the surgeon 8 (2010) 218222

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The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland
www.thesurgeon.net

Review

Routine spinal immobilization in trauma patients: What are the advantages and disadvantages?
S. Abram, C. Bulstrode*
Nufeld Department of Rheumatological Medicine and Surgery, University of Oxford, Level 2 Emergency Department, John Radcliffe 2 Hospital, Headington, Oxford OX3 9DU, UK

article info
Article history: Received 14 October 2009 Accepted 12 January 2010 Keywords: Spine Immobilization Cervical vertebrae Multiple trauma

abstract
Routine spinal immobilization for trauma patients has become established in developed countries throughout the world. Cervical spinal injury is, however, relatively rare in trauma patients, and immobilization practice was developed largely without rm supporting evidence. In recent years, published evidence has suggested that spinal immobilization may in some cases be harmful. The purpose of this article is to critically review the evidence and the implications for trauma patient management and outcomes. We searched MEDLINE, the Cochrane Database, Index Medicus and article references with a broad search strategy. Relevant results were analysed and critically reviewed in the context of trauma patient management. Our ndings present a growing body of evidence documenting the risks and complications of routine spinal immobilization. There is a possibility that immobilization could be contributing to mortality and morbidity in some patients and this warrants further investigation. 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

1.

Introduction

Since the rst course in 1978, Advanced Trauma Life Support (ATLS) has spread and been adopted by over 50 countries.1 A key recommendation of ATLS is routine cervical spine immobilization. This recommendation was developed because it was believed that immobilizing the spine would be the best way to prevent injury to the spinal cord following a traumatic injury,2 and that therefore it was in the best interests of all patients whose injuries had not yet been assessed. Cervical spinal injury is, however, relatively rare in trauma patients, occurring in around 2% of admissions.3 Furthermore,

the practice of cervical spine immobilization has little evidence base.4 Spine immobilization carries risk for both patient and paramedics in that it may delay extraction from a dangerous area, and may compromise the teams ability to maintain a safe airway. It can also be very uncomfortable for the patient especially if the immobilization is prolonged. Spinal cord injury is a severe and life-threatening complication of trauma. Furthermore, litigation associated with errors in spinal management that result in cord injury is costly, with average payouts in the region of $3 million in the United States.5 For these reasons, managing the risk of spinal cord injury in trauma patients is an understandable concern for medical professionals. Combined with the belief that

* Corresponding author. Tel.: 44 01865 220233; fax: 44 01865 221766. E-mail address: christopher.bulstrode@ndorms.ox.ac.uk (C. Bulstrode). 1479-666X/$ see front matter 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2010.01.002

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spinal immobilization was a relatively benign procedure, this practice became central to trauma patient management protocol. There is now, however, growing evidence that this approach can be harmful. The purpose of this paper is to critically review the evidence surrounding routine spinal immobilization. This evidence is presented with discussion of the implications in the context of trauma patient management and outcomes. It is not possible to perform a direct risk/benet analysis because, for obvious reasons, it is not possible to determine how many cord injuries have been prevented by spine immobilization.

2.

Methods

We searched MEDLINE from 1950 to 2009 with the Web of Science server. Keywords included the MeSH terms immobilization and spine and the text terms trauma, cervical immobilization, spinal immobilization, inline stabilization, cervical collar and cervical spine injury. Further searches were performed for the topics of airway management, neurological deterioration, head injury, unstable injuries and delayed diagnosis. Articles referenced by papers passing initial screening were also screened for relevance. In addition to MEDLINE, the databases of the Cochrane Library were searched. We reviewed the relevant evidence based implications of the ndings of all studies in the context of the management of trauma patients as a whole, and for the subset of patients with cervical spinal injuries.

3.
3.1.

Results
Possible benets

Several authors have attempted to establish the natural history of a spinal fracture that is not immobilized before diagnosis. Davis et al. performed a retrospective study in San Diego analysing cervical spine management in 32,117 trauma patients.3 They identied 740 (2.3%) patients with cervical spine injuries and, of these, 34 patients (4.6%) for whom the diagnosis was delayed. In these patients, 10 (29%) developed permanent neurological sequelae (death, quadriplegia, hemiplegia, or decit).3 If one assumes the same rate of deterioration would have occurred if all the cervical spinal injuries had been left unprotected, the number needed to treat (NNT) to prevent one incident of permanent neurological sequelae is 150. Platzer et al. analysed the records of 347 patients with cervical spinal injuries. There was delayed diagnosis in 18 patients (4.9%) and neurological symptoms developed in 8 (44%) of these patients, however only 2 (11.1%) developed a permanent decit.6 Assuming a similar, 2.3%, rate of cervical spinal injuries in trauma patients,3 the NNT calculated as above is 392. Other authors, however, have been unable to identify lasting complications in those with missed cervical fractures. Gerrelts et al. found no permanent complications in those

with delayed diagnosis of cervical spine fractures. The imaging of 1331 trauma patients was reviewed effectively excluding those patients for whom the spine was cleared clinically without imaging. Sixty-one patients (4.6%) had cervical spinal injuries; diagnosis was initially missed and made between 2 and 21 days after injury in 5 of these patients (8.2%). Two presented due to neck pain and three due to subtle neurological symptoms, but none developed permanent neurological decits.7 It has been suggested that the risk of neurological injury due to inadequate immobilization may be over-estimated.8 Evidence supporting this view includes a 5-year retrospective study carried out by Hauswald et al. The neurological outcomes for patients in a Malaysian hospital practicing no routine pre-hospital immobilization were compared to those in New Mexico where all trauma patients have spinal immobilization. Two physicians acting independently and blinded to the hospital of origin categorised neurological injury in patients into disabling or non-disabling. According to the authors, both hospitals had comparable patient groups, physician training and resources. Deterioration occurred less frequently and there was less overall neurological disability in the Malaysian patients.9 The authors suggest that, as a large amount of force is required to damage the spine and injure the spinal cord, movements during transport are unlikely to generate sufcient energy to result in additional injury.9 There were several weaknesses in this study. Patients who died at the scene or during transport were excluded, and the patient numbers (120 in the Malaysian group) may have been insufcient to detect a protective effect from the use of spinal orthoses. Also, whilst the Malaysian patients were most commonly injured in falls from heights, the New Mexico patients were most commonly injured in motor vehicle accidents.9 Neurological deterioration in those with spinal cord injury occurs in around 5% of patients even with good immobilization of the spine.10 Excluding mechanical injury, there are wellestablished mechanisms for spinal injury progression including haematoma, cord oedema, hypotension, inammation and vascular changes such as reduced microcirculation.11,12,13 Thumbikat et al. described three patients with ankylosing spondylitis (17%) who developed spinal epidural haematomas. Haematoma formation can be sufcient to cause tetraplegia, 4872 h after primary trauma.12 It should be noted, however, that the rate of spinal epidural haematoma formation is considered to be higher in ankylosing spondylitis patients than patients without the condition.12

3.2. 3.2.1.

Possible harm Ankylosing spondylitis

Some of the strongest evidence of harm from spinal immobilization practice comes from a recent 10 year retrospective review of all patients admitted for spinal cord injury (SCI) associated with ankylosing spondylitis to the Princess Royal Spinal Injuries Centre, Shefeld.12 The records of 18 patients, 15 traumatic and 3 following spinal surgery, were analysed. Twelve of the 15 trauma patients could walk immediately after the fall but subsequently deteriorated. Commonly,

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extension of the patients cervical spine during standard immobilization procedures resulted in the development of neurological decits.12 Thumbikat et al. highlighted the cases of several patients, including one patient who fell from some steps fracturing his cervical spine. He was placed in a hard collar and scoop stretcher by the ambulance crew and brought to hospital. He had normal power in all limbs on admission but later it was decided to transfer him to the specialist spinal unit. During 6-person inline transfer he complained of sudden shooting pain down one side and there was a sudden drop in blood pressure. On admission to the spinal unit he was tetraplegic.12 This patient later made a partial recovery but the case demonstrates that a standard spinal immobilization protocol can be extremely harmful to some patients. Another patient with ankylosing spondylitis and a C6C7 fracture was transported to hospital with her head on just one pillow, having been ambulant at the scene. For imaging the pillow was removed, positioning the head inline with the spine according to protocol. The patient mentioned being able to see more of the ceiling than she was used to and following the scan she was tetraplegic.12

far more common than cervical spine injury and the risks of raised intracranial pressure as a result of routine cervical spinal immobilization in this large group of patients should not be overlooked. Another risk for any immobilized patient, but particularly those immobilized for a prolonged period of time, is skin ulceration.22,23 This can occur within 48 h of a collar being tted.20

3.2.4.

Respiratory and airway management

3.2.2.

Delayed resuscitation

Hauswald et al. state that some spinal injuries are truly unstable and neurologically fragile and that these will benet from spinal immobilization. They argue, however, that often spinal injuries are stable biomechanically but neurologically unstable9 delayed resuscitation could lead to progression of these injuries. Side effects of an acute spinal cord injury include hypotension and reduced cardiac output,13 which reduce blood ow to the spinal cord. Spinal injuries are made worse by local circulation problems and there is a dose-response relationship with lower microcirculation resulting in more serious neurology.13 Spinal blood ow can be improved, however, by ensuring patients are kept normotensive and by giving nimodipine.13 Management in this way has been shown to improve spinal cord function.13 Spinally injured patients could, therefore, benet from early transfer to hospital where they can be carefully monitored and these complications treated. This transfer is commonly delayed by the pre-hospital spinal immobilization protocol, especially where a patient requires extrication from a vehicle, and this delay may be harming some patients who have spinal injuries.

3.2.3.

Head injury

Spinal immobilization has also been shown to raise intracranial pressure (ICP)14,15,16,17,18 another mechanism by which spinal immobilization could be harming neurological outcome. This rise in ICP has been found to be on average approximately 4.5 mmHg.14,17,18 Head injury is common, occurring in 34% of trauma patients, and is responsible for 27% of trauma deaths.19,20 Raised intracranial pressure is associated with worse neurological outcomes in patients suffering from head trauma.21 Patients with head injuries often have a reduced consciousness level, making it difcult to clear the cervical spine and leading to prolonged immobilization. Head injury is

Both the use of a hard collar, straps, and sandbags, as well as manual inline stabilization (MILS) compromise the ability to protect an airway. Heath et al. showed that the use of a combination of a hard collar, straps and sandbags reduced the view for laryngoscopy compared to MILS. In 56% of patients, moving to manual stabilization improved the view by one grade, and in 10% by two grades.24 MILS also impedes endotracheal intubation and is associated with increased failure rates. In a randomized controlled trial in elective surgical patients, intubation failed after 30 s in 50% of patients with MILS compared to 5.7% of those without stabilization.25 Gruen et al. examined the causes of trauma mortality in 44,401 patient admissions. There were 2594 deaths (5.8%) and errors were made in 64 patients (2.5%). One error was failure to secure an airway and this occurred in 16% of the 64 patients.26 The force applied by the laryngoscope blade during endotracheal intubation is transferred to the cervical spine.27 It was believed that MILS would reduce the force applied to the cervical spinal cord, however there is evidence that this may not be the case. Santoni et al. demonstrated that MILS doubles the force that must be applied during endotracheal intubation as well as conrming that it increases failure rates.28 The majority of these studies were done in controlled conditions utilising experienced anaesthetists in paralysed patients preparing for elective surgery who were selected as being low risk for difcult intubation. In an acute trauma environment, failure rates will almost certainly be higher and clinicians working under the pressure of time may apply even greater force with the laryngoscope. Santoni et al. reviewed the evidence for MILS and found that, although it may reduce movement in the cervical spine when there is no fracture present, there is little evidence that it does so when an unstable injury is present. In cadavers with unstable cervical spinal injuries, MILS during endotracheal intubation was found to either have no effect on cervical spinal movement or to increase movement at the injury site.28 A recent trial by Turner et al. failed to demonstrate a signicant effect of MILS on the motion of an unstable cervical injury in a cadaver model.29 Neurological deterioration during endotracheal intubation with MILS is exceptionally rare,30 however this does not preclude the possibility of MILS increasing the forces applied and the movement during intubation at the level of an unstable cervical spinal injury. As well as impeding endotracheal intubation, spinal immobilization also restricts respiratory function and increases the risk of aspiration. Patients restrained with

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a hard collar can suffer from dysphagia, resulting in an increased risk of aspiration.22 Totten et al. demonstrated that immobilization with a collar and backboard or vacuum mattress restricted measures of respiratory function by on average 15%.31 Finally, Bauer et al. showed that a long spinal board with straps signicantly impairs respiratory function.32 Respiratory failure is the cause of around 6% of trauma fatalities20 and any factors that might be increasing the frequency of respiratory failure or impeding its management should be carefully examined.

4.

Conclusion

Routine spinal immobilization in trauma patients has become established largely without an evidence base. The number needed to treat is unknown but large. There is a growing body of evidence documenting the risks and complications of this practice. There is a possibility that immobilization could be contributing to mortality and morbidity in some patients and this warrants further investigation. Improving pre-hospital criteria to determine which patients are really at high risk for needing spinal immobilization could reduce the number of patients exposed to the documented risks unnecessarily. Similarly, in the hospital setting, early assessment and clearance of the cervical spine should be considered by clinicians where possible.

Sources of nancial support

Not applicable.

references

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29. Turner CR, Block J, Shanks A, Morris M, Lodhia K, Gujar SK. Motion of a cadaver model of cervical injury during endotracheal intubation with a Bullard laryngoscope or a Macintosh blade with and without in-line stabilization. The Journal of Trauma 2009 Jul;67(1):616. 30. Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury:

historical review and current questions. Annals of Emergency Medicine 2007;50(3):23645. 31. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehospital Emergency Care 1999;3(4):34752. 32. Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary-function in the healthy, nonsmoking man. Annals of Emergency Medicine 1988 Sep;17(9):9158.