before we place them on a backboard to...

...to what? Did you mean to add another thought there?

But wait, in your previous post you said:

We have to remeber that by putting a pt on a LSB we are putting them in line for Cat Scan when they get to the hospital and an unknown amount of time on that board.

So which is it? Does the trauma team remove the patient from the backboard to conduct their assessment? Or does the patient stay on the backboard from an unknown amount of time while waiting in a mysterious line for a CAT scan?

It seems that you've completely flip flopped your position. Can you please pick one and clarify your stance?

Thanks

-be safe.

[Ace844]

we have the ability to clear C-Spine in my squad and it is listed in the PA BLS protocals. I think following those guidlines you can clear plenty of patients and save them alot of trouble. I heard it but really well at a CE class put on by our medical director. We have to remeber that by putting a pt on a LSB we are putting them in line for Cat Scan when they get to the hospital and an unknown amount of time on that board. If they don't need it it'll be a waste all around, but if you have any doubt board away!

[stcommodore]

If I had it at hand I would post it but why would I make something like that up? In a Trauma situation where you have callled it a Level one or two for example and you have the team working a patient then its obvious the board is going to go, but if the patient is stable and gets put in line in an ER then they may expect to wait awhile to get off the board. Why is this so hard to believe? Do we really believe that every single patient that says they have "neck pain" or whatever needs to be put on a board? I understand many systems protect themselves from the liability of mistake by boarding everyone, but to you as health professionals do the studies show we are doing any good by boarding everyone? Don't use the whole "well this one time ten years ago I had a patient that x" line either, what good are we doing people if we don't look at the bigger picture, do studies, research and change when the evidence says we should have years ago. We are never going to get anywhere as a medical profession if we refuse to act like the rest of the medical world.