Why We Need to Rethink C-Spine Immobilization

The spinal immobilization of trauma patients suspected of having spinal injury has been a cornerstone of prehospital care for decades. Current practices are based on the belief that a patient with an injured spinal column can deteriorate neurologically without immobilization. This concern has ballooned to include large numbers of patients with little or no chance of such an injury and caregivers with little appreciation for the complications caused by use of the cervical collar and spinal board. Somewhere between 1 million and 5 million patients receive spinal immobilization each year in the United States.^1,2

The injury of concern is not the cervical spine fracture but the unstable cervical fracture with the potential for further neurological deficits.³ It is clear that among severely traumatized patients admitted to hospitals, the rate of cervical spine fractures is 2%–5% and the rate of unstable cervical fractures is 1%–2%.^4–6 For patients with head injuries, the rate of cervical spine injuries increases substantially.⁷ Among patients with known unstable cervical spine fractures, half in one study demonstrated neurological deficits upon hospital arrival.⁸ Most clinicians would agree that this high-risk group would benefit from spinal immobilization, and we are truly concerned about that 0.5%–1% with unstable cervical spine fractures and intact spinal cords.

It is logical that among patients with lesser mechanisms of injury, the potential for unstable cervical spine fractures is much smaller. It is with this group that we must consider the trade-offs with the complications of cervical spine immobilization. Several studies have examined the rate of cervical fracture among generic blunt-trauma patients, whose mechanisms included MVCs, falls from standing, falls from heights and assaults. In these commonly encountered patients, the rate of cervical fracture is 1.2%–3.3%,^1,9–12 and the rate of cervical spinal cord injury is 0.4%–0.7%.^13,14

One of the larger studies of blunt-trauma patients with high-energy mechanisms had clear inclusion criteria and used a well-defined endpoint of clinically important cervical spine injury (essentially an unstable cervical spine fracture). In this Canadian system, patients with blunt assaults and falls from standing are generally not assessed for cervical spine injury. Among this cohort of patients with high-energy mechanisms, the rate of clinically important cervical spine injury was 0.6%.^1,15 This study outlined a clear method (the Canadian C-Spine Rule) for evaluating patients with normal GCS and determining by exam those who do not have clinically important cervical spine injuries. This method has been validated in the field.¹⁵ Other criteria have also been well studied to safely discriminate a subgroup without risk of cervical spine fracture.¹⁰ Many EMS systems have incorporated these methods of clinical clearance.

Trauma expert Peter Rhee, MD, and colleagues did a retrospective study of 4,390 blunt-assault patients and noted a cervical spine fracture rate of 0.4% and cervical spinal cord injury rate of 0.14%.⁶ Only 4 (0.03%) of 51 patients with fractures were considered to be unstable. There has been no study that specifically examines patients who fall from standing.

The subgroup that has been most studied is those who have penetrating trauma. One recent study led by Johns Hopkins’ Elliot Haut, MD, examined the national trauma registry for such patients.¹⁶ The authors demonstrated a doubling of mortality (OR 2.06) among patients who received cervical spine immobilization. It is unclear whether this implies causality or is a proxy for more severe injury. From more than 30,000 patients with penetrating trauma, 443 (1.43%) had spine fractures, and 116 (0.38%) had unstable spine fractures. Of those with unstable spine fractures, 86 (74%) had completed spinal injuries prior to immobilization. The authors concluded that in order to potentially benefit one person with spinal immobilization, 1,032 people would have to be immobilized. But in order potentially harm/contribute to one death, just 66 would have to be.

Many other case-control studies have also examined this issue.^6,17–22 A recent systematic review of the literature pointed out the low rate of unstable fractures and the relatively rare appearance of patients with unstable spine fractures and no neurologic deficits.²³ The authors, led by LSU’s Lance Stuke, MD, concluded there is no data to support routine spine immobilization in patients with penetrating injury to the neck, head or torso. They recommended the use of spinal immobilization only in the setting of obvious focal neurologic deficits. Following this logic, we could reach the same conclusion for patients who have suffered blunt assault and less-than-high-energy blunt trauma.

Complications

There are clearly clinical complications with cervical spinal immobilization as it is currently practiced. Pain is almost universal with the use of a hard board,^24–26 as well as the radiation and expense of x-rays and CTs. One recent study concluded that exposure to ionizing radiation (mostly from iatrogenic causes) is the leading environmental factor associated with breast cancer.²⁷ There are other potential problems with unclear clinical significance, such as mild respiratory compromise,²⁸ increased intracranial pressure^29,30 and the rare cases of distracting an unstable fracture.³¹

For such a commonly performed procedure, there has been a remarkable lack of progress in recent years on alternative methods of immobilization. The vacuum splint has some promise and should be further evaluated, especially for severely injured patients.³² It poses significant logistical issues to work out, such as decontamination and acceptance by trauma centers.

For patients with a much lower likelihood of cervical spinal cord injury, such as victims of blunt assaults and falls from standing or alcohol-intoxicated patients with minor scalp or facial injuries, we can consider other, much less restrictive methods of immobilization. These could range from using the hard collar without a board to using a soft roll with tape. We should be asking the inventive among us or our more creative prehospital supply companies to develop new and novel methods to accomplish less-restrictive immobilization. Alameda County is embarking on such a protocol. Those with severe trauma will be immobilized with a hard collar and backboard or a vacuum splint. Those with less-severe trauma will have spinal restriction with a hard collar alone or some other combination of soft restrictive devices.

Hopefully we can move away from the forest of used hard boards in the ambulance bays of our community hospitals and at the same time develop a saner policy for our patients with lower-energy injuries.

References

1. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA, 2001; 286: 1,841–8.

2. Orledge JD, Pepe PE. Out-of-hospital spinal immobilization: is it really necessary? Acad Emerg Med, 1998; 5: 203–4.

3. Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J, 2012 Sep 8 [epub ahead of print].

4. Grossman MD, Reilly PM, Gillett T, Gillett D. National survey of the incidence of cervical spine injury and approach to cervical spine clearance in U.S. trauma centers. J Trauma, 1999; 47: 684–90.

5. Lowery DW, Wald MM, Browne BJ, et al. Epidemiology of cervical spine injury victims. Ann Emerg Med, 2001; 38: 12–6.

6. Rhee P, Kuncir EJ, Johnson L, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma, 2006; 61: 1,166–70.

7. Morris CG, McCoy EP, Lavery GG. Spinal immobilisation for unconscious patients with multiple injuries. BMJ, 2004; 329: 495–9.

8. Scannell G, Waxman K, Tominaga G, Barker S, Annas C. Orotracheal intubation in trauma patients with cervical fractures. Arch Surg, 1993; 128: 903–5, discussion 5–6.

9. Meldon SW, Brant TA, Cydulka RK, Collins TE, Shade BR. Out-of-hospital cervical spine clearance: agreement between emergency medical technicians and emergency physicians. J Trauma, 1998; 45: 1,058–61.

10. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. 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. NEJM, 2000; 343: 94–9.

11. Domeier RM, Swor RA, Evans RW, et al. Multicenter prospective validation of prehospital clinical spinal clearance criteria. J Trauma, 2002; 53: 744–50.

12. Burton JH, Dunn MG, Harmon NR, Hermanson TA, Bradshaw JR. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma, 2006; 61: 161–7.

13. Domeier RM, Frederiksen SM, Welch K. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann Emerg Med, 2005; 46: 123–31.

14. Kwan I, Bunn F. Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Preh Dis Med, 2005; 20: 47–53.

15. Vaillancourt C, Stiell IG, Beaudoin T, et al. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med, 2009; 54: 663–71 e1.

16. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm than good? J Trauma, 2010; 68: 115–20, discussion 20–1.

17. Brown JB, Bankey PE, Sangosanya AT, Cheng JD, Stassen NA, Gestring ML. Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso. J Trauma, 2009; 67: 774–8.

18. Connell RA, Graham CA, Munro PT. Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma? Injury, 2003; 34: 912–4.

19. DuBose J, Teixeira PG, Hadjizacharia P, et al. The role of routine spinal imaging and immobilisation in asymptomatic patients after gunshot wounds. Injury, 2009; 40: 860–3.

20. Kaups KL, Davis JW. Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation. J Trauma, 1998; 44: 865–7.

21. Klein Y, Cohn SM, Soffer D, Lynn M, Shaw CM, Hasharoni A. Spine injuries are common among asymptomatic patients after gunshot wounds. J Trauma, 2005; 58: 833–6.

22. Lanoix R, Gupta R, Leak L, Pierre J. C-spine injury associated with gunshot wounds to the head: retrospective study and literature review. J Trauma, 2000; 49: 860–3.

23. Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE. Prehospital spine immobilization for penetrating trauma—review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma, 2011; 71: 763–9, discussion 9–70.

24. Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med, 1995; 26: 31–6.

25. Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med, 1994; 23: 48–51.

26. March JA, Ausband SC, Brown LH. Changes in physical examination caused by use of spinal immobilization. Preh Emerg Care, 2002; 6: 421–4.

27. Smith-Bindman R. Environmental causes of breast cancer and radiation from medical imaging: findings from the Institute of Medicine report. Arch Internal Med, 2012; 172: 1,023–7.

28. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Preh Emerg Care, 1999; 3: 347–52.

29. Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury, 1996; 27: 647–9.

30. Kolb JC, Summers RL, Galli RL. Cervical collar-induced changes in intracranial pressure. Amer J Emerg Med, 1999; 17: 135–7.

31. Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA, Kalantar SB, Hipp JA. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma, 2010; 69: 447–50.

32. Luscombe MD, Williams JL. Comparison of a long spinal board and vacuum mattress for spinal immobilisation. Emerg Med J, 2003; 20: 476–8.

Karl A. Sporer, MD, FACEP, FACP, is EMS medical director for Alameda County EMS in California. Reach him at karl.sporer@acgov.org.

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