Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries - A NAEMSP Comprehensive Review and Analysis of the Literature

Abstract

Objectives: Spinal motion restriction (SMR), requiring the use of a cervical collar and allowing for use of a vacuum splint or ambulance cot, and spinal immobilization, requiring the use of a backboard and a cervical collar, have long been established as the standard of care in the prehospital management of trauma. Both techniques are based on the hypothesis that post-injury movement of the spinal column may lead to the development of delayed neurological deficits. However, these techniques, which have the potential for significant patient harm, are without definitive evidence of clinical benefit. The objective of this review is to evaluate the potential pathophysiology to delayed neurological injury, and examine the potential harms and benefits of spinal immobilization and SMR.

Methods: A structured review of the literature was performed within the National Association of EMS Physicians (NAEMSP) Trauma Compendium Series. Searches were performed in PubMed, Embase, CINAHL, and Web of Science dating back to 1900 looking for manuscripts that addressed the pathophysiology of delayed neurological injury as well as the harms, and benefits, to spinal immobilization and SMR.

Results: Out of 3944 manuscripts screened, 115 manuscripts were identified. Noting that some manuscripts answered multiple study questions - 14 studies addressed the pathophysiology of disease to the phenomenon of delayed neurological injury, 55 studies examined the harms of immobilization procedures, 58 studies addressed the effectiveness of immobilization procedures, and 7 studies addressed other factors. Two case series were identified hypothesizing post-injury movement as the cause of delayed neurological injury; and 8 retrospective studies, including two case control studies and three retrospective cohort studies, were identified showing an association between hypoperfusion and worsening neurological injury. There were 55 studies showing harms, and no studies showing a definitive benefit to spinal immobilization.

Conclusions: There are no data in the published literature to support spinal immobilization and spinal motion restriction as standard of care. Efforts aimed to reduce the use of cervical collars should be considered, and the use of backboards and full body vacuum splints should be limited to the point in time of active patient extrication.