The definite risks and questionable benefits of liberal pre-hospital spinal immobilisation
a b s t r a c t
Introduction: The routine practice of pre-hospital spinal immobilisation (phSI) for patients with suspected Spinal injury has existed for decades. However, the controversy surrounding it resulted in the 2013 publication of a Con- sensus document by the Faculty of Pre-Hospital Care. The question remains as to whether the quality of evidence in the literature is sufficient to support the Consensus guidelines. This critical review aims to determine the va- lidity of current recommendations by balancing the potential benefits and side effects of phSI.
Method: A review of the literature was carried out by two independent assessors using Medline, PubMed, EMBASE and the Cochrane Library databases. Manual searches of related journals and reference lists were also completed. The selected body of evidence was subsequently appraised using a checklist derived from SIGN and CASP guidelines, as well as Crombie’s guide to critical appraisal.
Results: No reliable sources were found proving the benefit for patient immobilisation. In contrast there is strong evidence to show that pre-hospital spinal immobilisation is not benign with recognised complications ranging from discomfort to significant physiological compromise. The published literature supports the Consensus guide- line recommendations for safely reducing the impact of these side effects without compromising the patient. Conclusion: The literature supports the Consensus Guidelines but raises the question as to whether they go far enough as there is strong evidence to suggest phSI is an inherently harmful procedure without having any proven benefit. These results demonstrate an urgent need for further studies to determine its treatment effect.
(C) 2017
spinal cord injury is associated with significant morbidity and mor- tality. There is an immediate risk of death but also severe morbidities such as permanent hemiplegia and tetraplegia. Annually the UK and Ire- land have approximately 1000 new cases of spinal cord injury however this is a worldwide problem with all Nations at risk [1].
Pre-hospital spinal immobilisation
To reduce secondary neurological damage most pre-hospital care systems advocate spinal immobilisation for patients considered at risk. The inherent limitations of identifying this patient group, combined with the assumed benefits of immobilisation and its perceived innocu- ous nature, has led to a high level of over-treatment.
There is, however, growing concern regarding the effectiveness and potential complications of phSI [2].
E-mail address: [email protected] (T.A. Purvis).
The rationale of phSI, postulated by experts in the mid-1960s, was that after spinal trauma, an unstable vertebral column carries the risk of mechanically severing the spinal cord, leading to catastrophic neuro- logical sequelae.
As there is limited high quality evidence and research in pre-hospital care, the use of phSI continued on the basis of this theory long after its introduction in the mid-1960s. The procedure saw incorporation into the Advanced Trauma and Life Support course (ATLS), as well as local pre-hospital guidelines [1].
The scrutiny over phSI increased with the shift of focus towards ev- idence based medicine. This resulted in a number of publications questioning its efficacy. In 1998, Hauswald concluded from biomechan- ical studies that immobilising the spine is unlikely to prevent further spinal cord damage to the patient [3]. Local oedema and hypoxia were more likely to be contributors to secondary neurological damage. These are time dependent factors, potentially exacerbated by the delays to definitive care involved in immobilising the patient [3].
Since these studies were released, controversy has continued to
grow surrounding the procedure, with greater documentation of ad- verse effects of its use [2]. This has led to clinicians in the U.K. reflecting upon how phSI should be implicated in modern care.
http://dx.doi.org/10.1016/j.ajem.2017.01.045
0735-6757/(C) 2017
Consensus guidelines 2013
Connor et al. examined the evidence base concerning phSI on behalf of the Consensus group for the Faculty of Pre-Hospital Care [3]. Recom- mendations intended to reduce its side effects whilst maintaining the potential benefits included:
- Manual in line stabilisation (MILS) being a suitable alternative to a rigid collar.
- Support for the development and dissemination of an algorithm allowing for selective spinal immobilisation.
- Discouraging the use of immobilisation for penetrating trauma.
- Avoiding the immobilisation of ambulatory patients.
- Encouraging minimal patient handling.
- Discouraging the use of a spinal board for any role other than extrica- tion.
- Advocating the use of a vacuum mattress or scoop stretcher for prolonged transport.
- Rationale and aims
The 2013 Consensus Statement served to highlight that phSI may not be a benign process, with the potential for side effects of varying se- verity that all patients undergoing the procedure are exposed to. How- ever, the traditionalised process behind phSI may be saving many patients from death or significant disability. Therefore there is a neces- sity to examine the evidence base detailing the side effects as well as the potential benefits of phSI.
This critical literature review is designed to appraise the available
evidence regarding the potential benefits and side effects of phSI. This is done in order to determine whether the risks of traditional spinal im- mobilisation outweigh its proposed therapeutic value. In doing so, it also aims to:
- Determine whether the available literature on phSI agrees or dis- agrees with the 2013 Consensus statement.
- Critically appraise the available literature on phSI to determine whether the evidence base is strong enough to warrant further chang- es to the traditional protocol.
- Identify any areas where high quality research is still required.
By achieving these aims, recommendations may be made for the im- provement of the management of pre-hospital patients with suspected spinal injury.
This critical review aims to determine whether the side effects of pre-hospital spinal immobilisation outweigh the potential benefits. This is intended to determine the validity of the 2013 Consensus state- ment by scrutinising currently existing evidence.
Search strategy
Online searches were conducted on a number of databases including Ovid Medline, PubMed, Cochrane library, EMBASE, NHS knowledge Net- work and Google Scholar. Several related journal searches were also conducted of European Journal of trauma, JAMA, Lancet, New England Journal of Medicine, Clinical biomechanics and Spine. The databases and journals were selected based on their propensity for publishing ar- ticles related to this study.
MeSH (Medical subject heading) terms were used as search terms for all databases and journals where suitable, and combined with Bool- ean terminology. Search terms used included “Spinal Immobilisation”, “Immobilisation”, “Spinal injuries”, “spinal cord injuries“, “Spine”, “Emergency Medical Services” and “Emergency treatment”.
As well as searches using the search functions of the journal websites, the contents lists of all the journal publications used in the on- line search were also hand searched for relevant titles. However, due to time constraints, journals were only hand searched for three years from the time of this review.
Steps were taken to minimise the risk of publication bias. Unpub- lished records were sought out for potential inclusion. Reference sec- tions of all selected articles were also scanned for other relevant titles. Professionals in the field of emergency care and spinal immobilisation were also contacted, so that related unpublished literature could be identified (see Acknowledgements). Other potential grey literature sources were searched, including the websites of the London ambulance services, the Scottish and English ambulance services and the BASICS (British Association of immediate care service) website.
Study selection
As part of the screening process all articles which could not be defi- nitely excluded by title were examined by abstract. If necessary, the full text was then examined.
The inclusion and exclusion criteria for the review are included (see Table 1):
- For pragmatic reasons of time and cost, only English articles were con- sidered.
- The significant anatomical differences between humans and animals meant that the latter were not used in this study.
- The difference between pre-hospital and secondary care have a signif- icant effect on decision making, hence the focus on pre-hospital care [3].
- Only spinal injury through trauma was considered. Spinal injury can occur through Medical causes and congenital deformities but their management differs to that of Trauma victims.
- Studies on healthy volunteers were included because they can pro- vide useful information on both the biomechanics and ergonomics in- volved in phSI.
- Study design filters were not used due to the general lack of high qual- ity research in the pre-hospital field.
- It was decided that articles would not be excluded based solely on age, as there is a paucity of evidence in the literature regarding phSI.
- Quality assessment
In order to make the critical appraisal process as objective and sys- tematic as possible, a checklist was created based on the SIGN levels of evidence [4], and a ten-part questionnaire that combined questions from the CASP checklists [5], and Crombie’s “Guide to Critical Appraisal” [6]. An example of a completed version is available (Appendix 4). The contents of the checklist were agreed upon by all three authors of the study (TAP, PAD, BC). To ensure the best quality of articles was used, only articles assigned a score of 13 or greater were then assessed for in- dividual strengths and weaknesses. These results are presented in table format with the full body of data available as online supplementary ma- terial (Appendix 5).
Table 1
Inclusion and exclusion criteria.
Inclusion criteria Exclusion criteria
Studies in English Non English
Human studies Animal studies
Pre-hospital care In hospital care
Emergency services Long term treatment/rehabilitation
Traumatic spinal injury Non traumatic spinal injury Appraisal checklist score 13a or above Appraisal checklist score below 13a
a This minimum score was selected using the average scores of the first thirty articles appraised in order to ensure the higher quality articles were included in the study.
One reviewer (TAP) conducted the literature search, the hand searches of relevant journals, followed up reference lists and contacted experts in the field in the search for grey literature. Following this, a sec- ond reviewer repeated the process independently. The quality assess- ment was carried out by two independent reviewers (TAP, PAD) and disagreements over study eligibility or score were arbitrated by a senior author (BC), who would review the disputed article himself, and decide the appropriate score.
The database searches were repeated on a fortnightly basis between the beginning of January to the beginning of April of 2015. The last re- corded search of the literature for relevant articles was conducted on the 31st of March 2015.
- Results
A flow chart illustrating the process of the literature search is includ- ed (see Fig. 1). In total, 38 articles were included in the review. This
consisted of 8 systematic reviews, 2 meta analyses, 1 critical review, 6 case control studies, 2 cohort studies and 19 observational studies. These 38 papers were scored using the constructed checklist and com- ments were made concerning individual strengths and weaknesses of each study.
The breakdown of the checklist scores are included (see Table 2). The articles were subjectively scrutinised by the same two authors for the presence of biases of selection, detection, performance, attrition and reporting (see Table 3).
The two authors that carried out the individual appraisals (TAP, PAD) had no disagreements concerning article inclusion and produced similar scores for article appraisal. In cases where there was disagree- ment in article score, these varied by no more than a single point.
The scored articles were subsequently tabulated. The information recorded included title, type of study, main outcomes, whether these outcomes support the 2013 Consensus Statement, checklist score out of 20 and a summary of individual article strengths and weaknesses. A
Fig. 1. Flow diagram illustrating search strategy.
Documenting the answers for the appraisal checklist for each of the papers.a
Record author, date
SIGN score/10
q1
q2
q3
q4
q5
q6
q7
q8
q9
q10
Total score/20
Ahn, Singh et al., 2011
10
y
?
?
y
y
n
?
y
y
y
17.5
Anderson et al., 2010
8
n
y
y
?
y
?
y
y
?
y
15.5
Oteir et al., 2014
10
n
?
?
?
y
y
?
y
y
y
17
Oteir et al., 2015
10
y
?
y
y
?
y
?
y
?
?
17.5
Sundstrom et al., 2014
10
y
y
?
?
y
y
?
y
n
y
17.5
Blackham et al. Benger 2009
8
n
y
y
?
y
y
?
y
y
y
16
Kwan et al., 2007
10
y
y
y
y
?
y
?
?
?
y
18
Kwan et al., 2005
10
n
y
y
y
y
y
?
y
?
?
18.5
Abram et al., 2010
10
n
?
?
?
y
y
y
y
?
y
17
Ham et al., 2014
8
y
y
y
y
?
y
?
?
?
y
16
Stuke, 2011
8
y
y
y
?
y
y
y
y
n
y
16.5
Cordell et al., 1993
6
y
y
y
y
?
y
y
n
n
y
13.5
Chan et al., 1993
6
y
y
n
?
n
?
y
y
y
y
13
Berg et al., 2010
6
y
y
n
y
y
?
y
y
?
y
14
Hemmes et al., 2014
8
y
y
y
n
?
?
y
y
y
y
16
Mahshidfar, 2013
8
y
y
?
n
?
?
n
?
?
?
13
Edlich et al., 2011
6
y
y
?
?
y
y
?
?
?
y
13.5
Del Rossi, 2010
6
y
y
?
y
y
?
?
?
y
y
14
Krell, 2006
6
y
y
?
y
y
y
?
?
y
y
14.5
Johnson et al., 1996
6
y
y
?
?
n
y
y
?
y
y
13.5
Hamilton et al., 1996
6
y
y
?
n
y
y
n
y
y
y
13.5
Main et al., 1996
6
y
y
n
?
y
?
y
y
y
y
14
Mobbs, 2002
6
y
y
?
?
y
y
y
n
y
?
13.5
Davies et al., 1993
6
y
y
n
?
n
?
y
y
y
y
13
Dodd, 1995
6
y
y
?
?
y
?
n
y
y
?
13
Vallaincourt, 2009
6
y
y
y
?
y
y
y
?
y
y
15
Domeier, 2005
6
y
y
?
?
?
y
y
?
y
y
14
Stroh et al., 2001
6
y
y
?
?
y
y
y
y
y
y
15
Hoffman, 2000
6
y
y
y
?
?
y
y
?
y
y
14.5
Belbin, 2009
6
y
y
?
?
y
y
y
y
?
?
14
Ben Galim, 2010
6
y
y
n
n
y
?
y
y
y
?
13
Hauswald et al., 1998
6
y
y
?
?
y
y
y
?
y
?
14
Mazolewski et al., 1994
6
y
y
?
y
y
y
y
n
y
?
14
Ay and Aktas, 2011
6
y
y
y
y
?
n
?
y
?
?
13
Bruijns, et al., 2013
6
y
y
y
?
y
?
?
y
?
y
14
Del Rossi, 2008
6
y
y
n
?
y
y
?
y
y
?
13.5
Hood, 2015
10
y
y
?
?
?
y
y
y
y
?
18
Dixon, 2014
6
y
?
?
y
y
y
?
?
y
y
14
a Key for table Y = yes (1 point), N = no (0 points), ? = maybe/not sure (0.5 points).
summary table of the systematic reviews, meta-analysis and critical re- view are presented here (Table 4). Due to its large size, the complete table of results is available as online supplementary material (Appendix 5).
Consensus guidelines
It was noted that the conclusions drawn in the critically appraised articles correlated with the Consensus Guidelines, [3] (Appendix 10) regarding:
- Discouraging the use of immobilisation for penetrating trauma [7].
- Encouraging the use of new immobilisation technologies such as the Scoop stretcher [8], the Vacuum mattress [9], and the ResQRoll [10].
- Discouraging the routine use of cervical collars [9-10].
- Encouraging selective immobilisation rather than a blanket policy [11-14].
The articles identified with contrary conclusions to the Consensus guidelines were found to have been of low quality, containing substan- tial levels of bias, inconsistencies in the methodology and missing data.
Therefore the process of phSI, as endorsed by the 2013 Consensus guidelines, is sufficiently validated in the literature.
Side effects
The side effects of phSI are well documented. The evidence ap- praised confirmed that phSI can result in:
- Pain and discomfort, ranging from moderate to severe, that may con- tinue over the next 48 h [15].
- Tissue ischemia and increasing incidence of pressure ulcers, particu- larly in Unconscious patients [16].
- Increased respiratory effort, and decreased pulmonary function [17].
- Increased intracranial pressure [12].
- Longer hospital stays, increased radiographs and subsequent increase in cost and exposure to hospital acquired infections and radiation [18].
- Impeded examination of the neck [7].
- Cervical distraction [11].
- Delayed transport, increasing time to definitive care [19].
- Confounding clinical examination and vital sign recordings [20].
Hauswald [21], and the authors of three systematic reviews [18,22, 23], conclude that phSI may be contributing to patient morbidity and mortality.
Benefits
In contrast to side effects, no studies confirmed that phSI improved patient outcomes.
Numerous studies looked at occasional incidents where the patient’s vertebral fracture was missed until later in their care, and thus they were not immobilised beforehand. Their subsequent clinical outcomes were then evaluated, including Morbidity and mortality rates [24-26].
Platzer showed, via an observational study, that a delayed diagnosis of cervical spine injury correlated with higher rates of morbidity and mortality compared to patients who were diagnosed sooner [25].
Documenting risk of bias in each of the 38 papers.a
Record author, date
Selection bias
Performance bias
Detection bias
Attrition bias
Reporting bias
Ahn, Singh et al., 2011
-
+
+
?
-
Anderson et al., 2010
?
+
+
?
+
Oteir et al., 2014
?
+
+
-
-
Oteir et al., 2015
+
+
?
+
-
Sundstrom, 2014
-
+
?
-
?
Blackham, Benger,
?
?
-
+
-
2009
Kwan, Bunn, Roberts,
+
+
?
-
+
2007
Kwann et al., 2005
-
+
+
+
+
Abram et al., 2010
-
-
+
+
+
Ham et al., 2014
+
+
+
+
+
Stuke, 2011
-
?
+
+
+
Cordell, Hollingsworth et
al., 1993
-
-
-
+
+
This was possibly due to the ethical and litigious difficulties in creating such a study (see Table 5).
Four systematic reviews have also concluded that there is insuffi- cient evidence to validate the potential benefits of phSI [7,18,22,23].
Summary of results
- Quantifying the risks of immobilisation
Efforts were made to quantify the negative effects of phSI. The fre- quencies of the major side effects are presented (Table 6).
-
-
-
- A systematic review, by Ham et al., concerning the relationship be- tween collar immobilisation and subsequent pressure ulcers established a significant correlation (6.8% to 38% incidence) [16].
- In a prospective study by Chan and Goldberg, 21 healthy volunteers
-
-
were placed in backboard immobilisation and observed for half an hour. Within the immediate observation period, 100% of the subjects
Chan, Goldberg, 1993
-
+
-
+
?
reported pain, and 55% reported moderate to severe pain [15].
Berg, Nyberg et al.,
-
+
+
-
-
- The efficiency of the ambulance service as a whole may be affected by
2010
Hemmes and Brink, 2014
Mahshidfar, 2013
+
-
-
-
+
-
+
?
?
?
phSI. The National Audit office of the UK found the average cost of each ambulance use in 2011 to be between GBP176 and GBP251 [29]. This cost is increased by the time and resources used by the meticulous
Edlich, Mason et al., 2011
Del Rossi, 2010
Krell, 2006 Johnson, Hauswald
and Stockoff, 1996
Hamilton and Pons,
-
+
-
-
+
?
-
+
-
?
+
+
-
-
-
+
+
+
+
+
?
+
?
+
-
process of phSI. The response time of the ambulance service to other
patients may also be affected, which is expected to be less than 8 min for an unresponsive patient [29].
- The cervical collar was found in one study to press on the veins of the
neck, increasing the intracranial pressure by 4.4 mm Hg. This in- creases the potential risk of Neurological sequelae, particularly if the
1996
patient is also suffering from traumatic brain injury [12].
- Discussion
Main, Lovell, 1996
-
+
-
+
+
Mobbs, 2002
-
-
+
-
-
Davies et al., 1993
-
-
+
?
?
Dodd and Simon,
-
-
+
?
+
1995
Vallaincourt, 2009
-
+
?
?
-
Following a detailed search of the published and grey literature, 38
Domeier, 2005
-
+
+
?
?
papers were critically appraised to evaluate phSI. Extensive reliable ev-
idence was found detailing numerous side effects, with no proven ben- efit. It was also found that the Consensus Guidelines take effective steps towards minimising phSI’s potential complications.
Stroh and Braude,
2001
-
+
+
-
-
Hoffman, 2000
?
?
+
-
+
Belbin, 2009
+
?
+
+
+
Ben Galim, 2010
-
+
-
+
+
Hauswald, Ong et al.,
-
+
+
+
-
1998
Mazolewski and
?
+
+
+
+
Limitations
Mannix, 1994
This critical review focused only on English studies, and as such rel-
Ay and Aktas, 2011
+
+
-
?
?
evant articles may have been missed. However, given the methodology
Bruijns, Gully and
?
+
?
+
?
used to ensure the literature search was comprehensive, the probability
a Key for table: + = low risk of bias, - = high risk of bias, ? = unknown risk of bias.
Despite this observation, no connection is made between phSI and the prevention of Neurological deterioration. It was impossible to conclude from these studies that phSI would necessarily have prevented the neg- ative outcomes seen in these patients.
In the systematic review by Abram et al. [23], the number of immobilisations needed to prevent one patient from suffering perma- nent neurological damage was calculated using the work of Davis and Platzer [25,26]. The Number Needed to Treat (NNT) from Davis et al. was 150, and from Platzer et al. was 392 [25,26].
Conversely, Ahn and Singh found that 8% of vertebral column inju- ries were not immobilised and no clinical consequences resulted [19]. Gerrelts et al. found that patients with a delayed diagnosis of cervical spine fracture did not develop permanent Neurological deficits [27].
There were no Case-control studies that directly compared the out-
comes of patients who were immobilised against those that were not.
of the systematic reviews. However, the quality of the available evi- dence was the main subject of this critical review. As a result, the over- lap across systematic reviews was such that it did not affect the outcomes of the study.
Areas of weakness in the literature
Wallace, 2013
Del Rossi, 2008
Hood, 2015
-
+
+
+
+
?
+
+
-
+
of this occurring has been minimised.
The 38 papers that were critically evaluated included a number of
Dixon, 2014
?
?
+
+
?
systematic reviews on phSI. Some studies appeared in more than one
Oteir describes the “paucity of evidence” connecting phSI to a posi- tive effect on neurological outcomes [22]. In contrast, there is an abun- dance of reliable literature detailing the harm that phSI can inflict upon trauma victims with suspected spinal injury.
The study by Hauswald showed better neurological outcomes in a catchment area that did not use phSI compared to a region utilising the procedure. This may indicate that the practice has an overall nega- tive effect on patient outcomes [21]. He proposes that local hypoxia and oedema are greater contributors to secondary neurological injury than the risk of mechanical severance. If true, his hypothesis would strongly oppose the current school of thought on phSI. More research is required, however, to reliably validate these claims [28].
Summarising outcomes of the highest scoring articles of 38 included in this study.
Study Type Outcomes Support
consensus guidelines?
Checklist score/20
Individual strengths/weaknesses
Oteir, 2015 Systematic
review Oteir, 2014 Systematic
review
Cervical spine immobilisation is controversial in blunt trauma.
Routine use of cervical collar should be phased out, as side effects outweigh benefits.
Yes 15.5 Used Newcastle-Ottawa scale. Excluded groups with healthy
volunteers.
Yes 17 Use of numerous authors for literature search. Experts in the
field contacted. Only documented use of one database.
Ham et al.,
2014
Systematic
review
Immobilisation leading to increased incidence of
pressure sores in occiput and sacral areas, contributing to patient morbidity.
Yes 16 Used Research Appraisal Checklist for Nursing as well as
PRISMA statement. Only looked at quantitative studies.
Sundstrom, 2014
Critical review
Use of phSI should not delay transport to hospital Yes 17.5 Reference lists searched. Only documents use of one
database.
Ahn and Singh, 2011
Stuke et al., 2011
Anderson, 2010
Systematic review
Systematic review
Meta analysis
Remove patients from the spinal board as soon as possible. Suitable alternatives to use of cervical collar need to be found.
Little evidence supporting the use of phSI. Proper examination of the neck should take priority over immobilisation.
Selective immobilisation protocols NEXUS and CCSR have a high enough sensitivity to be used safely routinely.
Yes 15.5 Use of two reviewers and Delphi method of discussion. No
journal search found.
Yes 16.5 Bibliographies cross referenced and multiple authors
involved. No inclusion or exclusion criteria found.
Yes 15.5 Each paper was reviewed by three different authors. No
journal search found.
Abram, 2010 Critical
review
Immobilisation can be contributing to morbidity and mortality and this warrants further investigation.
Yes 17 Short methodology, no details found of searches for
unpublished literature or journal searches.
Blackham and Benger, 2009
Kwann, Bunn and Roberts, 2007
Kwann et al., 2005
Systematic review
Systematic review
Systematic review
NEXUS and CCSR both approach 100% sensitivity for detecting C-spine fractures.
Immobilisation may lead to airway compromise, contributing to patient morbidity and mortality.
Adverse effects of phSI including respiratory compromise, skin ischemia, longer hospital stays and increased costs.
Yes 16 Could not find explanation for search criteria or evidence of search for unpublished literature.
Yes 18 Articles assessed separately on their degree of allocation
concealment by multiple authors. No rationale for sensitivity analysis described.
Yes 18.5 Quality of allocation concealment was assessed.
Heterogeneity of results noted.
Barriers to change
Historical acceptance, concerns about Patient harm, and fears of lit- igation all provide barriers to the process of phSI. Consequently it will
Comparing the number of studies that documented risks vs benefits of phSI.
Studies showing risks of phSI
Studies showing benefits of phSI
Studies showing both risks and benefits of phSI.
Mahshidfar, 2013
Ahn, Singh et al., 2011
Oteir, 2015
Riggins, 1977
Anderson et al., 2010
Sundstrom, 2014
Platzer, 2006
Blackham and Benger, 2009
Kwann et al., 2007
Davies, 1993
Dodd, 1995
Kwann et al., 2005
-
Vallaincourt, 2009
Abram, 2010
-
Domeier, 2005
Ham, 2014
-
Stroh, 2010
Stuke et al. 2011
-
Hoffman, 2000
Cordell et al., 1993
-
Del Rossi, 2008
Chan, 1993
-
-
Berg, 2010
-
-
Hemmes, 2014
-
-
Edlich, 2011
-
-
Del Rossi, 2010
-
-
Krell, 2006
-
-
Johnson, 1996
-
-
Hamilton, 1996
-
-
Main, 1996
-
-
Mobbs, 2002
-
-
-
-
Belbin, 2009
-
-
Ben Galim, 2010
-
-
Hauswald, 1998
-
-
Mazolewski et al.,
-
-
1994
Ay and Aktas, 2014
-
-
Bruijins, 2013
-
-
Hood, 2015
-
-
Dixon, 2014
-
-
continue to be used by pre-hospital emergency personnel until there is substantial evidence showing it only causes harm with no Therapeutic effect.
- Conclusion
The evidence appraised in this critical review suggests that the side effects of phSI may outweigh the potential benefits. However, a lack of proven benefit for phSI does not definitively establish that there is no benefit to the practice.
- Recommendations
Ideally, a prospective, randomised controlled trial is required. This would be comparing patients with suspected spinal injury who undergo phSI with those who do not. However this would be very difficult to carry out, given the medico-legal implications of such a trial as well as the scale required to achieve statistical significance.
Hauswald’s theories regarding spinal injury should be investigated with further biomechanical studies to determine their efficacy, as this would have a significant influence on current practice [28].
Until the benefits of phSI can be reliably proven or disproven, the priority among clinicians is to minimise the negative effects of phSI, and to safely lower the number of patients subjected to it. The Consen- sus guidelines will achieve this, and their assimilation into U.K. practice is sufficiently warranted in the literature [3].
Contributorship statement
All three authors (TAP, PAD, BC) were involved in the planning of this study. TAP and PAD conducted the literature review and critical ap- praisal. BC arbitrated disagreements over study eligibility or score by reviewing disputed articles himself, and deciding the appropriate score. The study was submitted by TAP.
Quantifying the risks of phSI.
Risks of phSI
Types of study that demonstrate this risk:
Number of studies that demonstrated this risk out of the 36 articles appraised:
Percentage of studies that demonstrated this risk.
Delays in reaching
Systematic review, observational study
4
11.1%
definitive care: Masking of other
Systematic review, prospective observational study
5
13.9%
pathology:
Pressure ulcers:
Systematic review, randomised control trial, observational study,
8
22.2%
Pain and discomfort:
experiment
Systematic review, randomised control trial, observational study,
11
30.6%
Airway compromise:
experiment, prospective crossover study,
Systematic review, prospective observational
5
13.9%
Raised intracranial
Systematic review, prospective observational study,
3
8.33%
pressure:
Cervical vertebrae distraction
Decreased pulmonary function
Cadaveric study 1 2.78%
Cross-over trial 1 2.78%
Competing interests and funding
The authors acknowledge no competing interests and received no outside funding.
Acknowledgements
The authors are grateful for the kind assistance of Professor Sir Keith Porter, Dr. Carsten Lott, Dr. Sid Chocklett, Dr. John Ferris, Miss Jordan Edgren and Miss Rachel Bramah.
Appendix A. Supplementary data
Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2017.01.045.
- NSCIS. Spinal cord injury facts and figures at a glance; 2013.
- Kwan I, Bunn F, Roberts I. Spinal immobilisation for trauma patients. Cochrane Data- base Syst Rev 2001;CD002803. http://dx.doi.org/10.1002/14651858.CD002803.
- Connor D, Greaves I, Porter K, et al. Pre-hospital spinal immobilisation: an initial consensus statement, 30; 2013 2013-6.
- SIGN. Translation of levels of evidence. Unknown. http://www.sign.ac.uk/pdf/ sign104-ev-levels-trans.pdf.
- CASP. CASP tools and checklists. Unknown. http://www.casp-uk.net/#!casp-tools- checklists/c18f8.
- Crombie. The pocket guide to critical appraisal. Poc. Wiley-Blackwell; 1996http:// www.ebay.co.uk/itm/The-Pocket-Guide-to-Critical-Appraisal-By-Iain-Crombie-/ 291521186833?_trksid=p2141725.m3641.l6368.
- Stuke LE, Pons PT, Guy JS, et al. Prehospital spine immobilization for penetrating trauma-review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma 2011;71:763-9 discussion 769-70 10.1097/TA. 0b013e3182255cb9.
- Del Rossi G, Rechtine GR, Conrad BP, et al. Are scoop stretchers suitable for use on spine-injured patients? Am J Emerg Med 2010;28:751-6. http://dx.doi.org/10. 1016/j.ajem.2009.03.014.
- McDonald N, Webster M, Orkin A, Vanderburgh D, Johnson DE. The Long backboard vs the vacuum mattress. Prehosp Disaster Med 2014;110. http://dx.doi.org/10.1017/ S10490.
- Belbin R. A comparison of a new emergency extrication device (ResQRoll); 2009.
- Ben-Galim P, Dreiangel N, Mattox KL, et al. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma 2010;69:447-50. http://dx.doi.org/10.1097/TA.0b013e3181be785a.
- Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical hard collar on intracranial pressure after head injury. ANZ J Surg 2002. http://dx.doi.org/10.1046/j.1445-2197.2002. 02462.x (Published Online First).
- Vaillancourt C, Stiell IG, Beaudoin T, et al. The out-of-hospital validation of the Cana- dian C-Spine Rule by paramedics. Ann Emerg Med 2009;54:663-71:e1. http://dx. doi.org/10.1016/j.annemergmed.2009.03.008.
- Domeier RM, Evans RW, Swor RA, et al. Prospective validation of out-of-hospital spi- nal clearance criteria: a preliminary report. Acad Emerg Med 1997;4:643-6http:// www.ncbi.nlm.nih.gov/pubmed/9189196. (accessed 12 Feb2015).
- Chan D, Goldberg RM, Mason J, Chan L. Backboard versus mattress splint immobili- zation: a comparison of symptoms generated. J Emerg Med 1996:293-8. http://dx. doi.org/10.1016/0736-4.
- Ham W, Schoonhoven L, Schuurmans MJ, Leenen LPH. Pressure ulcers from spinal immobilization in trauma patients: a systematic review. J Trauma Acute Care Surg 2014:1131-41. http://dx.doi.org/10.1097/TA.000.
- Ay D, Aktas C, Yesilyurt S, et al. Effects of spinal immobilization devices on pulmo- nary function in healthy volunteer individuals. Ulus Travma Acil Cerrahi Derg 2011;17:103-7http://www.ncbi.nlm.nih.gov/pubmed/21644085. (accessed 11 Feb2015).
- Kwan I, Bunn F. Effects of Prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Prehospital disaster Med Off J Natl Assoc EMS Physicians World Assoc Emerg Disaster Med Assoc with Acute Care Found; 2005.
- Ahn H, Singh J, Nathens A, et al. Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and Evidence-based guidelines. J Neurotrauma 2011;28:1341-61. http://dx.doi.org/10.1089/neu.2009. 1168.
- Bruijns SR, Guly HR, Wallis LA. Effect of spinal immobilization on heart rate, blood pressure and respiratory rate. Prehosp Disaster Med 2013;28:210-4. http://dx.doi. org/10.1017/S1049023X13000034.
- Hauswald M, Ong G, Tandberg D, et al. Out-of-hospital spinal immobilization: its ef- fect on neurologic injury. Acad Emerg Med 1998;5:214-9. http://dx.doi.org/10. 1111/j.1553-2712.1998.tb02615.x.
- Oteir AO, Smith K, Jennings PA, et al. The prehospital management of suspected spi- nal cord injury: an update. Prehosp Disaster Med 2014;29:399-402. http://dx.doi. org/10.1017/S1049023X14000752.
- Abram S, Bulstrode C. Routine spinal immobilization in trauma patients: what are the advantages and disadvantages? Surgeon 2010;8:218-22. http://dx.doi.org/10. 1016/j.surge.2010.01.002.
- Riggins RS, Kraus JF. The risk of neurologic damage with fractures of the vertebrae. J Trauma 1977;17:126-33http://www.ncbi.nlm.nih.gov/pubmed/846019. (accessed 15 Feb2015).
- Platzer P, Hauswirth N, Jaindl M, et al. Delayed or missed diagnosis of Cervical spine injuries. J Trauma 2006;61:150-5. http://dx.doi.org/10.1097/01.ta.0000196673. 58429.2a.
- Davis JW, Phreaner DL, Hoyt DB, et al. The etiology of missed cervical spine injuries. J Trauma 1993;34:342-6http://www.ncbi.nlm.nih.gov/pubmed/8483172. (accessed 26 Feb2015).
- Gerrelts BD, Petersen EU, Mabry J, et al. Delayed diagnosis of cervical spine injuries. J Trauma 1991;31:1622-6http://www.ncbi.nlm.nih.gov/pubmed/1749033. (accessed 25 Feb2015).
- Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J 2013;30: 720-3. http://dx.doi.org/10.1136/emermed-2012-201847.
- Transforming Ambulance services. National Audit Office period 2010-2012. https:// www.nao.org.uk/report/transforming-nhs-ambulance-services/. (ISBN 9780102969719).
- Quality assessment
- Rationale and aims