Spinal immobilisation for trauma patients

  • Review
  • Intervention

Authors

  • Irene Kwan,

    Corresponding author
    1. Royal College of Obstetricians & Gynaecologists, National Collaborating Centre For Women's and Children's Health, London, UK
    • Irene Kwan, National Collaborating Centre For Women's and Children's Health, Royal College of Obstetricians & Gynaecologists, 2-16 Goodge Street, London, W1T2QA, UK. ikwan@ncc-wch.org.uk..

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  • Frances Bunn,

    1. University of Hertfordshire, Centre for Research in Primary and Community Care, Hatfield, Hertfordshire, UK
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  • Ian G Roberts

    1. London School of Hygiene & Tropical Medicine, Cochrane Injuries Group, London, UK
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Abstract

Background

Spinal immobilisation involves the use of a number of devices and strategies to stabilise the spinal column after injury and thus prevent spinal cord damage. The practice is widely recommended and widely used in trauma patients with suspected spinal cord injury in the pre-hospital setting.

Objectives

To quantify the effect of different methods of spinal immobilisation (including immobilisation versus no immobilisation) on mortality, neurological disability, spinal stability and adverse effects in trauma patients.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Injuries Group's specialised register, MEDLINE, EMBASE, CINAHL, PubMed, National Research Register and Zetoc. We checked reference lists of all articles and contacted experts in the field to identify eligible trials. Manufacturers of spinal immobilisation devices were also contacted for information. Searches were last updated in July 2007.

Selection criteria

Randomised controlled trials comparing spinal immobilisation strategies in trauma patients with suspected spinal cord injury. Trials in healthy volunteers were excluded.

Data collection and analysis

We independently applied eligibility criteria to trial reports and extracted data.

Main results

We found no randomised controlled trials of spinal immobilisation strategies in trauma patients.

Authors' conclusions

We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological 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 immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded. Large prospective studies are needed to validate the decision criteria for spinal immobilisation in trauma patients with high risk of spinal injury. Randomised controlled trials in trauma patients are required to establish the relative effectiveness of alternative strategies for spinal immobilisation.

摘要

背景

創傷病人的脊椎固定

脊椎固定要用到一些器材和策略來固定受傷後的脊柱,以避免脊髓的損傷。在懷疑脊髓損傷的到院前處置,這種做法普遍被推薦和廣泛用於創傷患者。

目標

對於創傷病患使用不同的脊椎固定(包括固定對照不固定)方法來量化對於死亡率,神經失能,脊椎穩定性及副作用的效果。

搜尋策略

我們檢索Cochrane Central Register of Controlled Trials (CENTRAL),the Cochrane Injuries 的專科登記資料庫,MEDLINE,EMBASE,CINAHL,PubMed,National Research Register以及Zetoc。我們檢閱所有文章的參考文獻並連絡該領域專家以確認合格的試驗。另外也連絡脊椎固定設備的廠商以獲得相關資訊。最近一次更新檢索是在2007年7月。

選擇標準

比較脊椎固定策略對脊髓可能受傷之創傷病患的隨機對照試驗。試驗排除健康的自願者。

資料收集與分析

我們分別將合格標準應用於試驗的報告並摘錄資料。

主要結論

我們沒有發現創傷病患使用脊椎固定策略的隨機對照試驗。

作者結論

我們沒有發現任何符合納入標準的隨機對照試驗。創傷病患其脊椎固定對於死亡率,神經失能,脊椎穩定度及副作用的效果仍不明確。因為氣管阻塞是預防創傷病患死亡的主要原因,而脊椎固定,特別是頸椎,可以促進氣管緩和,但也不能排除固定也許會增加死亡率和發病率的可能性。需要大量的前瞻性研究以驗證脊髓損傷高風險之創傷病患其脊椎固定的決定標準。隨機對照試驗需建立創傷病患使用其他脊椎固定策略的相對效果。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

創傷病人的脊椎固定 因為受傷造成的脊髓傷害會導致長期的失能且對生活品質有重大的影響。目前將創傷病人在到院前固定脊椎以避免更多的傷害的做法也許並不那麼必要,因為造成更嚴重傷害的可能性很小。固定的方法包括維持頭部在中線上,圓木滾動病患,使用背板及特殊的床墊,頸圈,沙袋及皮帶。這些過程可能會造成身體組織的壓力且不舒服,吞嚥困難及嚴重的呼吸問題。回顧的作者無法發現任何創傷病患使用脊椎固定策略的隨機對照試驗。比較不同脊椎固定策略的試驗是可行的。研究中健康的自願者被視為是有意識的病患,也許他們會移動姿勢以緩解因為固定所造成的不舒服,理論上它可能會使現有的脊髓傷害更加嚴重。

Plain language summary

Spinal immobilisation for trauma patients

Spinal cord damage from injury causes long-term disability and can dramatically affect quality of life. The current practice of immobilising trauma patients before hospitalisation to prevent more damage may not always be necessary, as the likelihood of further damage is small. Means of immobilisation include holding the head in the midline, log rolling the person, the use of backboards and special mattresses, cervical collars, sandbags and straps. These can cause tissue pressure and discomfort, difficulty in swallowing and serious breathing problems.

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.

Background

The incidence of spinal cord injury (SCI) in the USA is estimated to be between 40 and 50 cases per million people per year (SCI Center 1998). Spinal cord injury results in long-term disability, often with profound effects on the quality of life of the affected individuals and their carers. In the USA, the lifetime medical costs resulting from spinal cord injury are estimated at nine billion dollars per year (Miller 1994). Existing data in developing countries are limited. A study from Beijing estimated the incidence of SCI at seven cases per million people per year (Wang 1990). Acute traumatic SCI occurs in about 3% of trauma admissions, and around half of these injuries involved the cervical spine (Burney 1993). In males under the age of 50, road traffic crashes are the most common cause of SCI (Burney 1993).

In response to the concern that an unstable spine will increase the frequency and severity of neurological injury, a number of approaches have been developed that aim to achieve spinal immobilisation. The two main methods are manual stabilisation and the use of orthotic devices such as backboards and splints, with a combination of adjuncts including cervical collars, sandbags and straps. Pre-hospital spinal immobilisation aims to stabilise the spine by restricting mobility, thus preventing secondary SCI during extrication, resuscitation, transport and evaluation of trauma patients with suspected spinal instability. It is estimated that 5% of trauma patients with cervical spinal injuries have missed or delayed diagnosis (Davis 1993), resulting in preventable mortality and morbidity. Occult cervical spine injuries may be more likely to be missed in obtunded patients with unstable spines, in whom it may be masked by the pain of multi-system injury and altered level of alertness. Spinal immobilisation is now routinely practised in the pre-hospital care of trauma patients and is widely recommended in a range of resuscitation guidelines (Advanced LS 1993, Advanced Paediatric Life Support, Pre-hospital Trauma Life Support, Advanced Life Support Group 1993, ACS 1997).

Despite the widespread use of spinal immobilisation, the clinical benefits of pre-hospital spinal immobilisation have been questioned. It has been argued that spinal cord damage is done at the time of impact and that subsequent movement is generally not sufficient to cause further damage (Hauswald 1998). Most trauma patients do not have spinal instability and, hence, will not benefit from spinal immobilisation. Nevertheless, largely in response to the fear of litigation, some five million patients in the US receive spinal immobilisation every year (Orledge 1998). However, there may be adverse effects. Observational studies have shown that rigid collars may cause airway difficulties, increased intracranial pressure (Davies 1996), increased risk of aspiration (Butman 1996), restricted respiration (Totten 1999), dysphagia (Houghton 1996) and skin ulceration (Hewitt 1994). Because any benefits of spinal immobilisation may be outweighed by the risks, the value of routine pre-hospital spinal immobilisation remains uncertain.

This systematic review aims to quantify the effect of different spinal immobilisation devices (including immobilisation versus no immobilisation) on their ability to immobilise the spine and on mortality, neurological injury, and adverse effects in trauma patients.

Objectives

  • To quantify the effect of spinal immobilisation versus no spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients.

  • To quantify the effect of different spinal immobilisation strategies on mortality, neurological injury, spinal stability and adverse effects in trauma patients.

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials.

Types of participants

Trauma patients with suspected spinal cord injury.

Types of interventions

All strategies of spinal immobilisation including:

  • backboards, mattress splints

  • rigid and soft collars

  • sandbags, straps or tapes

  • collar and backboard combinations

  • holding the head in the midline

  • log rolling the patient.

Types of outcome measures

  • Mortality.

  • Neurological injury.

  • Degree of spinal stability.

  • Adverse effects.

Search methods for identification of studies

Electronic searches

We searched the following electronic databases;

  • Cochrane Injuries Group's specialised register

  • Cochrane Central Register of Controlled Trials (CENTRAL)

  • MEDLINE

  • EMBASE

  • CINAHL

  • National Research Register

  • ZETOC

  • http://www.clinicaltrials.gov

  • http://www.controlled-trials.com/mrct

These searches were last carried out in July 2007. The full search strategies are presented in the additional tables: Table 1 shows search strategies used previously in May 2003, Appendix 1 shows strategies used for the July 2007 update.

Table 1. Previous search strategies May 2003
May 2003
Cochrane Central Register of Controlled Trials (CENTRAL 2003,issue 2)
1. SPINE:TI or SPINAL:TI or CERVIX:TI or CERVICAL:TI or LUMBAR:TI or THORA*:TI or NECK:TI or WHIPLASH:TI
2. IMMOBILI*:TI or STABILI*:TI or STABLE:TI or COLLAR*:TI or BACKBOARD:TI or SPLINT*:TI or BOARD*:TI or STRAPPING:TI or STRAPPED:TI
3. HEADBLOCK:TI or SANDBAG:TI or ORTHOSIS:TI or ORTHOTIC:TI or BRACE*:TI
4. (#1 and #2) or #3
MEDLINE (1966-2003.5)
1. explode spine/ all subheadings
2. explode spinal injuries/ all subheadings
3.explode spinal cord injuries/ all subheadings
4. spine or spinal or cervix or cervical or lumbar or thora*
5. neck or whiplash
6. #1 or #2 or #3 or #4 or #5
7. immobili* or mobility
8. explode immobilization/ all subheadings
9. stabili*
10. collar*
11. backboard* or vacuum splint* or neutral position or strapping or strapped or straps or spine board* or tapes or taping
12. headblock* or sandbag* or (kendrick in ti,ab) or orthosis
13. orthotic
14. brace*
15. spine board* or splint*
16. #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15
17. log rol*
18. #16 or #17
19. #18 and #6
20. controlled clinical trial* or randomi* or explode research design / all subheadings or double blind or placebo or meta-analysis or metaanalys* or (clinical trial in pt)
21. #19 and #20
EMBASE (1966-2003.4)
1. explode spine/ all subheadings
2. explode "spinal-cord-injury"/ all subheadings
3. "cervical-spine-injury"/ all subheadings
4. explode "spine-injury"/ all subheadings
5. spine or spine or cervix or cervical or lumbar or thora*
6. neck or whiplash
7. #1 or #2 or #3 or #4 or #5 or #6
8. immobil* or mobility
9. stabili* or stable or collar*
10. backboard* or vacuum splint* or neutral position* or strapping or strapped or straps or spine board* or tapes or taping
11. headblock* or sandbag* or (kendrick in ti,ab) or orthodos* or orthotic* or brace*
12. spine board or splint* or halo
13. #8 or #9 or #10 or #11 or #12
14. #7 and #13
15. trial* or randomi*
16. double blind or placebo*
17. meta-analys* or metaanalys*
18. explode clinical trial/ all subheading
19. explode controlled study/ all subheadings
20. control*
21. #15 or #16 or #17 or #18 or #19 or #20
22. #21 and #14
23. human in de
24. nonhuman in de
25. #24 not (#24 and #23) *
26. #22 not #25
CINAHL (1982-2000.3)
1. (spine or spine or cervix or cervical or lumbar or thora*) in ti,ab,de
2. (neck or whiplash) in ti,ab,de
3. (immobil* or mobility) in ti,ab,de
4. (stabili* or stable or collar*) in ti,de,ab
5. (backboard* or vacuum splint* or neutral position* or strapping or strapped or straps or spine board* or tapes or taping) in ti,de,ab
6. (headblock* or sandbag* or (kendrick in ti,ab) or orthodos* or orthotic* or brace*) in ti,ab,de
7. (spine board or splint* or halo) in ti,de,ab
8. (trial* or randomi* or double blind or placebo*) in ti,ab,de
9. (meta-analys* or metaanalys* or control*) in de,ti,ab
10. #1 or #2
11. #3 or #4 or #5 or #6 or #7
12. #8 or #9 *
13. #10 and #11 and #12

Searching other resources

Additionally all references in the background papers were checked and six authors contacted to identify potential published or unpublished data. Eight manufacturers of immobilisation devices were also contacted. There was no language restriction in any of the searches.

Data collection and analysis

Selection of studies

One author (IK) examined the electronic search results for reports of possibly relevant trials and these reports were then retrieved in full. One author (FB) examined 10% of the electronic search results to check for agreement on eligibility criteria. Two authors (FB, IK) applied the selection criteria independently to the trial reports, resolving disagreements by discussion with a third author (IR).

The following are the proposed methods which will be applicable if trials are found during subsequent updates of the review.

Data extraction and management

Two authors will independently extract data and information on the following:

  • method of allocation concealment,

  • number of randomised patients,

  • type of participants,

  • type of interventions,

  • loss to follow-up,

  • length of follow-up.

The authors will not be blind to the study authors or journal when doing this. Results will be compared and any differences resolved by discussion.

Where there is insufficient information in the published report, we will attempt to contact the trial authors for clarification.

Assessment of risk of bias in included studies

Since there is evidence that the quality of allocation concealment particularly affects the results of studies (Schulz 1995), two authors will score this quality on the scale used by Schulz as shown below, assigning C to poorest quality and A to best quality:

  • A = trials deemed to have taken adequate measures to conceal allocation (that is, central randomisation; serially numbered, opaque, sealed envelopes; or other description that contained elements convincing of concealment)

  • B = trials in which the authors either did not report an allocation concealment approach at all or reported an approach that did not fall into one of the other categories.

  • C = trials in which concealment was inadequate (such as alternation or reference to case record numbers or to dates of birth).

If the method used to conceal allocation is not clearly reported, the trial author(s) will be contacted, if possible, for clarification.

Differences will be resolved through discussion.

We will assess the skewness of continuous data by checking the mean and standard deviation (if available). If the standard deviation is more than twice the mean for data with a finite end point, the data are likely to be skewed and it is inappropriate to apply parametric tests (Altman 1996). This is because the mean is unlikely to be a good measure of central tendency. If parametric tests cannot be applied, we will tabulate the data.

Assessment of heterogeneity

The groups of trials will be examined for statistical evidence of heterogeneity using a chi-squared test. If there is no obvious heterogeneity on visual inspection or statistical testing, pooled RR and 95% confidence intervals will be calculated using a fixed effects model.

Data synthesis

The following comparisons are proposed;

  • spinal versus no spinal immobilisation,

  • different strategies of spinal immobilisation.

For dichotomous outcomes, such as death, the relative risk (RR) will be calculated with 95% confidence intervals, such that a RR of more than 1 indicates a higher risk of death in the first group named. The RR will be used as it is more readily applied to the clinical situation.

Sensitivity analysis

The effect of excluding trials judged to have inadequate (scoring C) allocation concealment will be examined in a sensitivity analysis.

Results

Description of studies

See: Characteristics of excluded studies.

No randomised controlled trials comparing the effect of spinal immobilisation strategies on trauma patients were found.

Risk of bias in included studies

Not applicable.

Effects of interventions

Our search strategy identified 4453 potentially eligible reports. However, there were no trials meeting the inclusion criteria. A number of randomised controlled trials were identified comparing different spinal immobilisation strategies in healthy volunteers. The results of randomised 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 our inclusion criteria, we have summarised them in the additional tables (Table 2) of the review.

Table 2. Table of randomised controlled trials on healthy volunteers
AuthorsTitleType of studyParticipantsInterventionOutcome measuresResults
Black 1998Comparative study of risk factors for skin breakdown with cervical orthotic devices: Philadelphia and AspenRandomised controlled trial20 healthy volunteersPhiladelphia collar
vs
Aspen Collar
Skin breakdownNo significant difference in occipital pressure and skin temperature between collars. Significant increase in relative skin humidity with Philadelphia Collar (P<0.001)
Chan 1996Comparative study of risk factors for skin breakdown with cervical orthotic devices: Philadelphia and AspenRandomised controlled trial37 healthy volunteersStifNeck collar + Standard backboard
vs
StifNeck collar + Vacuum mattress splint
PainSubjects significantly more likely to complain of pain when immobilised on a backboard than on a vacuum mattress splint (P<0.001).
Cline 1985Comparative study of risk factors for skin breakdown with cervical orthotic devices: Philadelphia and AspenRandomised controlled trial97 healthy volunteersPhiladelphia collar
vs
Philadelphia collar + short board
vs
Hare extrication collar
vs
Hare extrication collar + short board
vs
rigid plastic collar
vs
rigid plastic collar + short board
vs
short board only
Immobilisation efficacy measured radiographicallySignificant reduction in spinal mobility with the short board technique (P<0.001).
Cordell 1995Pain and tissue-interface pressures during spine-board immobilisationRandomised controlled trial20 healthy volunteersCollar + Spine board with air mattress
vs
Collar + Spine board without mattress
Pain
Contact pressure
Significant increase in pain and tissue-interface pressures on spine board without air mattress (P<0.05)
Graziano 1987A radiographic comparison of prehospital cervical immobilisation methodsRandomised controlled trial45 healthy volunteersStifNeck Collar
vs
Short board technique
vs
Kendrick Extrication Device
vs
Extrication Plus-One
Degree of immobilisation efficacy measured radiographicallySignificant increase in cervical immobilisation efficacy with the Kendrick Extrication Collar and the Extrication Plus-One (P<0.05).
Hamilton 1996The efficacy and comfort of full-body vacuum splints for cervical immobilisationRandomised controlled trial26 healthy volunteersStifneck collar + backboard
vs
Backboard
vs
Stifneck collar + vacuum splint
vs
Vacuum splint
Degree of immobilisation efficacy and comfortSignificant increase in immobilisation efficacy and comfort with the vacuum splint (P<0.05).
Johnson 1996Comparison of a vacuum splint device to a rigid backboard for spinal immobilisationRandomised controlled trial30 paramedic studentsCollar + vacuum splint
vs
Collar + backboard
vs
Vacuum splint only
vs
Backboard only
Degree of immobilisation, comfort and speed of applicationNo significant difference in degree of immobilisation with the vacuum splint and the backboard, with or without collar.
Significant faster application with the vacuum splint than the backboard (P<0.001).
Significant improvement in comfort with the
Vacuum splint (P<0.001).
Lerner 1998The effects of neutral positioning with and without padding on spinal immobilisation of healthy subjectsRandomised controlled trial39 healthy volunteersCollar + backboard with occipital padding
vs
Collar + backboard without occipital padding
Incidence and severity of painNo significant decrease in incidence and severity of pain between padded and unpadded wooden backboard.
Lunsford 1994The effectiveness of four contemporary cervical orthosis in restricting cervical motionRandomised controlled trial10 healthy volunteersNo collar
vs
Philadelphia collar
vs
Miami J collar
vs
Malibu collar
vs
Newport collar
Degree of cervical motion measured with video framesSignificant reduced motion with each orthosis than 'no orthosis' (P<0.05).
Significant more restriction in mobility with the Malibu collar (P<0.05).
Perry 1999The efficacy of head immobilisation techniques during simulated vehicle motionRandomised controlled trial6 healthy volunteersStifNeck collar + roller towel + fracture board
vs
StifNeck collar + headbed + fracture board
vs
StifNeck collar + wedge + fracture board
Efficacy of head immobilisation techniquesNo effect in eliminating head movements with any of these techniques.
Totten 1999Respiratory effects of spinal immobilisationRandomised crossover trial39 healthy volunteersVacuum collar + vacuum mattress
vs
StifNeck collar + wooden board
Respiratory effectsSignificant respiratory restriction with whole-body spinal immobilisation compared with baseline (P<0.001).
No significant difference in respiratory restriction with both wooden board and vacuum mattress.
Delbridge 1993Discomfort in healthy volunteers immobilised on wooden backboards and vacuum mattress splints (Abstract)Randomised controlled trial12 healthy volunteersWooden backboard
vs
Vacuum mattress splint
Degree of discomfortSignificantly less discomfort with vacuum mattress splints (P<0.05).
Walton 1995Padded vs unpadded spine board for cervical spin immobilisationRandomised controlled trial30 healthy volunteersFoam-padded spine board
vs
Unpadded spine board
Comfort
Immobilisation efficacy
Sacral tissue oxygenation
Significantly less discomfort with padded spine board (P=0.024).
No significant difference in cervical range of motion.
No significant difference in sacral tissue oxygenation.
Mazolewski 1994The effectiveness of strapping techniques in spinal immobilisationRandomised controlled trial19 healthy volunteersBackboards with 4 torso strapping techniquesReduction in lateral motionSignificant improved lateral motion restriction
with addition of abdominal straps (P<0.05).
Manix 1995aComparison of prehospital cervical immobilisation devices using video and electromyographyRandomised controlled trial20 healthy volunteersCorrugated board (A)
vs
Reusable foam board (B)
vs
Tape with towel rolls (C)
Relevant evaluation criteria:
Motion restriction
Ease of application
Patient access
Environmental testing
Radiolucency
Storage size
Significant motion restriction with A and C compared with B (P<0.05).
Jedlicka 1999A comparison of the effects of two methods of spinal immobilisation on respiratory effort in the older adultRandomised controlled trial57 older adult
volunteers
Full length wooden backboard
vs
Vacuum immobilizer device
Respiratory effortSignificant increased respiratory effort with backboard (P<0.05).
Hauswald 2000A comparison of the effects of four methods of spinal immobilisation on ischaemic painRandomised controlled trial22 adult
volunteers
Traditional backboard
vs
Backboard padded with a folded blanket
vs
Backboard padded with a 3-cm gurney mattress
vs
Backboard and mattress padded with a 6-cm eggcrate foam pad
Ischaemic painSignificant increase in comfort with padded backboards (P<0.05).

Discussion

We did not find any randomised controlled trials comparing different strategies of spinal immobilisation in trauma patients. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients therefore remains uncertain.

We screened 4453 potentially relevant papers, checked their reference lists and contacted experts in the field. We also contacted manufacturers of immobilisation devices for additional information. While it is possible that we might have missed a randomised controlled trial comparing spinal immobilisation techniques in trauma patients, we believe that, due to our thorough search strategy, this is unlikely.

The current protocol for pre-hospital spinal immobilisation has a strong historical rather than scientific precedent, based on the concern that a patient with an injured spine may deteriorate neurologically without immobilisation. The medical and legal concern of missing a cervical spinal injury has lent strong support for the conservative approach of liberal pre-hospital spinal immobilisation to almost all patients with trauma and possible neck injury, regardless of clinical complaint (Butman 1996). It is also suggested that iatrogenic cord damage could be reduced with better paramedic training and improved immobilisation procedures (Perry 1999). However, it has been argued that considerable force is required to fracture the spine at the initial impact, and that any subsequent movements of the spine are unlikely to cause further damage to the spinal cord (Hauswald 1998). It has also been suggested that pre-hospital spinal immobilisation has never been shown to affect outcome and that estimates in the literature regarding the incidence of neurological injury due to inadequate immobilisation may have been exaggerated (Hauswald 1998; Hauswald 2000). This calls into question the present routine use of pre-hospital spinal immobilisation.

For some patients, effective spinal immobilisation is prudent and can be vital to prevent the devastating effects of cord damage, yet for many the excessive use of this precaution may not be beneficial or necessary. It is estimated that over 50% of trauma patients with no complaint of neck or back pain were transported with full spinal immobilisation (McHugh 1998). Unwarranted spinal immobilisation can expose patients to the risks of iatrogenic pain, skin ulceration, aspiration and respiratory compromise, which in turn can lead to multiple radiographs, resulting in unnecessary radiation exposure, longer hospital stay and increased costs. The potential risks of aspiration and respiratory compromise are of concern because death from asphyxiation is one of the major causes of preventable death in trauma patients.

A set of highly sensitive clinical criteria has been developed and validated (Hoffman 2000) to identify trauma patients at low risk of spinal injury and rule out their need for radiography. These are trauma patients with absence of: neck pain or tenderness, altered level of consciousness, neurological deficit, evidence of intoxication and painful distracting injury. It has been suggested that a similar decision instrument could be developed for use in the pre-hospital setting, to establish the need to immobilise or not to immobilise (Domeier 1999). This is in addition to the criteria of mechanism of injury as the main determinant for out-of-hospital spinal immobilisation.

There are a lack of data from randomised controlled trials to support the practice of pre-hospital spinal immobilisation in trauma patients. While it may not be possible to conduct randomised controlled trials of spinal immobilisation versus no immobilisation in trauma patients, it may be feasible to consider such trials, comparing the different spinal immobilisation strategies, in outcomes of immobilisation efficacy, respiratory effects, tissue pressure and patient comfort in this target population. Results of randomised 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 our inclusion criteria we have summarised them in the additional tables section of the review. For example in healthy volunteers, short-board technique was reported to be more efficient than collars alone in reducing spinal mobility (Cline 1985); vacuum mattress and padded backboards more comfortable than rigid backboards (Hamilton 1996; Hauswald 2000; Johnson 1996; Walton 1995). From these studies on healthy volunteers, it has been suggested that patients on whom spinal immobilisation has been used, and who are conscious, might reposition themselves to relieve the discomfort caused by ischaemia, which could theoretically worsen any existing spinal injuries. Patients who are unable to move or feel pain due to trauma are at risk of soft tissue injuries (Hauswald 2000).

Due to the absence of randomised controlled trials quantifying the effect of spinal immobilisation in trauma patients, and the possible adverse effects of its application, the value of routine pre-hospital spinal immobilisation remains uncertain.

Authors' conclusions

Implications for practice

We found no randomised controlled trial which met our inclusion criteria in this review. The effect of pre-hospital spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients therefore remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation (particularly of the cervical spine) can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded.

Implications for research

Large prospective studies are needed to validate the decision criteria for spinal immobilisation in trauma patients with high risk of spinal injury. In addition, randomised controlled trials to compare different immobilisation strategies on trauma patients need to be considered in order to establish an evidence base for the practice of pre-hospital spinal immobilisation.

Acknowledgements

We thank D Mohan, C Mock, R Norton and M Varghese of the WHO Pre-hospital Trauma Care Steering Committee for their comments and advice on the review.

We also thank R Wentz and K Blackhall for help with the searching, and Dr Jegede for help identifying useful background papers.

Finally, thanks to the authors of background papers and manufacturers for supplying additional information.

Data and analyses

Download statistical data

This review has no analyses.

Appendices

Appendix 1. Search strategy

July 2007 update search strategies

INJURIES SPEICALISED REGISTER
(spine or spinal) AND (immobile or immobilize or immobilization or stabili* or stable or brace or splint*)

MEDLINE 2007/June week 4
1.exp Spinal Injuries/
2.exp Spinal Cord Injuries/
3.((spine or spinal or cervix or cervical or lumbar or thora$) adj3 (injur$ or trauma$)).ab,ti.
4.whiplash.ab,ti.
5.or/1-4
6.exp Immobilization/
7.exp Orthotic Devices/
8.(backboard$ or vacuum splint$ or neutral position or strapping or strapped or straps or spine board$ or tapes or taping or log roll$).ab,ti.
9.(headblock$ or sandbag$).ab,ti.
10.or/6-9
11.5 and 10
12.(randomised or randomized or randomly or random order or random sequence or random allocation or randomly allocated or at random or controlled clinical trial$).tw,hw.
13.clinical trial.pt.
14.12 or 13
15.exp models, animal/
16.exp Animals/
17.exp Animal Experimentation/
18.exp Disease Models, Animal/
19.exp Animals, Laboratory/
20.or/15-19
21.Humans/
22.20 not 21
23.14 not 22
24.11 and 23

EMBASE 2007/ week 27
1.exp Spinal Cord Injury/
2.exp Spine Injury/
3.((spine or spinal or cervix or cervical or lumbar or thora$ or neck) adj5 (injur$ or trauma$)).ab,ti.
4.whiplash.ab,ti.
5.or/1-4
6.exp IMMOBILIZATION/
7.exp ORTHOTICS/
8.(backboard$ or vacuum splint$ or neutral position or strapping or strapped or straps or spine board$ or tapes or taping).ab,ti.
9.(headblock$ or sandbag$ or orthosis or orthotic or brace$ or splint).ab,ti.
10.(immobili$ or mobility or stabili$ or collar$ or log roll$).ab,ti.
11.or/6-10
12.5 and 11
13.exp animal model/
14.Animal Experiment/
15.exp ANIMAL/
16.exp Experimental Animal/
17.13 or 14 or 15 or 16
18.Human/
19.17 not 18
20.(randomised or randomized or randomly or random order or random sequence or random allocation or randomly allocated or at random or controlled clinical trial$).tw,hw.
21.exp clinical trial/
22.20 or 21
23.22 not 19
24.12 and 23

Central 2007, issue 2 and National Research Register 2007, issue 2
#1MeSH descriptor Spinal Injuries explode all trees #2MeSH descriptor Spinal Cord Injuries explode all trees
#3injur* and (spine or spinal or cervix or cervical or lumbar or thora* or neck)
#4trauma* and (spine or spinal or cervix or cervical or lumbar or thora* or neck)
#5whiplash
#6(#1 OR #2 OR #3 OR #4 OR #5)
#7MeSH descriptor Immobilization explode all trees
#8MeSH descriptor Orthotic Devices explode all trees
#9immobili* or mobility or stabili* or collar* or orthotic or orthosis or brace* or splint*
#10backboard* or vacuum splint* or neutral position or strapping or strapped or straps or spine board* or tapes or taping or log roll*
#11headblock* or sandbag*
#12(#7 OR #8 OR #9 OR #10 OR #11)
#13(#6 AND #12)
#14(#13), from 2003 to 2007

www.clinicaltrials.gov and http://www.controlled-trials.com/mrct
(spine or spinal) AND ( immobile OR immobilize or immobilization or stabilize or stable or brace or splint ) [ALL-FIELDS]

ZETOC
Searched 11-07-07
spinal* immobil* trial*
or
spine* immobil* trial*
or
spinal immobil* random*
or
spine* immobil* random*

What's new

DateEventDescription
11 September 2008AmendedConverted to new review format.

History

Protocol first published: Issue 3, 2000
Review first published: Issue 2, 2001

DateEventDescription
8 August 2007New search has been performedAugust 2007
An updated search was conducted in July 2007. No new randomised controlled trials comparing spine immobilisation strategies in trauma patients with suspected spinal cord injury were identified.

Contributions of authors

IK helped to design the protocol, examined search results, applied inclusion criteria and wrote the review. FB examined search results, applied inclusion criteria, and helped to write the review. IR commented on the protocol and helped to write the review.

Declarations of interest

None known.

Sources of support

Internal sources

  • Institute of Child Health, University of London, UK.

External sources

  • Global Programme on Evidence for Health Policy (GPE), World Health Organisation, Switzerland.

Characteristics of studies

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Black 1998Participants were healthy volunteers.
Chan 1996Participants were healthy volunteers.
Cline 1985Participants were healthy volunteers.
Cordell 1995Participants were healthy volunteers.
Delbridge 1993Participants were healthy volunteers.
Graziano 1987Participants were healthy volunteers.
Hamilton 1996Participants were healthy volunteers.
Hauswald 2000Participants were healthy volunteers.
Jedlicka 1999Participants were healthy volunteers.
Johnson 1996Participants were healthy volunteers.
Lerner 1998Participants were healthy volunteers.
Lunsford 1994Participants were healthy volunteers.
Manix 1995aParticipants were healthy volunteers.
Manix 1995bParticipants were healthy volunteers.
Mazolewski 1994Participants were healthy volunteers.
Perry 1999Participants were healthy volunteers.
Totten 1999Participants were healthy volunteers.
Walton 1995Participants were healthy volunteers.

Ancillary