Lack of Association between Cervical Spine Injuries and Prehospital Immobilization: From Tradition to Evidence

Abstract

Background: Cervical spine (C-spine) trauma usually results from blunt injuries and is traditionally managed by prehospital spinal immobilization using a cervical collar. We sought to examine if prehospital C-spine immobilization is associated with actual C-spine injuries and what factors are associated with the decision to immobilize the C-spine. Methods: We retrospectively analyzed blunt trauma patients treated by Israeli Defense Force (IDF) medical teams from 2015 to 2020. Children, penetrating injuries, and non-threatening injuries were excluded. Demographic data, injury characteristics, and prehospital information were collected from the IDF Trauma Registry's electronic medical records and merged with corresponding hospital data from the Israeli National Trauma Registry. Results: Overall, 220 patients were included, with a mean age of 32 and a predominance of male patients (78%). Most injuries were due to motor vehicle collisions (77%). In total, 40% of the patients received a cervical collar. C-spine injuries were present in 8%, of which 50% were immobilized with a cervical collar. There were no significant differences in the incidences of C-spine injuries or disability outcomes with or without collar immobilization. The use of a collar was significantly associated with backboard immobilization (OR = 14.5, p < 0.001) and oxygen use (OR = 2.5, p = 0.032). Conclusions: Prehospital C-spine immobilization was not associated with C-spine injury or neurological disability incidences. C-spine immobilization by medical providers may be influenced by factors other than the suspected presence of a C-spine injury, such as the use of a backboard. Clear clinical guidelines for inexperienced medical providers are called for.

Keywords: cervical spine; clinical practice guidelines; prehospital immobilization; trauma.

Figure 1

Comparison of cervical spine management protocols. CCS = Canadian cervical spine rule; NEXUS = national emergency X-radiography utilization study; MTLS = military trauma life-support protocols of the Israeli Defense Forces; PHTLS = prehospital life-support protocols; MDA = Magen David Adom (the Israeli civilian organization for prehospital care) protocols. (*) The CCS and the NEXUS criteria are meant to indicate spinal imaging in-hospital; the MTLS, PHTLS, and MDA protocols are meant to indicate spinal immobilization in the prehospital setting.