Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Is there any protective effect from EMS spinal immobilization? Part I

 

Is there any protective effect from EMS spinal immobilization?

The way to find out is to look at the evidence. I do not see anything in any papers supporting the protective effect of strapping the patient to a long spine board with a rigid collar around the neck.

There is a rare condition – deterioration of neurologic function following trauma.

How rare?
 

During the period 1988 through 1993, approximately 12,700 trauma patients were admitted to inpatient services at the U.S. hospital and 16.600 to the University of Malaysia.[1]

 

Out of the approximately 30,000 trauma patients there were 454 spinal injuries. In the US there were 334 spinal injuries out of 12,700 trauma patients. That means that just 2.6% of the immobilized patients actually had any kind of spinal injury. If the goal is to encourage people to do something the wrong way, doing it routinely for no possible benefit is one way to accomplish that goal.

The American EMS study participants had to immobilize 37 patients with no spinal injury for every 1 patient with a spinal injury.

If strapping the patient to a long spine board with a rigid collar around the neck is a completely good and wonderful treatment, that helps every patient with a spinal cord injury, that means the NNT (Number Needed to Treat[2]) is 38.

Coincidentally, I count 38 backboards (and one scoop) in this picture.

 

Picture credit from Voodoo Medicine Man.
 

We have to assume a lot to get an NNT of 38.

How much evidence is there of benefit from strapping the patient to a long spine board with a rigid collar around the neck?

None.

In this study, the patients strapped to a long spine board with a rigid collar around the neck did not appear to receive any benefit from this wonderful goodness of the treatment.
 

The real NNT for these patients appears to be infinite.

Zero out of 12,700.

Does that mean that we just need to treat more patients?

If it helps just one patient – it’s worth it!
 

That is only true if –

The treatment causes no harm.

AND

The treatment has no cost.

AND

The treatment takes no time.

AND

The treatment does not require any skill.
 

Spinal immobilization does not satisfy any of those criteria.

Treating more patients does not appear to increase the possibility of helping patients.

Treating more patients only appears to increase the possibility of harming patients.

If we really want to know, we need to have a large enough randomized study.

Do we really want to know?

Dr. Dave Ross believes that we need to continue to use spinal immobilization, but he also wants to know the truth.[3]

Part II will examine the NNH (Number Needed to Harm).

Footnotes:

[1] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed – indexed for MEDLINE]

[2] The NNT, Explained
The NNT
Article

[3] Confessions of a recovering field spine clearance addict — revisited
November 02, 2012
By Dave Ross
EMS1.com
Article

The place I work is tiny, so its inclusion would not affect the outcome, but that is no reason to suggest that our patients are not affected by this wishful thinking-based treatment. Our patients should not be subjected to this harm.

.

Comments

  1. I agree with your point of view of this article. This is a good article. Very timely given us so much useful information. Thank you!

    Rheumatologists

  2. I know this is a little bit of thread necromancy, but where is Part II? My Google-fu doesn’t seem to be able to find it.