Spinal immobilization in trauma patients: is it really necessary? Mark Hauswald, MD,*† and Darren Braude, MD, MPH†‡§

The acute management of potential spinal in trauma In the early days of trauma care, patients were brought to patients is undergoing radical reassessment. Until recently, it the hospital by any means available. Eventually, ambu- was mandatory that nearly all trauma patients be immobilized lances began transporting many of these patients but with a back board, hard , head restraints, and without providing medical treatment en route. It was not body strapping until the spine could be cleared radiologically. until the early 1970s that emergency medical technicians This practice is still recommended by many references. It is were routinely trained to provide care before the patient now clear that this policy subjects most patients to expensive, arrived at the hospital. Initially, the care provided was painful, and potentially harmful treatment for little, if any, not based on direct evidence of efficacy; rather, it was benefit. Low-risk patients can be safely cleared clinically, even based on reasonable assumptions and extrapolation from by individuals who are not physicians. Patients at high risk for in-hospital treatment. Prehospital care came to include spinal instability should be removed from the hard surface to spinal immobilization based on the logical premise that avoid tissue ischemia. Understanding the rationale for these some trauma patients had spinal injuries, and some of changes requires knowledge of mechanisms of , these injuries destabilized the spinal column. Deteriora- physiology, and biomechanics as they apply to spinal tion of spinal cord injuries has been attributed to move- injuries. Curr Opin Crit Care 2002, 8:566–570 © 2002 Lippincott Williams & ment of these destabilized injuries after the initial event Wilkins, Inc. and before definitive fixation [1••], but this relation- ship is not well substantiated in the literature. Spinal immobilization offered the promise of preventing the *Office of Clinical Affairs, †Department of , ‡Lifeguard Air exacerbation of devastating injuries with apparently little Transport, and §Emergency Medical Service Academy, University of New Mexico, Albuquerque, New Mexico, USA. downside. Soon these practices became a fundamental tenet of trauma care. Spinal immobilization, however, Correspondence to Mark Hauswald, MD, Office of Clinical Affairs, University of New Mexico Health Sciences Center, CRTC Room B-30, Albuquerque, NM has never been proven to prevent secondary spinal injury 87131-5121, USA; e-mail: [email protected] [2]. This dogma is now undergoing radical reassessment, Current Opinion in Critical Care 2002, 8:566–570 and researchers are asking whether spinal immobilization is necessary in the routine early treatment of trauma Abbreviations patients [3]. EMS emergency medical service NEXUS National Emergency X-Radiography Utilization Study The basis for this heresy lies in a reevaluation of the ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc. underlying mechanism for . Permanent spinal cord injury requires partial or complete transection of the cord or axonal necrosis, which requires energy deposition within the cord or its blood vessels. Because most spinal cord injuries are the result of , this energy transfer occurs at the point of impact. Often there are several impacts involved. For instance, a pa- tient may strike the windshield during a rapid decelera- tion motor vehicle collision and subsequently strike the pavement at a high rate of speed after ejection. At the time of impact, tremendous energy is transferred to the cord. In some cases, the cord is actually partially or com- pletely transected by bone fragments or extreme move- ment of the bones out of their normal alignment. It seems intuitively unlikely that subsequent movement of the spine within its normal range of motion and essen- tially without resistance would add significantly to the damage already done. Cases of deterioration from move- ment of unstable spinal injuries during extrication, trans- port, and initial evaluation undoubtedly do occur, but it is clear from clinical experience and the literature that 566 Is spinal immobilization necessary? Hauswald and Braude 567 this is an uncommon problem. In fact, the only study that (2) How should these patients with possible unstable compared patients who were and were not immobilized injuries be immobilized? during transport showed an increased risk of neurologic (3) Which trauma patients require radiography in the injury in the immobilized population [3]. emergency department? (4) How can the spine be cleared in the obtunded patient? The term unstable is used differently among different (5) Are there special considerations for pediatric patients? specialties and for different clinical situations. A patient (6) Are there significant differences between patients may be at risk for neurologic deterioration for a variety of with blunt versus penetrating injury? reasons and yet be mechanically stable. Other patients may be at risk for bony remodeling and physical defor- Which trauma patients might benefit from mity from long-term, unopposed gravitational force [4•] spinal immobilization during transport? but may be both neurologically and mechanically stable Traditional prehospital guidelines have called for the im- in the short term. In most cases, the term unstable de- mobilization of any patient who has sustained a traumatic notes injuries meeting the standard radiologic definition mechanism of injury with any potential for energy trans- of two-column disruption [5]. This is a sensitive rather fer to the neck. This practice is unnecessary [20]. Some than specific definition; injuries that have two-column emergency departments routinely perform radiographs disruption may have no associated spinal cord injury and on anyone who arrives immobilized [21], and many pa- will not necessarily deteriorate from movement. The re- tients develop pain from immobilization itself [9,10•]. mainder of this report concerns injuries that have short- For every patient seen by the or ICU, tens term biomechanical instability—that is, those that may to hundreds are evaluated and cleared by emergency result in increased neurologic injury if not protected dur- physicians. ing initial evaluation and treatment. Several recent studies have demonstrated that emer- gency medical service (EMS) providers can use simple If it is assumed that spinal manipulation is not the major guidelines to determine which patients are at risk for factor causing secondary injury, then how does one ex- clinically significant (ie, potentially unstable) spinal inju- plain the clinical deterioration of spinal cord injury seen ries and forego immobilization in the rest [20,22–24]. commonly in clinical practice? A variety of factors con- This practice of selective immobilization is distinguished tribute to spinal cord ischemia, including vascular com- from actual spine clearance [20]. Interestingly, these pro- promise, hypotension, hypoxia, edema, electrolyte shifts, tocols for selective prehospital spinal immobilization are free radical formation, and inflammatory mediators independent of mechanism of injury. They evaluate for [6,7,8••]. Although it is clearly impossible to perform neck pain, neck tenderness, neurologic deficit, and reli- controlled trials comparing outcomes with and without ability of the physical examination, thereby excluding these factors, strong evidence from animal models and intoxicated, hemodynamically unstable, and obtunded clinical associations indicates that these factors are cru- patients. Many EMS systems also exclude multisystem cial determinants of final outcome. trauma patients. Therefore, most patients seen by the trauma team will still arrive immobilized. These selec- This whole issue would be irrelevant if immobilization tive immobilization protocols are becoming more com- was benign, but it is not. Documented adverse effects mon and are endorsed by the National Association of include pain [9,10•], restriction of breathing [11–13], tis- EMS Physicians [25]. The new American Association of sue ischemia [14] with resulting decubiti formation Neurological Surgeons guidelines, however, still empha- [15,16], and increased intracranial pressure [17–19]. size mechanism of injury rather than the physical exami- Other adverse effects include difficult nursing care, in- nation as a means to make these decisions in the prehos- creased risk of aspiration, increased trans- pital setting [1••]. ports, treatment and evaluation delays, increased radio- graphs, and increased costs. How should patients with possible unstable injuries be immobilized? Therefore, the answer to the title question is that spinal Most trauma patients in the United States arrive at the immobilization in trauma patients is necessary some- hospital immobilized. Routinely, this immobilization in- times; however, this answer provides no practical guid- cludes a hard spine board, a cervical collar, and a means ance to the practitioner. The real issue is how harm to to prevent rotation of the head. Spine boards were de- the patient can be minimized from underimmobilization veloped as a means of extricating patients from a motor or overimmobilization. The issue can be restated as sev- vehicle while maintaining spinal precautions; they were eral clinically relevant questions: not intended as an immobilization device [26]. Some EMS services use padded boards or vacuum splints, (1) Which trauma patients might benefit from spinal im- which lessen but do not eliminate pain [10•,14]. Because mobilization during transport and initial evaluation? most trauma patients are close to a hospital, and leaving 568 Trauma the patient on the board after extrication is efficient and gardless of whether the results of their cervical spine eases transfer to and from the ambulance , it is radiographs and computed tomography (CT) scans are often reasonable to leave the patient on the board. Un- negative [31–33]. This definitive study may be a mag- fortunately, this practice has been extrapolated to imply netic resonance image or dynamic fluoroscopic that leaving the patient on the board is necessary for flexion/extension studies. Usually, this study is deferred immobilization, and patients remain inappropriately on for as long as 1 week until the patient improves enough hard spine boards in the emergency department [27,28]. to be clinically evaluated, or dies. During this period, the A hard cervical collar and a firm mattress are the standard patient is maintained with routine spinal precautions. means of immobilizing patients with documented un- Unfortunately, these precautions significantly compli- stable injuries in the emergency department or ICU be- cate nursing care in the ICU and expose the patient to all fore the application of traction or definitive stabilization. of the aforementioned risks. The other group counts on the rarity of unstable ligamentous injury in the setting of Patients who arrive at the hospital immobilized on a completely normal radiographs. If the results of the ini- spine board or vacuum splint should be evaluated im- tial spine work-up, including radiographs and possibly mediately. If continued spinal immobilization is deemed CT, are normal, spinal precautions are discontinued necessary, the patient should be carefully log rolled off of [34,35]. The current recommendations of the American the board and placed on a firm mattress. This transfer Association of Neurological Surgeons encompass all of may be briefly delayed for initial stabilization and emer- these options [36••]. gency radiographs, but leaving patients on a board for other reasons is medically inappropriate. Prehospital pa- Are there special considerations for tients with prolonged transport times or patients being pediatric patients? transferred from one facility to another should not re- Because most young children do not tolerate immobili- main on a hard board. zation well, it is ideal to avoid it whenever possible. Chil- Which trauma patients require radiography dren tend to injure their upper spine and often die be- in the emergency department? fore transport. Fortunately, pediatric spinal injuries are This is one of the best-researched questions in emer- rare, and many of the injuries that do occur do not in- gency medicine. The multicenter National Emergency volve an underlying unstable spinal injury [37,38]. X-Radiography Utilization Study (NEXUS) enrolled Therefore, if pediatric trauma patients were never im- 34,069 patients [29]. The investigators determined that mobilized, an unstable injury would rarely be missed. only patients with midline neck tenderness, focal neu- However, considering the potential tragic outcome of an rologic deficit, altered mental status, intoxication, or unrecognized injury, the goal should still be to identify painful distracting injury require radiographs to exclude patients at high risk for unstable injury and immobilize spinal injury. Neck pain was not a criterion nor was a them appropriately. mechanism of injury. These criteria were 99.6% sensitive for clinically significant (ie, potentially unstable) injuries. Given the lower numbers of pediatric spine injuries, it is A large trial in Canada derived a different set of criteria, much harder to conduct powerful research. There is in- which appear to be equally sensitive but more compli- sufficient evidence to recommend applying selective im- cated to use [30••]. These criteria are currently under- mobilization criteria to young children in the prehospital going validation. setting. However, the criteria are commonly applied, and the practice seems reasonable in some cases, particularly The NEXUS criteria are very similar to the prehospital in children old enough to converse. There is evidence to criteria mentioned. Therefore, as more EMS systems use suggest that children who can communicate adequately selective spinal immobilization protocols, more of the may be evaluated for clinical clearance in the emergency patients who arrive immobilized will indeed require ra- department in the same manner as adults [39••,40••]. diographs. For trauma and critical care specialists, the Once the decision is made to immobilize, anatomic dif- spectrum bias of their patient population will less com- ferences must be considered to achieve a neutral posi- monly allow clearance without radiographs. However, tion, particularly the proportionally larger head and these criteria can be applied to any patient who has a prominent occiput. reliable clinical examination. Although many clinicians automatically consider any fracture to be a distracting Are there significant differences between injury affecting examination reliability, others are more patients with blunt versus penetrating comfortable making case-by-case decisions. mechanisms of injury? How is the spine cleared in the case of the Patients with certain kinds of penetrating injuries are obtunded patient? extremely unlikely to have biomechanical unstable cer- There seem to be two major schools of thought on this vical or thoracic spines. For example, patients who are issue. One group obtains a definitive study to rule out shot in the head do not absorb enough energy to break ligamentous injury in all obtunded trauma patients, re- the spine. Kaups and Davis [41] looked at 215 patients Is spinal immobilization necessary? Hauswald and Braude 569 with gunshot wounds to the head. The only three pa- 3 Hauswald M, Ong G, Tandberg D, et al.: Out-of-hospital spinal immobiliza- tion: its effect on neurologic injury. Acad Emerg Med 1998, 5:214–219. tients with spinal injury had direct wounds to the spinal 4 Vaccaro AR, Silber JS: Post-traumatic spinal deformity. Spine 2001, column with entrance or exit wounds suggesting trans- • 26(suppl):S111–S118. cervical trajectory. There were no indirect spinal injuries. This review examines the long-term issues associated with spine injury and Newtonian physics requires that the energy imparted by presents alternative perspectives on instability and neurologic deterioration. 5 Davis F: Spinal stability as defined by the three-column concept in acute a bullet decelerated to a stop by tissue is equal to that of spine trauma. Clin Orthop Rel Res 1984, 189:65–76. the recoil of the pistol. If the recoil from a weapon placed 6 Harrop JS, Sharan AD, Vaccaro AR, et al.: The cause of neurologic deterio- against the side of a head does not deposit enough en- ration after acute cervical spinal cord injury. Spine 2001, 26:340–346. ergy to break the neck, then being shot in the head 7 Amar A, Levy M: Pathogenesis and pharmacological strategies for mitigating should not, either. secondary damage in acute spinal cord injury. Neurosurgery 1999, 44:1027. 8 McCormick P: Blood pressure management after acute spinal cord injury. •• Section on Disorders of the Spine and Peripheral Nerves of the American The situation is perhaps different for patients who have Association of Neurological Surgeons. Neurosurgery 2002, 50:58–62. direct penetrating injuries to the spine. Spinal cord in- This is another chapter from the Neurosurgery guidelines and is a good review of the evidence on the effects of hypotension on spinal cord injury. jury from usually occurs at the time 9 Chan D, Goldberg R, Tascone A, et al.: The effect of spinal immobilization on of injury from direct cord damage and not from the cre- healthy volunteers. Ann Emerg Med 1994;23:48–51. ation of a biomechanically unstable lesion. However, 10 Cross DA, Baskerville J: Comparison of perceived pain with different immo- firearms can generate enough energy to disrupt the clas- • bilization techniques. Prehosp Emerg Care 2001, 5:270–274. This study involved healthy volunteers placed on hard spine boards or two different sic two columns, and unstable injuries have been re- vacuum mattresses. Not surprisingly, the spine boards caused more pain. ported in a small percentage of patients [42–44]. 11 Bauer D, Kowalski R: Effect of spinal immobilization on pulmonary functionin the healthy, non-smoking man. Ann Emerg Med 1988, 17:915–918. In the absence of controlled studies, a logical approach is 12 Schafermeyer R, Ribbeck BM, Gaskins J, et al.: Respiratory effects of spinal to immobilize any victim of penetrating firearm trauma immobilization in children. Ann Emerg Med 1991, 20:1017–1019. who has a focal neurologic deficit or altered mental status 13 Totten V, Sugarman D: Respiratory effects of spinal immobilization. Prehosp Emerg Care 1999, 3:347–352. in whom the trajectory likely traverses the spinal col- 14 Hauswald M, Hsu M, Stockoff C: Maximizing comfort and minimizing ische- umn, provided that immobilization does not interfere mia: a comparison of four methods of spinal immobilization. Prehosp Emerg with management of the airway or bleeding vessels. Care 2000, 4:250–252. 15 Linares H, AR M, Suarez E, et al.: Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics 1987, Conclusions 10:571–573. Like much of medicine, spinal immobilization is a con- 16 Mawson AR, Biundo JJ Jr, Neville P, et al.: Risk factors for early occurring cept that became the standard of care based on common pressure ulcers following spinal cord injury. Am J Phys Med Rehabil 1988, sense rather than research. There are convincing biome- 67:123–127. chanical arguments and some preliminary research that 17 Kolb JC, Summers RL, Galli RL: Cervical collar-induced changes in intracra- nial pressure. Am J Emerg Med 1999, 17:135–137. suggest that spinal immobilization may not be necessary, 18 Hunt K, Hallworth S, Smith M: The effects of rigid collar placement on intra- even in many trauma patients with unstable injuries. Un- cranial and cerebral perfusion pressures. Anesthesia 2001, 56:511–513. til further research clarifies which injuries, if any, truly 19 Mobbs R, Stoodley M, Fuller J: Effect of cervical hard collar on intracranial benefit from immobilization, immobilization will remain pressure after . AustNZJSurg 2002, 72:389–391. the standard practice. The clinician’s goal should be to 20 Stroh G, Braude D: Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. apply it only to those patients predicted to be at risk for Ann Emerg Med 2001, 37:609–615. unstable injury and to do as little harm from immobili- 21 Cone D, Wydro G, Mininger C: Current practice in clinical cervical spine zation as possible. clearance: implication for EMS. Prehosp Emerg Care 1999, 3:42–46. 22 Domeier RM: Prospective validation of out-of-hospital spinal clearance crite- References and recommended reading ria: a preliminary report. Acad Emerg Med 1997, 4:643–646. Papers of particular interest, published within the annual period of review, 23 Domeier RM: Prehospital clinical findings associated with spinal injury. Pre- have been highlighted as: hosp Emerg Care 1997, 1:11–15. • Of special interest 24 Domeier RM, Evans RW, Swor RA, et al.: The reliability of prehospital clinical •• Of outstanding interest evaluation for potential spinal injury is not affected by mechanism of injury. Prehosp Emerg Care 1999, 3:332–337. 1 McCormick P: Cervical spine immobilization before admission to the hospital. •• Section on Disorders of the Spine and Peripheral Nerves of the American 25 Domeier RM: Indications for prehospital spinal immobilization. National Asso- Association of Neurological Surgeons. Neurosurgery 2002, 50(suppl): ciation of EMS Physicians Standards and Practice Committee. Prehosp S7–S17. Emerg Care 1999, 3:251–253. This is the first chapter in the latest Guidelines for the Management of Acute Cer- vical Spine Injuries from the Congress of Neurological Surgeons and the American 26 Hauswald M, McNally T: Confusing extrication with immobilization: the inap- Association of Neurological Surgeons, which appeared as a supplement in Neu- propriate use of hard spine boards for interhospital transfers. Air Med J 2000, rosurgery. This is a great resource for anyone taking care of trauma patients. Each 19:126–127. chapter begins with a summary of the evidence, followed by a review of the litera- 27 Lerner EB, Moscati R: Duration of patient immobilization in the ED. Am J ture. Unfortunately, we disagree with the conclusions of this particular chapter. Emerg Med 2000, 18:28–30. There is enough evidence that selective immobilization based on clinical criteria rather than mechanism of injury should at least be an option for prehospital 28 Cooke MW: Use of the within the accident and emergency de- management. partment. J Accid Emerg Med 1998, 15:108–109. 2 Kwan I, Bunn F, Roberts I: Spinal immobilization for trauma patients. In The 29 Hoffman JR, Mower WR, Wolfson AB, et al.: Validity of a set of clinical criteria Cochrane Library, issue 2. Oxford: Update Software; 2002. to rule out injury to the cervical spine in patients with blunt trauma: National 570 Trauma

Emergency X-Radiography Utilization Study Group. N Engl J Med 2000, 37 Kokoska ER, Keller MS, Rallo MC, et al.: Characteristics of pediatric cervical 343:94–99. spine injuries. J Pediatr Surg 2001, 36:100–105. 30 Stiell I, Wells GA, Vandemheen KL, et al.: The Canadian c-spine rule for ra- 38 Patel JC, Tepas JJ, Mollitt DL, et al.: Pediatric cervical spine injuries: defining •• diography in alert and stable trauma patients. JAMA 2001, 286:1841–1848. the disease. J Pediatr Surg 2001, 36:373–376. This study is the Canadian answer to the NEXUS trial. This is actually just the derivation of a clinical decision rule for when to obtain c-spine radiographs in 39 McCormick P: Management of pediatric cervical spine and spinal cord inju- asymptomatic trauma patients but includes almost 9000 patients. Prospective vali- •• ries. Section on Disorders of the Spine and Peripheral Nerves of the American dation of the rule is pending. Association of Neurological Surgeons. Neurosurgery 2002, 50(suppl): S85–S99. 31 Brooks RA, Willett KM: Evaluation of the Oxford protocol for total spinal clear- This chapter of the Neurosurgery guidelines reviews all of the critical issues in the ance in the unconscious trauma patient. J Trauma 2001, 50:862–867. early assessment and management of pediatric spinal injury. Most interestingly, 32 Harris MB, Kronlage SC, Carboni PA, et al.: Evaluation of the cervical spinein they support the use of clinical rather than radiographic assessment of the spine in the patient. Spine 2000, 25:2884–2891; discussion 2892. selected pediatric patients. 33 Sees DW, Rodriguez Cruz LR, Flaherty SF, et al.: The use of bedside fluo- 40 Viccellio P, Simon H, Pressman BD, et al.: A prospective multicenter study of roscopy to evaluate the cervical spine in obtunded trauma patients. J Trauma •• cervical spine injury in children. Pediatrics [serial online] 2001, 108:E20. 1998, 45:768–771. This study presents the pediatric subgroup data from the NEXUS trial. Because spinal injury is rare in young children, the numbers are small, but these are the best 34 Chiu WC, Haan JM, Cushing BM, et al.: Ligamentous injuries of the cervical data available on clinical spine clearance in pediatric patients. spine in unreliable blunt trauma patients: incidence, evaluation, and outcome. J Trauma 2001, 50:457–463. 41 Kaups KL, Davis JW: Patients with gunshot wounds to the head do not re- quire cervical spine immobilization and evaluation. J Trauma 1998, 44:865– 35 Davis JW, Kaups KL, Cunningham MA, et al.: Routine evaluation of the cer- 867. vical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. J Trauma 2001, 50:1044–1047. 42 Apfelbaum JD, Cantrill SV, Waldman N: Unstable cervical spine without spi- nal cord injury in penetrating neck trauma. Am J Emerg Med 2000, 18:55–57. 36 McCormick P: Radiographic assessment of the cervical spine in symptomatic •• trauma patients. Section on Disorders of the Spine and Peripheral Nerves of 43 Cornwell EE III, Chang DC, Bonar JP, et al.: Thoracolumbar immobilization for the American Association of Neurological Surgeons. Neurosurgery 2002, trauma patients with torso gunshot wounds: is it necessary? Arch Surg 2001, 50(suppl):S36–S43. 136:324–327. This chapter of the Neurosurgery supplement reviews the evaluation of the spine in the obtunded trauma patient. Based on the available evidence, the authors support 44 Isiklar ZU, Lindsey RW: Low-velocity civilian gunshot wounds of the spine. very diverse practices. Orthopedics 1997, 20:967–972.