The Immo Traffic Light System as a Decision-Making Tool for Prehospital Spinal Immobilization—A Systematic Review

Abstract

Background: Spinal injuries are difficult injuries to assess yet can be associated with significant neurological damage. To avoid secondary damage, immobilization is considered state of the art trauma care. The indication for spinal immobilization must be assessed, however, for potential complications as well as its advantages and disadvantages.

Methods: This systematic review addressing the question of the correct indication for spinal immobilization in trauma patients was compiled on the basis of our previously published analysis of possible predictors from the Trauma Registry of the German Society for Trauma Surgery. A Delphi procedure was then used to develop suggestions for action regarding immobilization based on the results of this review.

Results: The search of the literature yielded 576 publications. The 24 publications included in the qualitative analysis report of 2 228 076 patients. A decision tool for spinal immobilization in prehospital trauma care was developed (Immo traffic light system) based on the results of the Delphi procedure. According to this system, severely injured patients with blunt trauma, severe traumatic brain injury, peripheral neurological symptoms, or spinal pain requiring treatment should be immobilized. Patients with a statistically increased risk of spinal injury as a result of the four cardinal features (fall >3m, severe trunk injury, supra clavicular injury, seniority [age >65 years]) should only have their spinal motion restricted after weighing up the pros and cons. Isolated penetrating trunk injuries should not be immobilized.

Conclusion: High-quality studies demonstrating the benefit of prehospital spinal immobilization are still lacking. Decision tools such as the Immo traffic light system can help weigh up the pros and cons of immobilization.

Figure 1

PRISMA flow diagram of literature search and study selection

Figure 2

The Immo traffic light system for responsive adult patients. The ABC approach to the unstable patient has priority over immobilization. With “yellow” patients or patients with more than one of the 4 cardinal feature points, there should be a sound justification why, after appropriate risk assessment, immobilization was not performed but instead only restriction of movement. The subjective parameter “pain” requires assessment and interpretation by a qualified member of the medical staff, as does the parameter “obviously severely injured”. TBI, traumatic brain injury; GCS, Glasgow Coma Scale; NRS, numeric rating scale