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

- Rogue Medic

Allow Me To Manipulate.. I Mean Immobilize Your Spine – Part I


ResearchBlogging.org

At EMS Office Hours, Jim Hoffman, Josh Knapp, and I have a bit of a debate about the merits of spinal immobilization/spinal motion restriction.

Allow Me To Manipulate.. I Mean Immobilize Your Spine.

If I have a spinal injury, will strapping a collar on my neck (one that is generally replaced soon after the patient arrives at a trauma center) provide some protection from spinal injury, have no effect on spinal injury, or cause some worsening of spinal injury?

The research says – we don’t know.

If I have a head injury, my intracranial pressure will probably be raised by a cervical collar.

According to a review of seven papers examining the effects of cervical collars on intracranial pressure.

In conclusion, there is evidence that rigid collars for cervical spine protection may exacerbate intracranial hypertension in patients with severe head injury. Although the clinical significance of this phenomenon has not yet been convincingly established, the detrimental effects of increased ICP in head-injured patients are well known.[1]

If I have a complete dislocation of my spine, the collar will probably cause a greater separation of the spine, which could make things a lot worse very quickly.

Evidence that application of a cervical extrication collar can lead to catastrophic neurologic complications in patients with unstable cervical injuries has been previously described.4,5,10,18–20 A critical analysis of these reports supports the concern that the application of a collar could potentiate neurologic and/or vascular injury. Although this can occur at any level, the upper cervical spine seems to be particularly vulnerable.21

In this study, frank separation of the head and upper neck from the rest of the spine was seen in every cadaver after a cervical collar was applied.[2]

If I have an unstable spinal injury, spinal immobilization seems to produce worse outcomes than not immobilizing a patient with an unstable spinal injury.

The difference in neurologic disability between immobilized patients in the United States and unimmobilized patients in Malaysia was statistically significant. It may be that immobilization increases the risk of neurologic injury secondary to tissue hypoxia, perhaps by delaying resuscitation or perhaps the benefit of immobilization is so small that it is unmeasurable given our sample size.[3]

Disabling cervical spine injuries in 30% of patients with immobilization, but in only 25% without immobilization.

Disabling thoracic spine injuries in 21% of patients with immobilization, but in only 6% without immobilization.

Disabling lumbar spine/sacral spine injuries in 12% of patients with immobilization, but in only 2% without immobilization.

These are just the serious problems that people will deny are caused by spinal immobilization, even though there is no research that demonstrates that prehospital spinal immobilization is beneficial.

We discussed these and more in the podcast. I did mistakenly state that the numbers from the Hauswald study did not reach statistical significance, but I provided a quote that contradicts my error.

People claim that it would be unethical to deprive patients of this standard of care in order to find out if it really is as dangerous as it seems.

How is it ethical to force this treatment on unsuspecting patients with no attempt at informed consent?

Ma’am, allow me to explain the treatments we intend to provide.

If you have a head injury, this collar will raise the pressure inside your head, which is bad.

If you have an unstable fracture of your neck, this collar may cause your spine to come apart, which is bad.

If you have an injury that might disable you, prehospital immobilization will make it more likely that you end up disabled, which is bad.

We do this because prehospital immobilization is considered the standard of care. We provide this standard of care to protect us from being sued by you.

We aren’t immobilizing patients to protect them from injury. We are immobilizing patients to protect ourselves, our bosses, our medical directors, and our organizations from the people we are supposed to be protecting – our patients.

We claim that it is unethical to do otherwise.

We claim it is ethical to behave unethically.

Could we come up with a better way of demonstrating that we do not have a clue about ethics?

‘I can’t believe THAT!’ said Alice.

‘Can’t you?’ the Queen said in a pitying tone. ‘Try again: draw a long breath, and shut your eyes.’

Alice laughed. ‘There’s no use trying,’ she said: ‘one CAN’T believe impossible things.’

‘I daresay you haven’t had much practice,’ said the Queen. ‘When I was your age, I always did it for half-an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.[4]

I must have been absent the day they covered this, because I am just not very good at believing the impossible things we are expected to believe.

Go listen to the podcast.

More in Part II later on. Also posted over at Research Blogging. Go check out the rest of the excellent material there.

And check out the other information referenced in the show –

Great article at EMS Village – Spinal Immobilization Decision Algorithm – Author: Colleen M Hayes, MBA, RN, EMT-P

EMS Research Podcast – Spine Immobilization in Penetrating Trauma: More Harm Than Good?

Spinal Assessment Learning Guide – pdf.

EMS Garage Episode 22: Jet Laggin

Dr. Bledsoe – Top Ten EMS Studies

Future Ditch Doctor post mentioned in this episode.

Footnotes:

[1] Rigid cervical collar and intracranial pressure of patients with severe head injury.
Ho AM, Fung KY, Joynt GM, Karmakar MK, Peng Z.
J Trauma. 2002 Dec;53(6):1185-8. Review. No abstract available.
PMID: 12478051 [PubMed – indexed for MEDLINE]

[2] Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury.
Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA, Kalantar SB, Hipp JA.
J Trauma. 2010 Aug;69(2):447-50.
PMID: 20093981 [PubMed – indexed for MEDLINE]

[3] 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]

[4] Through the Looking-Glass
by Lewis Carroll
The Millennium Fulcrum Edition 1.7
CHAPTER V. Wool and Water

Just before this part –

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Ho AM, Fung KY, Joynt GM, Karmakar MK, & Peng Z (2002). Rigid cervical collar and intracranial pressure of patients with severe head injury. The Journal of trauma, 53 (6), 1185-8 PMID: 12478051

Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA, Kalantar SB, & Hipp JA (2010). Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. The Journal of trauma, 69 (2), 447-50 PMID: 20093981

Hauswald M, Ong G, Tandberg D, & Omar Z (1998). Out-of-hospital spinal immobilization: its effect on neurologic injury. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 5 (3), 214-9 PMID: 9523928

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Comments

  1. Ever heard of the x-collar? Seems to me that with proper application it wouldn’t cause any of these problems.

  2. “Ma’am, allow me to explain the treatments we intend to provide.

    If you have a head injury, this collar will raise the pressure inside your head, which is bad.

    If you have an unstable fracture of your neck, this collar may cause your spine to come apart, which is bad.

    If you have an injury that might disable you, prehospital immobilization will make it more likely that you end up disabled, which is bad.

    We do this because prehospital immobilization is considered the standard of care. We provide this standard of care to protect us from being sued by you.”

    I wonder how many patients would still want to be boarded if they had this explained to them?

  3. But, But, if we don’t put a collar on them, they’ll be paralyzed, and possibly die. EMS wouldn’t tell patients this if it’s not the truth, right? Say it ain’t so Rogue, say it ain’t so.

  4. One thing I’ve always found interesting in the spinal immobilization debate is that at least one EBM website I know (and the only one dedicated to EMS that I know of) actually ranks selective spinal immobilization higher (II, fair evidence) than spinal immobilization itself (III, insufficient evidence).

    http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=214#Spinal%20Immobilization

    http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=214#C-Spine%20Clearance

  5. This is science and the art of praticing medicine. Things change, there is
    Evidence for and against, etc.

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