DRL Shelf: Spinal Immobilization

This is the sub-section of the Digital Research Library containing all material on the topic of spinal immobilization, C-spine injury, spinal clearance, acute care for traumatic spine injuries, and related matters.



The practice of prehospital spinal immobilization is based on physiological grounds. Since traumatic injury involving the spine often produces neurological sequelae (such as paralysis) by compromising the spinal cord, and initial hospital care for such injuries typically involves stabilization (via surgery, traction devices, or various forms of collars), it is hypothesized that some damage to the cord can be avoided if early spinal immobilization is provided by EMS.

It is agreed that many spinal cord injuries occur instantaneously at the time of initial trauma, in which case immobilization provides no benefit. It is also agreed that many spinal injuries (clinically insignificant fractures or dislocations) will never threaten the cord at any time. Prehospital immobilization is therefore meant to address middle cases: injuries which create instability in the spine that could damage the cord with the wrong movement, but have not yet done so (or at least not yet completely).

The practice has became widespread, yet has never been tested in any controlled trials. Now that it is considered standard of care, it has become nearly impossible to conduct controlled studies, since omitting immobilization is considered unethical. Only a single poorly-controlled study [Hauswald 1998] attempted to compare neurological outcomes between cohorts with and without immobilization; it showed a slight harm and no benefit associated with immobilization. There is an epidemiological argument that the incidence of complete spinal cord injuries (versus incomplete) decreased during the 1970s, when professional EMS — and hence C-spine care — became widespread in the US; some experts attribute this decrease to prehospital immobilization. Support for this claim is sparse.

Nearly all of the literature consists of observational studies (chart reviews, analyses of trauma registries, etc). Most focus on these areas:

Spinal clearance: Since spinal injury (particularly cervical spine injury) may be non-obvious, yet missing its presence is theoretically disastrous, most at-risk patients receive radiological examination in the ED. Several algorithms, particularly NEXUS and the Canadian C-spine Rule, have been developed establishing criteria to omit radiography in some low-risk patients; these have been repurposed for selective immobilization in the prehospital setting, since a patient who does not need radiography clearly does not need to be immobilized. [Search for NEXUS or Canadian.] A related body of research investigates the cause, and resulting morbidity, of missed diagnoses of spinal fracture. A sub-set of this examines the existence of “occult” C-spine fractures, which present without pain or neurological deficit; a number of case reports exist, but most have been questioned. [Search for missed, delayed, occult, or deterioration.]

Prevalence: It is useful for both prehospital and ED personnel to understand the likelihood that a given trauma patient may have a C-spine injury. A large body of work has therefore been done to determine the frequency of spinal injury among patients with head trauma, loss of consciousness, facial trauma, penetrating trauma, and various mechanisms of injury (search for desired terms). In most populations of adult blunt trauma patients, the incidence of non-trivial C-spine injury is reliably around 2%; this increases with injury severity or decreased GCS. A related group of studies examines complications of fracture other than cord damage [search for artery], and risk factors for fracture [search for ankylosing or DISH].

Effectiveness of stabilizing devices: Current standard of care for immobilization involves a combination of rigid cervical collar, blocks and tape or a head-bed device, and a hard longboard with straps. (Sandbags were often used in the past, but are now considered harmful.) Validating the effectiveness of these and other devices (scoop stretchers, vacuum splints, foam mattresses, KED, etc.) is the focus of a number of studies, often using cadavers, although some recent studies have used motion capture and live participants. As a rule, these studies are never done in vivo using true injuries. [Search for collar, extrication, board, or movement.]

Adverse effects of immobilization: Various studies, mostly small-scale trials, have demonstrated significant (although usually non-lethal) harmful effects from board-and-collar immobilization. These include pain and discomfort, development of pressure ulcers, pulmonary restriction, challenges to airway management, and most significantly, delay of transport for time-critical trauma patients. [Search for the desired terms.]

When considering research, it is important to understand that the endpoint for these studies is usually the presence of a radiologically-defined C-spine injury which experts feel could potentially damage the cord. Whether said injury has a non-trivial potential of damaging the cord prior to hospital arrival (i.e. the EMS phase) is usually not addressed. Although anecdotal reports of sudden neurological deterioration in patients with unstable C-spine fracture are widespread (“he turned his head and suddenly became paralyzed”), this has never been reported in the literature during the EMS interval; a small number of similar reports exist after hospital admission [see Harrop, Bohlman, and Davis for examples], but never before. One study [Toscano 1988] directly asserts that such injuries are common, but is terse and difficult to extrapolate from.


The following points are generally accepted, including by authorities such as the NAEMSP, PHTLS, American Association of Neurological Surgeons (AANS), and Cochrane Review:

  1. There is little to no evidence for the benefit of prehospital spinal immobilization.
  2. Despite this, its theoretical benefit, coupled with the potentially catastrophic harm — and catastrophic liability — of its absence supports its use on precautionary grounds.
  3. Penetrating trauma patients generally should not be immobilized; this has been shown to clearly increase their mortality [search for penetrating, but see especially Haut].



To view newly added material, search for the triple asterisk (***)

[5-13-13] 2 papers added

[4-18-13] 1 paper added

[4-2-13] 1 paper added

[3-26-13] Shelf created. 6 papers added.



Title Author Year Type Size Design Results Ranking
Maximizing comfort and minimizing ischemia: a comparison of four methods of spinal immobilization Hauswald M, Hsu M, Stockoff C 2000 Prospective comparative trial, non-blinded, convenience sample 22 Compared patient comfort among healthy volunteers lying upon backboards with different padding materials. More padding was more comfortable. 2
Out-of-hospital spinal immobilization: its effect on neurologic injury Hauswald M, Ong G, Tandberg D, Omar Z 1998 Retrospective cohort study 454 Chart review comparing neurological outcome in blunt spinal trauma patients between an American system with prehospital spinal immobilization and a Malaysian system without immobilization. Non-immobilized Malaysian patients had slightly but significantly better neurological outcomes. 5
Spinal immobilisation for trauma patients (Review) Kwan I, Bunn F, Roberts I 2001 Systematic review 4453 Cochrane review of randomized controlled trials comparing outcomes among spinal trauma patients after various types of immobilization No qualifying studies were identified. 5
Prospective analysis of acute cervical spine injury: a methodology to predict injury Jacobs LM, Schwartz R 1986 Prospective cohort study, single-site 233 Studied head/neck trauma patients and compared the ability of physicians, radiographs, and specific clinical criteria to predict the presence of cervical spine injury Physicians were specific but not sensitive at predicting injury; radiographs were sensitive but not specific; neurological criteria and falls over 10 feet were the only predictive signs. 3
Cervical Spine Motion During Extrication: A Pilot Study Shafer JS, Naunheim RS 2009 Prospective comparative trial, non-blinded, convenience sample 1 Used motion capture to compare C-spine movement while extricating a healthy volunteer from a car using four methods: self-extrication; self-extrication with C-collar; rapid extrication with C-collar; KED extrication with C-collar Self-extrication with C-collar produced the least spinal movement; KED extrication with C-collar produced the most movement. 2
Cervical Spine Motion During Extrication Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS 2013 Prospective comparative trial, non-blinded, convenience sample 10 Expansion of Shafer 2009 pilot. Used motion capture to compare C-spine movement while extricating healthy volunteers using four methods: self-extrication; self-extrication with C-collar; rapid extrication with C-collar; KED extrication with C-collar Similar to pilot study. 5
Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group (NEXUS) Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI 2000 Prospective cohort study, multi-site 34069 Studied blunt trauma patients and compared the ability of a five-part clinical decision rule to predict the presence of cervical spine injury. Rules: no midline cervical tenderness, focal neurological deficits, altered mental status, intoxication, or distracting injury. 2.4% had C-spine injury. For detecting clinically-significant C-spine injury, the algorithm's sensitivity was 99.6% and specificity was 12.9%; the negative predictive value was 99.9% and the positive predictive value was 1.9%. 5
The cause of neurologic deterioration after acute cervical spinal cord injury Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ 2001 Retrospective analysis 186 Chart review of patients with complete spinal cord injury to determine how many suffered delayed neurological deterioration after the initial trauma, and to examine the causes 6% of patients had neurological worsening within 30 days. None with penetrating inury worsened. 3% worsened within the first 24 hours, of which: only one worsened within 1 hour; none worsened in the prehospital period; many had ankylosing spondylitis; most worsened during application of immobilization devices. 4
Distribution and patterns of blunt traumatic cervical spine injury Goldberg W, Mueller C, Panacek E, Tigges S, Hoffman JR, Mower WR; NEXUS Group 2001 Prospective, descriptive observational study, multi-site 34069 Sub-study using NEXUS data; determined prevalence of C-spine injuries among blunt trauma patients and categorized them by significance, type, and location. 2.4% of patients had radiographic lesions; 68% of these were fractures, the remainder subluxations or dislocations. C2 was most often fractured. 70.7% of injuries were "clinically significant." 2
Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature Bohlman HH. 1979 Retrospective analysis 300 Chart review of patients with C-spine injuries, describing their types of injury, complications, management, and outcomes Secondary deterioration often occurred during attempts at surgical or other stabilizing intervention. GI bleeds and PE were common complications. Ankylosing spondylitis was associated with poor outcomes. 1
A re-conceptualisation of acute spinal care Hauswald M 2012 Review article 23 Examines the theories behind the current standard of care for immobilization of acute spinal injury, including the biomechanical models, pathophysiology of injury, and more rational treatment options Secondary injuries will rarely occur within the normal range of motion; they require force to be applied within abnormal spinal positions. Long boards are not rational for transport; a comfortable, high-friction surface should be used. Cervical collars may have some benefit but can also increase injury. Standing takedowns are irrational. 4
The relevance of the occult cervical spine controversy and mechanism of injury to prehospital protocols: a review of the issues and literature Butman AM, Schelble DT, Vomacka RW 1996 Systematic review 100 Reviews the available studies at time of publication ("nearly 100") investigating spinal injury and the role of prehospital immobilization. Supports the modern standard of care, including immobilization based on mechanism, a cautious role for field clearance, and the efficacy of current techniques. 2
Early management of the patient with trauma to the spinal cord. Geisler WO, Wynne-Jones M, Jousse AT 1966 Retrospective analysis of convenience sample 958 Reviews spinal injury patients treated by the authors over 25 years, examining the prevalence of neurological deterioration, and outcomes after surgery. 3% of patients experienced no initial symptoms but later deteriorated neurologically, most after hospital admission. Surgical intervention offered little to no benefit in most patients. 2
Neurologic recovery following rapid spinal realignment for complete cervical spinal cord injury. Brunette DD, Rockswold GL. 1987 Case report 1 Discusses the case of an injured 17-yo male with complete paralysis after a C-spine fracture. Near-complete recovery was demonstrated after careful immobilization and traction. 1
Emergency transportation in the event of acute spinal cord lesion. Hachen HJ. 1974 Report on local methods 0 Describes the development of an air ambulance service for transport of local spine injury patients in Switzerland. Outcomes were reportedly improved after a critical care-type helicopter service was introduced. Scoop stretchers and vacuum mattresses were favored for patient movement. 1
Overdistraction: a hazard of skull traction in the management of acute injuries of the cervical spine. Jeanneret B, Magerl F, Ward JC. 1991 Case series 5 Describes cases where spinal traction after acute spinal fracture (then standard of care) resulted in neurological deterioration. Recommends cautious application of traction, with no more than 2kg of traction in most cases. 1
The unstable occult cervical spine fracture: a review. Mace SE. 1992 Review article 62 Discusses the existence of patients without pain, tenderness, neurological symptoms, or obstacles to assessment (even without traumatic history), yet with radiological evidence of C-spine fracture. Numerous cases without such clinical findings are described in the literature, although none that worsened during the prehospital phase. 4
Occult cervical spine fracture in an ambulatory patient. Bresler MJ, Rich GH. 1982 Case report 1 Describes a case of a conscious, ambulatory patient with no neck pain after significant trauma six hours earlier who was found on x-ray with a significant C4 fracture Typical report of delayed diagnosis of C-spine fracture. Pt presented for wrist pain only; no neurological deficits were noted except slight reflex abnormalities. She was managed invasively and did well. 1
Occult cervical spine fractures--a misstated concept. Holliman CJ, Wuerz RC. 1992 Correspondence 0 Response to Mace 1992 Describes various errors and flaws in the Mace review, and notes that almost none of the cited cases of "occult" injury meet reasonable NEXUS-type criteria 2
Asymptomatic cervical injuries: a myth? Gatrell CB. 1985 Correspondence 0 Response to various reports of occult spinal injury Notes that in nearly all reported cases, NEXUS-type rule-outs are present (pain, confounders, etc). The authors from one such study respond. 2
Asymptomatic occult cervical spine fracture: case report and review of the literature. McKee TR, Tinkoff G, Rhodes M. 1990 Case report 1 Describes a case of an elderly man s/p MVA who had no complaints of neck pain, confounding factors, or neurological deficits, yet was found upon imaging with a C2 fracture. He was managed conservatively and did well; he never noted any neurological deficits and the injury remained asymptomatic. 1
Cervical Spine Injury: An Evidence-Based Evaluation Of The Patient With Blunt Cervical Trauma. (EBMedicine) Grossheim LF, Polglaze K, Smith R 2009 Systematic review 250 Reviews all available literature pertaining to ED care of blunt cervical trauma, including clinical and radiographic clearance. Recommends various roles for clinical clearance (expanded NEXUS-type criteria), plain radiographs, CT, and MRI. 5
Characteristics of injuries to the cervical spine and spinal cord in polytrauma patient population: experience from a regional trauma unit. Prasad VS, Schwartz A, Bhutani R, Sharkey PW, Schwartz ML. 1999 Retrospective analysis, single-site 468 Chart review of C-spine injuries at a Canadian trauma center. Correlates mechanism, age, gender, and type/severity of injury. 27% of C-spine injuries produced injury to the cord. Injury to the lower C-spine caused more neurological harm. Backseat MVA occupants suffered more neurological harm than front occupants. 3
Neurologic deterioration secondary to unrecognized spinal instability following trauma -- a multicenter study. Levi AD, Hurlbert RJ, Anderson P, Fehlings M, Rampersaud R, Massicotte EM, France JC, Le Huec JC, Hedlund R, Arnold P. 2006 Retrospective analysis of convenience sample 24 Senior spine surgeons were asked to remember examples of patients who received "spinal clearance" yet suffered later neurological deterioration; 24 cases were presented (.21% of all spine patients, .025% of all trauma). 3 died; 3 were paralyzed; others had partial loss or radiculopathy. MVA was most common mechanism. Ankylosing spondylitis was high-risk. Average delay to secondary presentation was 20 days. Many had distracting injuries. Insufficient imaging was most common cause of missed diagnosis. 4
Prevention of neurological deterioration before admission to a spinal cord injury unit. Toscano J 1988 Prospective, descriptive observational study, single-site. 123 Spinal cord injury patients at a regional spine center during a 2-yr period were enrolled. Author interviewed ambulance staff, witnesses, patient, hospital staff, examined charts, to determine whether their neurological status worsened between initial injury and specialty admission. 28% deteriorated during EMS care; spine injury was "not suspected" by EMS in most cases and adequate immobilization not provided. Author attributes all cases of deterioration to mishandling. No literature cited. 4
Cervical spine injury: analysis and comparison of patients by mode of transportation. Urdaneta AE, Stroh G, Teng J, Snowden B, Barrett TW, Hendey GW. 2013 Retrospective cohort study, multi-site 718 Chart review of C-spine injuries arriving at three hospitals. Compared those who arrived by EMS vs. those who self-presented and examined their injury patterns. 93% arrived by EMS and were usually MVAs. 7% self-presented and were usually falls or sport injuries. EMS patients were less often triaged to low-acuity areas. Both groups had the same rate of neurological compromise; EMS had more "unstable" injuries, but self-presenters still were 30% unstable. 2
Exclusion of cervical spine injury: a prospective study. Cohn SM, Lyle WG, Linden CH, Lancey RA. 1991 Retrospective and prospective analysis, single-site 135 Chart review (retrospective and then prospective) of consecutive blunt trauma patients in a single center, examining their rate of C-spine injury, how this was diagnosed, and effect on airway management. 11-12% had C-spine injury. Most underwent intubation or operation prior to clearance without apparent neurological harm. Mean time to spinal clearance was 6-15 hours (many over 24 hours). 3
The etiology of missed cervical spine injuries. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. 1993 Retrospective analysis, multi-site 740 Chart review of C-spine injuries in six trauma hospitals, examining the rate at which diagnosis of their C-spine injury was missed or delayed, the cause of delay, and resulting sequelae 2.3% of trauma patients had C-spine injury. 4.6% of these had a delayed/missed diagnosis (<1 day to 30 days). 29% of these suffered complications (including paralysis and death). Inadequate imaging was the common cause. 2
The Canadian C-spine rule for radiography in alert and stable trauma patients. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J. 2001 Prospective cohort study, multi-site 12782 10 Canadian hospitals enrolled consecutive stable, alert adult patients with blunt head or neck trauma. A standard clinical exam was performed and the findings correlated with eventual diagnosis of "important" C-spine injury. 1.7% of patients had significant C-spine injury. Predictive value of numerous clinical and mechanism factors were evaluated; a three-part decision rule was derived with 100% sensitivity and 42.5% specificity for important C-spine injury. 5
The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G, Reardon M, Holroyd B, Lesiuk H, Wells GA. 2003 Prospective cohort study, multi-site 8283 Nine Canadian tertiary hospitals conducted a validation study identical to the Stiell 2001 derivation, except they included both the derived Canadian C-spine criteria and the NEXUS criteria, and compared their relative predictive values for significant C-spine fracture. 2% of patients had significant C-spine injury. The Canadian criteria were 99.4% sensitive and 45.1% specific for significant C-spine injury. The NEXUS criteria were 90.7% sensitive and 36.8% specific. Some physicians did not apply the head-rotation criteria from the Canadian rule. 3
Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. Stiell IG, Clement CM, Grimshaw J, Brison RJ, Rowe BH, Schull MJ, Lee JS, Brehaut J, McKnight RD, Eisenhauer MA, Dreyer J, Letovsky E, Rutledge T, MacPhail I, Ross S, Shah A, Perry JJ, Holroyd BR, Ip U, Lesiuk H, Wells GA. 2009 Prospective comparative trial, non-blinded, multi-site. 11824 Twelve Canadian hospitals were matched into six similar pairs, each with an intervention and control center. Intervention centers were trained to use the Canadian C-spine rule to reduce radiography. Data was recorded for 12 months before and after adoption of the rule. The Canadian rule had sensitivity of 100% Radiography was reduced by 12.8% in the intervention sites and increased by 12.5% at the control sites. These trends continued after the termination of the intervention period. 2
The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Vaillancourt C, Stiell IG, Beaudoin T, Maloney J, Anton AR, Bradford P, Cain E, Travers A, Stempien M, Lees M, Munkley D, Battram E, Banek J, Wells GA. 2009 Prospective cohort study, multi-site 1949 Three Canadian EMS systems were trained (2-hour web session) to use a modified version of the Canadian C-spine rule (no "delayed pain" criterion) on eligible patients with potential blunt neck injury. Their predictive accuracy was evaluated against the eventual diagnosis. .6% of patients had significant C-spine injury. Paramedics using the rule were 100% sensitive and 37.7% specific for detecting it. They conservatively misinterpreted it in 16.4% of cases. 37.7% (731 patients) of immobilizations could have been prevented using the rule. Interobserver kappa was .93. 5
Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. Stiell IG, Clement CM, O'Connor A, Davies B, Leclair C, Sheehan P, Clavet T, Beland C, MacKenzie T, Wells GA. 2010 Prospective cohort study, multi-site 3633 Six Canadian hospitals trained 191 ED triage nurses (2 hours each) to implement the Canadian C-spine rule. They applied it to eligible patients in triage with potential blunt neck injury, and their predictive accuracy was evaluated against the eventual diagnosis. 1.2% of patients had significant C-spine injury. Triage nurses using the rule were 90.2% sensitive and 43.9% specific for detecting it. Four injuries were missed with no resulting harm, and after retraining there were no further misses. Interobserver kappa was .78. 3
Prospective Performance Assessment of an Out-of-Hospital Protocol for Selective Spine Immobilization Using Clinical Spine Clearance Criteria. Domeier RM, Frederiksen SM, Welch K. 2005 Prospective cohort study, multi-site 13357 First responders in two counties were trained to use a modified NEXUS criteria for spinal immobilization. Data was collected over four years and their predictive success for significant C-spine injury was evaluated. 3% of patients had spine injury; .37% had cord injury. First responders were 92% sensitive and 40% specific for detecting significant C-spine injury. 33 injuries were missed, none with compromise to the cord. 39% fewer patients were immobilized under the protocol. 4
Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments. Dickinson G, Stiell IG, Schull M, Brison R, Clement CM, Vandemheen KL, Cass D, McKnight D, Greenberg G, Worthington JR, Reardon M, Morrison L, Eisenhauer MA, Dreyer J, Wells GA. 2004 Secondary retrospective analysis of prospective data set 8924 Data from the original Canadian C-spine derivation study (Stiell 2001) was reanalyzed retrospectively to determine the predictive value of the NEXUS criteria (all captured in the initial dataset) in that patient population. The NEXUS criteria predicted significant C-spine injury with sensitivity 92.7% and specificity 37.8%. There were 11 misses, none with resulting negative outcomes. Applying the criteria clinically could have reduced radiography by 68.9% to 62.8%. 2
Pain and tissue-interface pressures during spine-board immobilization. Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. 1995 Prospective crossover trial, non-blinded, convenience sample 12 Healthy volunteers alternated lying upon wooden backboards and wooden backboards with EHOB commercial foam overlay for 80 minutes each, with a break between. They rated relative and absolute pain, and pressure was measured at their occiput, sacrum, and heels. Lying upon the mattress was less painful at all times, and produced less pressure at all areas, than lying upon the bare backboards. 2
Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW. 2012 Meta-analysis 15 Reviewed all available literature involving the NEXUS and Canadian C-spine criteria, graded their quality, and extracted data on their demonstrated sensitivity and specificity. The Canadian C-spine rule had sensitivity from 90% to 100% (median LR+ 1.69) and specificity from 1% to 77% (median LR- .18). The NEXUS rule had sensitivity from 83% to 100% (median LR+ 1.44) and specificity from 2% to 46% (median LR- .30). In the only direct comparison, the Canadian rule was superior. 4
Unintentional strangulation by a cervical collar after attempted suicide by hanging. Lemyze M, Palud A, Favory R, Mathieu D. 2011 Case report 1 Describes a patient who survived attempted hanging, was immobilized by C-collar, but continued to deteriorate neurologically after admission. Most short-fall hangings cause death by impeding cerebral venous return. CT showed cerebral edema and no C-spine injury; after removal of the C-collar the patient improved rapidly. 2
Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Stroh G, Braude D. 2001 Case-control study 504 Chart review of patients with diagnosis of C-spine injury from five hospitals over a six-year period. Those who arrived by EMS were reviewed to determine whether they were immobilized prehospitally, and if the EMS service's modified NEXUS criteria successfully predicted their injury. 1.8% (9) patients were not immobilized. .8% (4) could not be immobilized due to refusal, agitation, or kyphosis. .4% (2) were inappropriately not immobilized. .6% (3) were missed by the criteria (all young or old). 2 patients had long-term neurological deficits. The criteria was 99% sensitive for detecting injury. 3
Does applying the Canadian Cervical Spine rule reduce cervical spine radiography rates in alert patients with blunt trauma to the neck? A retrospective analysis. Rethnam U, Yesupalan R, Gandham G. 2008 Retrospective cohort study 114 Chart review of patients from two UK hospitals. Adult patients with C-spine radiography for suspected injury were examined to determine whether the Canadian C-spine rule would have eliminated the need for imaging. Only 10% (12) patients had all aspects of the rule applied, including 45-degree rotation. Not including this, 75% (86) patients ruled-in as low-risk and might have foregone radiography. 1.7% (2) patients had significant injury and would have been detected by the rule. 1
Vertebral artery injury after acute cervical spine trauma: rate of occurrence as detected by MR angiography and assessment of clinical consequences. Friedman D, Flanders A, Thomas C, Millar W. 1995 Prospective cohort study, single-site. 37 C-spine injured patients at a spinal cord center who underwent MRI were evaluated using MR angiograms to determine the prevalence of vertebral artery injury. Normal control subjects were also evaluated. 24% (9) patients had arterial occlusion or narrowing. 2.7% (1) patient had a stroke from vertebral artery occlusion and died. The rest had no neurological deficit. 2
Pre-hospital Management of Spinal Cord Injuries. Green BA, Eismont FJ, O'Heir JT. 1987 Review article 10 Reviews the historical practice of prehospital care for spinal injury in the US and makes recommendations for current standard-of-care. Recommends the use of scoop stretchers to move patients to backboards; gentle manual traction; and other typical measures. Asserts that the incidence of partial (versus total) spinal cord injury has increased from the 1970s into the 1980s due to training of first responders. 1
Neurologic complications following immobilization of cervical spine fracture in a patient with ankylosing spondylitis. Podolsky SM, Hoffman JR, Pietrafesa CA. 1983 Case report 1 Describes an 80-year-old female with ankylosing spondylitis who fell and complained of neck pain without neurological deficit, yet suffered neurological deterioration upon all attempts to stabilize her spine or apply traction in a neutral position. The patient had a C5-C6 fracture and eventually died. 2
Traumatic Paraplegia and Tetraplegia in Ankylosing Spondylitis. Guttmann L 1966 Case series 7 Presents seven patients with ankylosing spondylitis who suffered traumatic spinal injuries. Many of the injuries were at lower vertebral levels (thoracic, lumbar). Many suffered catastrophic outcomes from relatively minor mechanisms of injury. 2
Fractures and dislocations of the spine complicating ankylosing spondylitis: A report of six cases. Grisolia A, Bell RL, Peltier LF 1967 Case series 6 Describes the cases of six patients with ankylosing spondylitis and traumatic spinal fractures. Of the six ankylosing spondylitis patients admitted for spinal injury, 83% (5) had neurological deficit and 50% (3) had complete transection and severe instability. 2
Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficiency and communication. Vandemark RM. 1990 Review article 21 Discusses clinical challenges and the practical application of existing evidence surrounding spinal immobilization and clearance in the ED. Recommends risk-stratification of potential C-spine trauma patients with a scaled approach to imaging. Suggests that plain films are not 100% sensitive. Recommends clear communication between providers, particularly radiologists and ED physicians, when referring to spinal "clearance." 1
Cervical radiographic evaluation of alert patients following blunt trauma. Fischer RP. 1984 Prospective cohort study, single-site. 333 Consecutive, alert blunt head trauma patients who could respond to questions and commands were enrolled; their eventual diagnosis was later evaluated. 1.5% had cervical fracture, and all had cervical pain/tenderness. None had neuro findings, but .9% of non-injured patients did have neuro findings. 79% had LOC. 32% were drinking. 19% had other major injury. 13% had skull fracture. 2.4% had intracranial injury (depressed skull fx, subdural or epidural hematoma). 3
Post-traumatic neck pain: a prospective and follow-up study. McNamara RM, O'Brien MC, Davidheiser S. 1988 Prospective cohort study, multi-site 351 Alert patients with neck pain after trauma who could provide a reliable history completed a questionnaire in the ED and were followed through and after discharge to determine their outcome. 2% had C-spine fracture or ligamentous injury. Immediate onset of pain, midline cervical tenderness, and limited range-of-motion were all 100% sensitive for injury. 43% had persistent pain/neuro symptoms. Many sought further care after discharge. 66% were pursuing litigation. 4
Delayed diagnosis of cervical spine injuries. Gerrelts BD, Petersen EU, Mabry J, Petersen SR. 1991 Retrospective cohort study, single-site 1331 All patients with "severe blunt injury" and spinal imaging were reviewed to identify those whose diagnosis of C-spine injury was delayed, and determine the clinical consequences. 5.6% of patients had C-spine injury. 18% of them died. 30% of the remainder had neuro deficits, 16% with complete transection. 8.2% had diagnosis delay 2+ days; none of them had long-term deficit. 3
Etiology and clinical course of missed spine fractures. Reid DC, Henderson R, Saboe L, Miller JD. 1987 Prospective cohort study, single-site 253 Assessed consecutive "spinal trauma" patients at a tertiary center and followed to identify those who were later diagnosed with spinal injury after discharge. 15% of patients had a delay in diagnosis of fx, many with intoxication, multiple fractures, other major trauma, head injury or LOC. Delayed diagnoses had the same overall incidence of neurological deficit as early diagnosis, but had 9.1% greater chance of worsening in the interim. 3
Delayed sequelae of vertebral artery dissection and occult cervical fractures. Tulyapronchote R, Selhorst JB, Malkoff MD, Gomez CR. 1994 Case series 3 Describes three patients who suffered delayed neurological sequelae after C-spine trauma. All cases demonstrated occlusion or injury to vertebral arteries, even when spinal injury was not initially diagnosed. 1
Multicenter prospective validation of prehospital clinical spinal clearance criteria. Domeier RM, Swor RA, Evans RW, Hancock JB, Fales W, Krohmer J, Frederiksen SM, Rivera-Rivera EJ, Schork MA. 2002 Prospective cohort study, multi-site 8975 EMS providers performed and documented a modified NEXUS exam in trauma patients who underwent prehospital spinal immobilization. The criteria were later evaluated for their predictive value for a diagnosis of spinal injury (by radiography or by follow-up after discharge). 3.3% of patients had spinal injury. .66% had cord injury. The criteria were 95% sensitive and 35% specific for injury, with 4.7% PPV and 99.5% NPV. Fifteen injuries were missed; none had neurological sequelae. Clinical application of the criteria could have reduced immobilization by 35%. 5
Clinical prediction of cervical spine injuries in children. Radiographic abnormalities. Rachesky I, Boyce WT, Duncan B, Bjelland J, Sibley B. 1987 Retrospective analysis, multi-site. 2133 Chart review of pediatric patients (<18) who underwent C-spine radiography for trauma at two tertiary centers. Clinical findings were evaluated to determine the most predictive criteria for a diagnosis of C-spine injury. 1.2% had C-spine injury. A criteria combining "history of neck pain" and/or "vehicular accident with head trauma" was 100% sensitive and 68% specific for injury, and would have reduced imaging by 32%. 3
Risk factors for early occurring pressure ulcers following spinal cord injury. Mawson AR, Biundo JJ Jr, Neville P, Linares HA, Winchester Y, Lopez A. 1988 Prospective cohort study, single-site 39 Consecutive patients with traumatic spinal cord injury and neuro deficit were interviewed and examined after admission to correlate the later development of pressure ulcers with their duration of spinal immobilization. 59% developed pressure ulcers within 30 days, most within the first four days. Those with ulcers within 8 days were immobilized significantly longer; those with ulcers within 30 days were immobilized insignificantly longer. 4
Incidence of cervical spine injuries in association with blunt head trauma. Bayless P, Ray VG. 1989 Retrospective analysis, single-site. 176 Chart review of all adult patients presenting to a trauma center with significant blunt head trauma, evaluating the prevalence of resulting cervical spine injury. 1.7% of patients had cervical spine injury. All had either neck pain or were uncooperative; none had neuro deficit. 3
Cervical injury in head trauma. Neifeld GL, Keene JG, Hevesy G, Leikin J, Proust A, Thisted RA. 1988 Prospective cohort study, multi-site. 856 Adult patients with blunt head/neck trauma warranting radiography at four trauma centers underwent a standard history and exam to determine incidence of C-spine injury. 3.16% of patients had C-spine injury. Those who were altered, had neuro deficits or distracting injury were 5.1% likely to have injury. The remainder were 1.5% likely, and all had midline neck tenderness; none had lateral or no neck pain. 4
Injuries to the cervical spine causing vertebral artery trauma: case reports. Schwarz N, Buchinger W, Gaudernak T, Russe F, Zechner W. 1991 Case series 4 Describes four cases of vertebral artery insufficiency caused by blunt C-spine trauma. Most cases involved vertebral dislocations producing neurological signs which resolved after stabilization. One patient died from vertebral artery embolism during surgical intervention. 2
Assessing multiple trauma: is the cervical spine enough? Pal JM, Mulder DS, Brown RA, Fleiszer DM. 1988 Retrospective analysis, single-site 371 Review of trauma registry at single trauma center. Multiple injury or severe burn patients with spinal injury were identified and analyzed for case details. 17% of the cohort had spinal injury, of which 27% were cervical (24% of which had neuro deficit), 27% thoracic (15% with deficit), 38% lumbosacral (30% with deficit), and 8% multiple. Deficits from one cervical injury worsened in-hospital, and improved after one thoracic injury. Most cord injuries were complete. (Author Q&A included.) 4
Cervical spine clearance: a review. Richards PJ. 2005 Review article 221 Extensively reviews existing literature on acute spinal injury care, focusing on early hospital management and clearance by clinical means and imaging. Presents various recommendations, particularly for high suspicion and high reliance on CT, with deemphasis on the role of flexion/extension films. 2
Cervical collars are insufficient for immobilizing an unstable cervical spine injury. Horodyski M, DiPaola CP, Conrad BP, Rechtine GR 2nd. 2011 Prospective comparative trial 5 Lightly embalmed cadavers were manipulated using cranial tongs and monitored using motion capture. Motion and resistance were measured: with and without two types of collars; before and after instability was produced below C5. Neither collar significantly limited spinal movement in either intact or unstable cadavers. 3
Caring for the patients with cervical spine injuries: what have we learned? Ghafoor AU, Martin TW, Gopalakrishnan S, Viswamitra S. 2005 Systematic review 70 Reviews literature and makes recommendations for early management of patients with suspected C-spine injury, focusing on airway interventions. Recommends high suspicion and the use of Macintosh or Bullard laryngoscopes. 2
Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria (NEXUS) for C-spine radiography in young trauma patients. Ehrlich PF, Wee C, Drongowski R, Rana AR. 2009 Retrospective cohort study, single-site 275 Chart review of all patients <10 years at a pediatric trauma center to determine the predictive value of NEXUS vs. Canadian C-spine criteria for C-spine injury. 2.5% had significant C-spine injury. In patients who underwent radiography, NEXUS would have been 43% sensitive and 96% specific; CCR would have been 86% sensitive and 94% specific. (Each could have been applied in only ~86% of cases.) In non-imaged patients, there were no injuries, but NEXUS identified 8 and CCR identified 13. 4
Backboard versus mattress splint immobilization: a comparison of symptoms generated. Chan D, Goldberg RM, Mason J, Chan L. 1996 Prospective crossover trial, non-blinded, convenience sample 37 Healthy volunteers age 17-49 were either immobilized in the usual manner on longboards or upon vacuum splints for 30 minutes, then described their pain. Two weeks later the groups were reversed. Patients were ~3 times as likely to complain of pain after longboard immobilization, especially at the occiput or lumbosacrum. 2
The effect of spinal immobilization on healthy volunteers. Chan D, Goldberg R, Tascone A, Harmon S, Chan L. 1994 Prospective comparative trial, non-blinded, convenience sample 21 Healthy volunteers age 10-43 were fully immobilized by medics and laid on boards for 30 minutes, then asked to describe pain or other simptoms, immediately and after 48 hours. 100% of patients developed immediate symptoms, 55% moderate to severe; 29% had symptoms at 48 hours. 3
Are scoop stretchers suitable for use on spine-injured patients? Del Rossi G, Rechtine GR, Conrad BP, Horodyski M. 2010 Prospective comparative trial, non-blinded 5 Global instability was surgically induced below C5 in five lightly-embalmed cadavers. Sensors on C5 and C6 monitored intervertebral movement while log-rolling onto a spineboard, lifting onto a spineboard, or use of a scoop stretcher. The scoop stretcher produced insignificantly less spinal movement than the two spineboard methods. 3
Airway management in adults after cervical spine trauma. Crosby ET. 2006 Review article 143 Extensively and comprehensively examines the literature surrounding various aspects of early management after spinal injury, with a focus on the effects of airway management on C-spine immobilization. Reviews numerous options for management, but suggests that evidence in most cases is lacking. 4
Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. 1992 Prospective cohort study, single-site 974 Blunt trauma patients undergoing radiography at a trauma center had data forms completed by the treating staff describing various clinical features. Their predictive value was correlated against final diagnosis of spinal fracture. 2.7% had C-spine injury. No single factor was highly predictive, but a NEXUS-type combination was effective. The presence of "whiplash"-type injury had excellent NPV; neck pain (not tenderness) had poor PPV. Pretest clinical judgment had excellent NPV. 4
Deterioration following spinal cord injury. A multicenter study. Marshall LF, Knowlton S, Garfin SR, Klauber MR, Eisenberg HM, Kopaniky D, Miner ME, Tabbador K, Clifton GL. 1987 Retrospective analysis of prospective dataset 283 Data from a spinal registry was analyzed to extract consecutive spinal cord-injured patients admitted to five trauma centers, and analyzed to isolate cases of neurological deterioration after admission. 4.9% deteriorated, almost all during an intervention (traction, halo vest application, etc). 2
Ascending cord lesion in the early stages following spinal injury. Frankel HL. 1969 Case series 7 Describes patients who suffered spinal injury with neurological deficit, and over the course of days experienced gradually ascending paralysis. Initial injuries were all thoracic, and some ascended as high as C7. Worsening was from 2 to 18 days post-injury. Many had fever. Edema, hematoma, and other causes were suspected. (Discussion included.) 1
Neurologic deterioration after cervical spinal cord injury. Farmer J, Vaccaro A, Albert TJ, Malone S, Balderston RA, Cotler JM. 1998 Retrospective analysis, single-site 19 Chart review of C-spine cord injuries to investigate the traits of those that suffered delayed neurological deterioration. 1.8% of all C-spine cord injuries deteriorated. Average delay until deterioration was ~4 days. Most injuries were at C5-C6. Ankylosing spondylitis, vertebral artery injury, and sepsis were high-risk. 3
Missed and mismanaged injuries of the spinal cord. Poonnoose PM, Ravichandran G, McClelland MR. 2002 Retrospective analysis, single-site 569 Chart review of spinal cord injury patients to isolate those whose care was affected by a delay in recognition and diagnosis of their injury. 9.1% of patients had a delay in diagnosis, and 58% of those had resulting inappropriate/negligent care. Authors attribute further deterioration to mismanagement in 50% of cases. Inadequate imaging, altered mental status, and ankylosing spondylitis were often involved. 2
Guidelines for the management of acute cervical spine and spinal cord injuries. Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC, Mielke DH. (Am. Assoc. Neuro Surgeons, Congress of Neuro Surgeons) 2002 Systematic review with position statement 104 Comprehensive review by the AANS/CNS of existing literature (over 800 studies in total) involving all aspects of acute care for spinal injury Finds no high-quality evidence for most questions of care, but recommends general adherence to current standard of care, including prehospital immobilization with collar and board, which should be removed as soon as possible. 5
EMS Spinal Precautions and the Use of the Long Backboard. National Association of EMS Physicians (NAEMSP) and American College of Surgeons Committee on Trauma (ACS-COT) 2013 Position statement 0 Position statement on the topic of spinal immobilization by the NAEMSP and ACS-COT. No evidence or justifications included. Notes dearth of evidence for prehospital immobilization, but recommends its use in NEXUS-positive patients. Suggests low-risk patients can wear a C-collar and sit upon a stretcher, and that all patients should be removed from backboards ASAP. 4
New focus on spinal cord injury. Gunby I. 1981 News piece 0 News piece interviewing Paul R. Meyer, Jr of the Midwest Regional Spinal Cord Injury Care System, describing recent developments in acute spinal care and their effects on patient outcomes. Quotes Dr. Meyer stating that in 1979, 55% of cord injuries at their center were complete, which declined to 39% in 1981. Other sources corroborate, and attribute the decrease to prehospital interventions. 3
Why do we put cervical collars on conscious trauma patients? Benger J, Blackham J. 2009 Review article 22 Opinion piece on the currently widespread practice of prophylactically immobilizing conscious patients after potential spinal trauma. Notes that no evidence has demonstrated a benefit from any spinal immobilization, secondary deterioration is usually an inevitable, gradual edematous/hemorrhagic process, and collars/boards cause some harm; suggests conscious patients can adequately limit their own movements. 2
Care of the multiply injured patient with cervical spine injury. Garfin SR, Shackford SR, Marshall LF, Drummond JC. 1989 Review article 58 Reviews literature and makes recommendations for early management of patients with C-spine injury and other significant trauma. Offers typical standard-of-care recommendations, including early immobilization and imaging. Suggests EMS immobilization has lead to a decrease in complete cord injury since its adoption. 2
Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck trauma. Ramasamy A, Midwinter M, Mahoney P, Clasper J. 2009 Retrospective analysis, multi-site 90 Chart review of UK military casualties from Middle East theater who sustained penetrating neck trauma, investigating their incidence of C-spine injury. 22% had C-spine injury; none of the remainder had AMS or neuro deficit. Of those with C-spine injury, 90% died and 80% had cord injury; of those who survived to admission, all had AMS or neuro deficit, 66% eventually died, of which 75% had unstable spines, and survivors all had stable injuries. 4
Spine immobilization in penetrating trauma: more harm than good? Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. 2010 Retrospective cohort study, multi-site 45284 Data mine from US trauma registry (NTDB), investigating patients with isolated penetrating trauma, and comparing outcomes among those with spinal immobilization vs. without. Patients matched by injury severity and other variables. Immobilized patients were more seriously injured, but after adjusting for confounders, were still twice as likely to die (OR 2.06). This was consistent across all subgroups, although insignificant for stab wounds. .01% had incomplete, unstable spine injury. NNT for spine preservation was therefore 1,032; NNH for mortality was 66. 5
Thoracolumbar immobilization for trauma patients with torso gunshot wounds: is it necessary? Cornwell EE 3rd, Chang DC, Bonar JP, Campbell KA, Phillips J, Lipsett P, Scalea T, Bass R. 2001 Retrospective cohort study, multi-site 1000 Data mine from Maryland trauma registry investigating patients with penetrating torso gunshot injuries to determine their incidence of spinal trauma and mortality. 14.1% had spinal injury. Of those, 52% had complete neuro deficits (none with unstable spines), 41% had incomplete or no deficit, and only 1.4% (.2% of total) were operatively stabilized. 3
Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma? Connell RA, Graham CA, Munro PT. 2003 Retrospective analysis, multi-site. 1929 Data mine of Scotland trauma registry (STAG) investigating patients with isolated penetrating trauma to determine incidence and type of spinal injury. .62% had significant spinal cord injury from penetrating trauma, most from sharp weapons. About half were complete. All were immobilized, and all were either in traumatic arrest or had clinically obvious neuro deficit. 4
Prehospital stabilization of the cervical spine for penetrating injuries of the neck - is it necessary? Barkana Y, Stein M, Scope A, Maor R, Abramovich Y, Friedman Z, Knoller N. 2000 Retrospective analysis, single-site. 44 Chart review of Israeli military casualties, all immobilized, who suffered penetrating neck trauma; investigated the incidence of unstable spinal injuries. 22% of survivors had neck hematoma or subcutaneous emphysema hidden by the C-collar. None needed surgical stabilization and only one needed traction. All patients either died or suffered immediate total transection; none were thought to benefit from prehospital immobilization. Most injuries were from projectiles. 2
Stability of cervical spine fractures after gunshot wounds to the head and neck. Medzon R, Rothenhaus T, Bono CM, Grindlinger G, Rathlev NK. 2005 Retrospective analysis, single-site. 81 Chart review of consecutive patients at an inner city trauma center with gunshot wounds to the head or neck and resulting cervical spine fracture. Of 81 potential C-spine involvements, 23% actually had C-spine fracture. 14% of assessable patients had neuro deficit, of which 27% were unstable fractures (3.7% of total). 75% were awake without deficit; none had fracture. 6% were altered and all had stable fractures. Most needed airway management. 3
Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee. Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE. 2011 Position statement with systematic review 20 Systematically reviews available evidence on spinal immobilization for penetrating trauma and offers recommendations from the PHTLS committee for prehospital care. There is no evidence and little physiological rationale for immobilizing penetrating trauma; resulting spinal injury is rarely unstable, and this practice increases mortality. It is not recommended. 5
Increased risk of death with cervical spine immobilisation in penetrating cervical trauma. Vanderlan WB, Tew BE, McSwain NE Jr. 2009 Retrospective cohort study, single-site 188 Chart review of patients with penetrating cervical trauma at a trauma center; investigated the effects of C-spine immobilization on mortality. C-spine immobilization increased chance of death by odds ratio of 2.77 (CI 1.18-6.49). When analyzing only isolated penetrating cervical injuries, the odds ratio was 8.82 (CI 1.09-194.19). The OR for death in prehospital or ED setting was 3.36 (CI 1.12-10.74). 2
Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. Rhee P, Kuncir EJ, Johnson L, Brown C, Velmahos G, Martin M, Wang D, Salim A, Doucet J, Kennedy S, Demetriades D. 2006 Retrospective analysis, multi-site 24246 Chart review of patients at two trauma centers with either blunt or penetrating trauma after assault; investigating their incidence of C-spine injury and their outcomes. .4% of blunt assault patients had C-spine fx (27.8% of those had cord injury, and 1 patient had cord injury without fx), 33% of those needed surgical fixation, and 83% of those presented with neuro deficits. 1.3% of gunshot assaults had C-spine fx (69% with cord injury, and 3 had cord injury without fx), 15% of those needed surgical fixation, and 85% of those presented with neuro deficit. 12% of stabbing assaults had C-spine fx (66% had cord injury, and 2 had cord injury without fx), 33% of those needed surgical fixation, and 100% of those presented with neuro deficits. 4
National survey of the incidence of cervical spine injury and approach to cervical spine clearance in U.S. trauma centers. Grossman MD, Reilly PM, Gillett T, Gillett D. 1999 Retrospective analysis, multi-site 111219 Poll of 165 trauma centers compiling data on the annual incidence of C-spine and cervical spinal cord injuries among their total admissions. 4.3% of all admissions had C-spine injury. 3.0% had C-spine injury without cord injury (1.3% had C-spine injury with cord injury), and .70% had cord injury without spine injury. .01% of all C-spine injuries had delayed/missed diagnosis. 3
Glass intact assures safe cervical spine protocol. Sochor M, Althoff S, Bose D, Maio R, Deflorio P. 2013 Retrospective cohort study, multi-site 14191 The NASS CDS national database of automobile collisions (crashes towed from the scene only) was polled to determine frequency of significant C-spine injury among patients meeting criteria: age 16-60; seated in front wearing lap and shoulder belts; windows (rolled up) and windshield had no damage; and front airbags present but not deployed. The criteria were 95.20% sensitive (CI 91.45%-98.95%) and 54.27% specific for significant C-spine injury, with NPV 99.92%. Six cases were missed, most with no cord involvement. 4
Stabilization of spinal injury for early transfer. Burney RE, Waggoner R, Maynard FM. 1989 Retrospective cohort study, single-site 61 Chart review of patients transferred into a spinal trauma center to establish whether the method and timing of transfer contributed to neurological deterioration. No patients deteriorated neurologically during or after transport, and 43% showed later improvement. Those transferred within 24 hours were more likely to improve (49%) than others (10%). Most were immobilized by longboard and collar or similar methods. Use of ground, helicopter, or fixed-wing transport was immaterial. 2
The Canadian C-spine rule performs better than unstructured physician judgment. Bandiera G, Stiell IG, Wells GA, Clement C, De Maio V, Vandemheen KL, Greenberg GH, Lesiuk H, Brison R, Cass D, Dreyer J, Eisenhauer MA, Macphail I, McKnight RD, Morrison L, Reardon M, Schull M, Worthington J; Canadian C-Spine and CT Head Study Group. 2003 Retrospective analysis of prospective dataset 6265 Secondary analysis of data from Stiell 2001 to compare the predictive value (for significant C-spine injury) of the Canadian C-spine rule against unstructured clinical judgment of the treating physicians. Physician judgment was 92% sensitive for predicting the possibility of injury (>0% estimated pretest probability) before radiographs; the Canadian rule was 100% sensitive. Their specificity was 53.9%, versus 44.0% for the Canadian rule. 5 cases would have been missed by physician judgment. 1
Avoiding a pitfall in resuscitation: the painless cervical fracture. Maull KI, Sachatello CR. 1977 Correspondence 0 Remarks on early acute care for patients with potential spinal injury. Notes that, in the authors' experience, clinically occult spinal injury is possible, and asserts without evidence that such patients should be radiographically cleared before manipulating their neck. 1
Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation. Kaups KL, Davis JW. 1998 Retrospective cohort study, single-site 215 Chart review of patients at a trauma center with gunshot wounds to the head, investigating their incidence of unstable cervical spine injury. Although most patients had spinal immobilization in the field, none likely benefitted, as only 1.3% had bullet paths involving the spine, all of whom either died or had no neurological deficit. Airway management was probably negatively affected by immobilization. 3
Initial evaluation and management of gunshot wounds to the face. Demetriades D, Chahwan S, Gomez H, Falabella A, Velmahos G, Yamashita D. 1998 Retrospective analysis, single-site 247 Chart review of patients admitted to a trauma center with gunshot wounds to the face, investigating clinical details and the incidence of various complications 8.1% of patients had cervical spine injury resulting from a gunshot wound to the face. 2
Efficacy of cervical spine immobilization methods. Podolsky S, Baraff LJ, Simon RR, Hoffman JR, Larmon B, Ablon W. 1983 Prospective comparative trial, non-blinded, convenience sample 25 Healthy volunteers were immobilized using various methods (several types of hard cervical collar, soft collar, sandbags, and combinations), asked to articulate their neck, and movement at the neck was measured by manual goniometer. Sandbags, tape, and a Philadelphia collar together were the most effective method. A soft collar had little effect. 3
Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma (EAST) practice management guidelines committee. Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, Holevar MR, Khwaja KA, Mayglothling JA, Shapiro MB, Winston ES. 2009 Position statement with systematic review 78 Updated recommendations for ED C-spine clearance from the EAST committee. Recommends clinical clearance for NEXUS-positive patients with intact, pain-free range-of-motion. Recommends against immobilization for penetrating head trauma unless the missile trajectory involves the spine. 3
The risk of neurologic damage with fractures of the vertebrae. Riggins RS, Kraus JF. 1977 Retrospective analysis, multi-site 619 Secondary analysis of Kraus 1975 data, an 18-county review of hospital and coroner data in years 1970-1971. Correlated the incidence of vertebral fracture against incidence of spinal cord injury in the study population. ~14% of spinal fractures/dislocations suffered cord injury. Fracture of vertebral body and posterior elements, with displacement, had over 61% chance of cord injury. C-spine injury had neuro deficit in 39%; thoracic, 10%; and lumbar, 3%. 3
Recent trends in mortality and causes of death among persons with spinal cord injury. DeVivo MJ, Krause JS, Lammertse DP. 1999 Retrospective analysis, multi-site 28239 Data mine of NSCISC registry from Shriner's and Model SCI centers; analyzed traumatic spinal cord injury patients admitted since 1970 and investigated trends in outcome over time. Mortality after injury decreased by two-thirds after 1973, but long-term mortality among 1-year survivors rebounded after 1993 above initial levels. 2
Fractures and dislocations of the cervical spine; an end-result study. Rogers WA. 1957 Case series 77 Review of C-spine injured patients treated by the author over the 1940s. 64% had neuro symptoms. ~10% of patients experienced early neurological deterioration after the initial injury; all were anterior dislocations. 2
Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: much ado about nothing. Velmahos GC, Theodorou D, Tatevossian R, Belzberg H, Cornwell EE 3rd, Berne TV, Asensio JA, Demetriades D. 1996 Prospective cohort study, single-site 549 Enrolled alert, cooperative, non-intoxicated blunt trauma patients arriving in spinal immobilization but without neck pain at a trauma center. Attempted spinal clearance by assessing neck tenderness and pain-free range-of-motion in rotation and flexion. 0% of patients who completed the clinical exam without pain had radiographically-apparent spinal injury, despite distracting injuries in 38.6% and craniofacial injury in 35%. Unnecessary radiographic clearance cost $200k+ and often delayed discharge by up to a day. 4
Unnecessary out-of-hospital use of full spinal immobilization. McHugh TP, Taylor JP. 1998 Prospective cohort study, single-site 129 Enrolled patients at a trauma center who arrived with C-spine immobilization and were free from NEXUS criteria as well as pregnancy, recent seizure, or high trauma score. Investigated their incidence and timing of neck/back pain. 51.9% had no neck/back pain on scene, but 31.3% of them developed pain after immobilization. 33.3% had neck pain at the scene, which increased to 44.2% at the ED. 31% had back pain at the scene, which increased to 49.6% at the ED. No patient had pain decrease, and many were not asked about pain before immobilization. 3
Clinical examination and its reliability in identifying cervical spine fractures. Duane TM, Dechert T, Wolfe LG, Aboutanos MB, Malhotra AK, Ivatury RR. 2007 Prospective cohort study, single-site 534 Blunt trauma patients at a trauma center were examined for neck pain/tenderness, deformity, or neuro deficits. The results were compared against the diagnosis of C-spine fx by neck CT. 9.7% had C-spine fx on CT. The clinical exam was 76.9% sensitive and 54.7% specific for fx, with 15.5% PPV and 95.7% NPV. For those with GCS 15, no intoxication or distracting injury, sensitivity was 58.8% and specificity 62.7%; 57% of missed injuries in that cohort needed stabilization. 3
Neurologic deterioration associated with airway management in a cervical spine-injured patient. Hastings RH, Kelley SD. 1993 Case report 1 Describes a 65-yo male s/p MVA, non-intoxicated, ambulatory with minor neck pain, slight left arm weakness, seemingly normal neck x-rays and no other deficits. Due to airway obstruction he became hypoxic and hypotensive, and was intubated. After waking he had no motor function in the legs, and weakness in both arms. CT found C6-C7 displacement. Deterioration was thought due to combination of anterior and central cord syndrome from hyperextension, possibly edematous/hemorrhagic. 2
Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. Demetriades D, Charalambides K, Chahwan S, Hanpeter D, Alo K, Velmahos G, Murray J, Asensio J. 2000 Retrospective cohort study, single-site 292 Large trauma center chart review of patients after MVAs or falls with resulting C-spine injury, investigating the incidence of cord injury without vertebral fracture. 2.0% of MVAs and falls had C-spine injury, of which 85.6% had fx (20% with neuro symptoms). 10.6% had subluxation without fx (45.2% with neuro signs). 3.8% had cord injury without fx or ligament injury. 2
Spinal cord injury as a result of endotracheal intubation in patients with undiagnosed cervical spine fractures. Muckart DJ, Bhagwanjee S, van der Merwe R. 1997 Case series 2 Describes two patients with unrecognized C-spine fx who suffered neurological deterioration after induction and intubation for surgery. One patient was conscious after MVA with no deficit on partial exam; he became completely quadriplegic after general anesthesia, and C2 pedicle fx with subluxation was found. Another was conscious without deficit after multiple GSWs; after anaesthesia he had near-total quadriplegia from C6 burst fx. Both recovered fully. 2
Changing Patterns of Fracture in the Dorsal and Lumbar Spine. Griffith HB, Gleave JR, Taylor RG. 1966 Retrospective analysis, single-site 155 Chart review of spinal fractures admitted to a British hospital in 1947-1957, investigating the incidence and traits of thoracic and lumbar fracture. 62% of all spinal fractures were non-cervical (thoracic or lumbar), mostly from falls or severe MVA (no restraints, 60%+ rollovers), mostly wedge or crush-in-flexion type. 10% had cord injury, 14% (2 patients) of which were incomplete (both in conus/cauda equina). 2
Diagnosing and Managing Spinal Injury in Patients with Ankylosing Spondylitis. Waldman SK, Brown C, Lopez de Heredia L, Hughes RJ. 2013 Review article 12 Briefly reviews the literature surrounding care for AS patients after blunt trauma, and presents three case reports illustrating the challenges. All three case reports involved spinal fractures after falls. The authors recommend high suspicion in AS patients, although neutral alignment in a collar is not always appropriate due to kyphosis. 1
Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Westerveld LA, Verlaan JJ, Oner FC. 2009 Systematic review with meta-analysis 93 Review literature (1980-2007) on spinal fracture in patients with AS or DISH (diffuse idiopathic skeletal hyperostosis). Pools data on certain traits for meta-analysis. Most fractures were from low-energy falls, cervical, and hyperextension-type. Delay in diagnosis was common. 40-67.2% had neuro deficit on admission, and ~14% deteriorated further in the first 3 months. Mortality was from 3-13% 2
Cervical spine control; bending the rules. Maskery NS, Burrows N. 2002 Case report 1 Describes a 77-yo male who fell on a ski slope, subsquently complaining of neck pain and loss of sensation and function in all extremities; he was promptly immobilized. Radiography revealed diffuse idiopathic skeletal hyperostosis (DISH) and a C3/C4 fx. C-collar was removed and his neck was flexed with a pillow; x-ray showed reduction of the fracture, and his neuro status improved, eventually regaining moderate function. Brown-Sequard and partial central and posterior cord syndromes were diagnosed. 2
Effect of cervical hard collar on intracranial pressure after head injury. Mobbs RJ, Stoodley MA, Fuller J. 2002 Prospective comparative trial, non-blinded, consecutive sample 10 10 consecutive patients with a GCS <10 and ICP monitoring in place following head injury were studied with and without a semi-rigid collar in place. Nine out of 10 patients had a rise in ICP following application of the collar (mean 4.4 mmHg, p < 0.05). The effect seemed to be more prominent in patients with low baseline ICP's. 3
*** Prehospital cervical spinal immobilization after trauma. Theodore N, Hadley MN, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Ryken TC, Walters BC. 2013 Systematic review with position statement 109 Update of AANS/CNS recommendations (Hadley 2002) for care of acute spinal injury. Recommends field immobilization for all patients with possible spinal injury; however, recommends against immobilization in penetrating trauma or for NEXUS-cleared patients. Recommends the hard collar with blocks, backboard, and straps, but discourages sandbags. 3
*** A review of spinal immobilization techniques. De Lorenzo RA. 1996 Review article 91 Reviews available literature on prehospital spinal immobilization, with an emphasis on techniques and devices. Describes the available methods and their underlying evidentiary basis, including the hard collar and its variations, longboard and shortboard with straps, different block or headbed devices, KED, and different strapping techniques. 3

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