Rethinking prehospital

c-spine immobilization

Terje Sundstrøm MD PhDK. G. Jebsen Brain Tumor Research Center

Department of NeurosurgeryHaukeland University Hospital

Bergen, Norway

Level II

§  Spinal immobilization of all trauma patients with a known or suspected CSI or SCI; however, experienced personnel should evaluate the need for immobilization during transport

§  Fully awake and communicable patients that are not intoxicated, without neck pain/tenderness, neurologically intact, and without distracting injuries should not be immobilized (NEXUS)

Level III

§  The preferred method of immobilization is the combination of a rigid collar and supportive blocks on a spine board with straps

§  Sandbags and tape alone should not be used and spinal immobilization in patients with penetrating trauma is not recommended

How frequent are cervical injuries?

§  Severe c-spine injury in Norway 2009-2012§  Median age 54§  Incidence 16.5 / 100.000 / year§  Spinal cord injury 13%§  18% operated

§  1-4% of major trauma patients§  1/5 have spinal cord injury§  More common if reduced consciousness

§  Up to 100 patients are immobilized for every patient that has a significant c-spine injury

Ref.: Hasler 2011 & 2012; ATLS 9th ed 2012; Demetriades 2000; Chiu 2001; Deasy 2011; Fredø 2014

Just as important as Airway control?

§  ABCs: Routine application of rigid collars

§  Uncertain effect on mortality, neurological injury, spinal stability, and of adverse effects

§  Growing body of evidence and opinion against this practice

Ref.: Rogers 1957; Bohlman 1979; Gunby 1981; ATLS 9th ed 2012; Kwan 2007; Hauswald 2002; Abram 2010; Deasy 2011; Benger 2009; Abram 2010; Sporer 2012; Sundstrøm 2014

How good are rigid collars at motion control?

§  Never examined in real trauma patients

§  Numerous studies in simulated environments (cadavers, healthy volunteers)§  Any form of stabilization is superior to no stabilization§  No benefit of adding collars to head blocks

Ref.: Deasy 2011; Conrad 2010; Horodyski 2011; Holla 2012; Chandler 1992; Graziano 1987; Podolsky 1983; Huerta 1987; Perry 1999; Shafer 2009

Do collars reduce secondary spinal cord injury?

§  Dubious claim: “3-25% of SCIs are secondary and result from inappropriate management”

§  5% of patients experience neurological worsening even with proper immobilization

§  New Mexico (collar) vs Malaysia (no collar): More neurological disability with a collar§  Patients maintain a position of comfort with muscle spasm protecting the

spine, and movements during transport are unlikely to generate sufficient energy to result in additional injury

Ref.: Hauswald 2000; Marshall 1987; Huang 2009; Thumbikat 2007; Tator 1991; Hauswald 1998; Sundstrøm 2014

What happens if cervical injuries are overlooked?

§  Five studies: Up to 8% of spinal injuries were missed, but there were no neurological deficits

§  But, delayed diagnosis can result in permanent deficits§  Pooled data: 52 injuries missed, 12 permanent deficits

§  NB! Application & removal of a trauma collar usually spans a couple of hours, whereas the window between trauma and diagnosis for missed injuries can be from days to weeks

Ref.: Armstrong 2007; Brown 1998; Domeier 2005; Domeier 2002; Stroh 2001; Gerrelts 1991; Davis 1993; Platzer 2006

§  Considerable force is required to fracture the cervical spine, and subsequent low-energy movements are unlikely to cause secondary spinal cord injury

§  Most spinal injuries are biomechanically stable in the acute phase, and unstable injuries that have not caused acute, irrevocable injuries are very rare

§  ‘‘It is likely that minor degrees of cervical spine movement are without consequence and more significant movement prevented by common sense”

Ref.: Hauswald 1998; Plumb 2013; Hauswald 2012

Potential harmful effects of collars§  Distraction of injured segment

§  Poorly fitted (reduced efficacy, increased risk)

§  Ankylosing spondylitis (5% of fx-patients)

§  Raised intracranial pressure (ca 4.5 mmHg)

§  Delays release and rescue procedures (including resuscitation)

§  More difficult trauma examination (missed injuries)

§  More difficult airway management (intubation, aspiration, respiratory restriction)

§  Pressure ulcers, discomfort and pain (confounding factors)

§  Radiology to ‘‘clear the neck’’ is more likelyRef.: Bivins 1988; Papadopoulos 1999; Podolsky 1983; Ben-Galim 2010; Hauswald 1998; Thumbikat 2007; Davies 1996; Mobbs 2002; Craig 1991; Kolb 1999; Hunt 2001; Goutcher 2005; Holla 2012; Heath 1994; Thiboutot 2009; LeGrand 2007; Santoni 2009; Doran 1995; Patterson 2004; Meschino 1992; Shatney 1995; Bauer 1988; Totten 1999; Lockey 1999; Houghton 1996; Hewitt 1994; Hodgson 2000; Houghton 1996; Sheerin 2007; Chan 1994; Chan 1996; Hauswald 2000; Main 1996; Walton 1995

Potential harmful effects of collars§  Distraction of injured segment

§  Poorly fitted (reduced efficacy, increased risk)

§  Ankylosing spondylitis (5% of fx-patients)

§  Raised intracranial pressure (ca 4.5 mmHg)

§  Delays release and rescue procedures (including resuscitation)

§  More difficult trauma examination (missed injuries)

§  More difficult airway management (intubation, aspiration, respiratory restriction)

§  Pressure ulcers, discomfort and pain (confounding factors)

§  Radiology to ‘‘clear the neck’’ is more likelyRef.: Bivins 1988; Papadopoulos 1999; Podolsky 1983; Ben-Galim 2010; Hauswald 1998; Thumbikat 2007; Davies 1996; Mobbs 2002; Craig 1991; Kolb 1999; Hunt 2001; Goutcher 2005; Holla 2012; Heath 1994; Thiboutot 2009; LeGrand 2007; Santoni 2009; Doran 1995; Patterson 2004; Meschino 1992; Shatney 1995; Bauer 1988; Totten 1999; Lockey 1999; Houghton 1996; Hewitt 1994; Hodgson 2000; Houghton 1996; Sheerin 2007; Chan 1994; Chan 1996; Hauswald 2000; Main 1996; Walton 1995

Informationfromalargevolumeofstudiesdisfavoringtheuseofcollarshasnotbeensufficientlyappreciatedandhashadamarginalinfluenceonthepracticeofprehospitalspinalimmobilization

Moving our practice forward

§  Low quality evidence for and against collars

§  Few patients need spinal immobilization, and clearance protocols should be optimized to identify these high-risk patients (NEXUS, CCSR, others)

§  Systematic literature review + Expert consensus

§  Prospective clinical trial unlikely§  ATLS: “... unlikely to occur in North America, but could perhaps be done

elsewhere”

Ref.: Armstrong 2007; Brown 1998; Domeier 2005; Domeier 2002; Stroh 2001; Gerrelts 1991; Davis 1993; Platzer 2006

Recent developments

Application of a cervical collar is not recommended

Manual in-line stabilization is a suitable alternative to a cervical collar

Adequate stabilization can be achieved with manual in-line stabilization or head blocks (full guideline!)

Selective spinal motion restriction protocols are needed...

Ref.: Connor 2013; ACEP 2015; Zideman 2015; Kornhall 2017

Summary

§  Spinal immobilization à Spinal motion restriction

§  Uniform protocols à Triage-based guidelines

§  Rigid collar à Head blocks / Manual in-line stabilization

§  Hard surface stretchers à Soft surface stretchers