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Three Part Question

In [adults who are alert (Glasgow Coma Score 15 with no intoxication) following trauma] does [cervical spinal immobilisation versus no cervical spinal immobilisation] reduce the incidence of [neurological deficit]?

Clinical Scenario

A 37-year-old man is involved in a rear-end shunt road traffic collision (RTC). He is alert and is brought to hospital with no cervical spine immobilisation in place. You wonder whether efforts should have been made to immobilise his cervical spine to protect from potential spinal cord injury.

Search Strategy

Medline 1946 - week 1 June 16. [(cervical AND spine).ti,ab OR c-spine.ti,ab OR (C AND Spine).ti,ab OR (spinal AND cord AND injury).ti,ab OR pre-hospital.ti,ab OR prehospital.ti,ab
OR paramedic.ti,ab
OR (suspected adj2 spinal AND cord AND injur*).ti,ab
OR (suspected adj2 SCI).ti,ab
OR (suspected AND spinal AND cord AND injur*).ti,ab
OR (potential AND spinal AND cord AND injur*).ti,ab
OR (potential AND SCI).ti,ab
OR exp TRANSPORTATION OF PATIENTS/] AND [(spin* AND immobili*).ti,ab OR (spin* AND stabili*).ti,ab
OR (cervical AND collar).ti,ab
OR (c-spine AND clearance).ti,ab OR (scoop AND stretcher).ti,ab
OR (spin* AND board OR longboard OR immobili* AND board)].

Search Outcome

4870 titles were found. Review of title identified 124 potential studies. Interrogation of title and abstract revealed 78 articles; there were 5 full text narrative reviews and 1 retrospective cohort study were relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hauswald M et al. 1998 United States	454 patients with spinal injuries who were transported directly from the scene of the incident to study hospital. One group (n=120) were not immobilised during transport. The other group (n=334) were immobilised.	Retrospective cohort study.	‘Neurological disability’ as defined by study authors.	13 patients (11%) in the non-immobilised group developed neurological disability compared to 70 (21%) in the immobilisation group. Less neurological disability in the non-immobilised cohort with odds ratio calculated at 2.03, correlating with <2% chance of immobilisation being beneficial.	Comparison made between participants from 2 different countries, with different classifications of disabling injury. Method of immobilisation not described. Patients in non-immobilised group transported to hospital by non-medical personnel, so had no pre-hospital care. Small sample size in both groups. GCS not measured in patient groups, unable to distinguish whether patients were alert, as per the three-part question, or obtunded.
				Less neurological disability in the non-immobilised cohort with odds ratio calculated at 2.03, correlating with <2% chance of immobilisation being beneficial.

Comment(s)

Hauswald directly compared immobilisation to no immobilisation, but there were methodological flaws, low population numbers and the method of immobilisation was not well defined. It is unclear from this study whether spinal immobilisation reduces the incidence of neurological deficit. There is a low incidence of confirmed spinal injury, particularly in those who are alert and conscious. Little is known about the rate of secondary spinal cord injury (caused by inadequate spinal immobilisation). As such designing a randomised control trial comparing immobilisation to no immobilisation would require significant population sizes to sufficiently power the study to show statistical significance.

Editor Comment

Trauma

Clinical Bottom Line

There is insufficient evidence to determine any benefit (or harm) in spinal immobilisation of alert trauma patients. Further high quality evidence is required before any recommendation can be made, and in the meantime, local policy should be followed.

References

1. Hauswald M, Ong G, Omar Z, et al. Out-of-hospital spinal immobilization: its effect on neurological injury. Acad Emerg Med 1998;5:214-219