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Date: July 21, 2023

Reference: McDonald et al. Patterns of change in prehospital spinal motion restriction: a retrospective database review. AEM July 2023

Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM.

Case: A 42-year-old is struck in the face by a slowly moving I-beam at work. He has a brief loss of consciousness (LOC) and then awakens and is ambulatory on scene. Emergency Medical Services (EMS) is called and on arrival the patient is walking but has obvious facial trauma and is complaining of some neck pain. He has midline neck tenderness but no limb numbness or paresthesia. As an EMS crew member, you are tasked with deciding what method of spinal motion restriction to use.

Background: We have covered head injuries including concussions multiple times on the SGEM. This has included looking at the Canadian CT Head Rules/Tools (SGEM#106, SGEM#266, and SGEM#272). We have also covered concussions (SGEM#112, SGEM#331, and SGEM#362).

Another core element of emergency department (ED) and pre-hospital care is the assessment for potential spinal injuries [1,2].  Patient care and positioning has evolved over time, previously routine spinal immobilization (SI) was with a cervical spine collar, placement on a long, rigid backboard, and straps or head blocks.

Over time this has evolved to spinal motion restriction (SMR) with more variable use of cervical collars, patient positioning, and accessories such as head rolls and tape [3-4]. This has evolved due to recognition of some of the adverse effects of immobilization as well as limitations to its benefits.

The role of the cervical collar itself varies by jurisdiction and it is not entirely clear which devices and procedures are most effective at reducing potentially harmful spinal motion [5-11]. Existing research on SMR confirms decreases in the use of long backboards and increases in collar-only treatment [12-14].  Some of this research has observed substantial under-treatment among patients who met criteria for precautions, as well as some patients with confirmed injuries who received no treatment from EMS [15-16].

Other studies have observed no increase in the diagnosis of cervical spine injuries, however, variable practice and the possibility of patients not receiving appropriate treatment remains a concern [17-18]. In order for standards for acute management of spinal injuries to progress, we must optimize patient protection and limit harm [19].

Clinical Question: How has the rate of pre-hospital spinal immobilization/spinal motion restriction changed from 2009 to 2020?

Reference: McDonald et al. Patterns of change in prehospital spinal motion restriction: a retrospective database review. AEM July 2023

  • Population: EMS patients with traumatic injuries
    • Excluded: None
  • Intervention: Spinal immobilization/spinal motion restriction
  • Comparison: This is a retrospective review and includes several changes over time, thus the comparison is the change in rate over time of SMR
    • Important Changes Were:
      • In 2009, selective spinal immobilization using NEXUS criteria was implemented.
      • In July 2012, changing documentation required paramedics to record the indications for SI/SMR in all cases.
      • In November 2014, cases of isolated penetrating trauma were exempted from SMR.
      • In April 2016, treatment guidelines were revised to allow for collar-only treatment in low-risk scenarios (patient ambulatory prior to paramedic arrival)
  • Outcome:
    • Primary Outcome: Rate of spinal immobilization/spinal motion restriction
    • Secondary Outcomes:
      • Rates of splinting and wound care as proxy measures of the incidence of trauma care over time.
      • Patient and practice-related factors associated with potential changes over time. Patient related factors include age, sex, acuity, mechanism of injury and indications for treatment.
      • Practice-related factors included cervical collar size, patient positioning, the proportion of collar only use, rate of treatment of penetrating trauma.
  • Type of Study: Retrospective database review

Neil McDonald

This is an SGEMHOP and we are pleased to have the lead author on the show. Neil McDonald is an Advanced Care Paramedic in Winnipeg, MB, where he works as a Training Officer and Research Coordinator for the Winnipeg Fire Paramedic Service. He also holds a PhD in Applied Health Sciences and a cross appointment as Lecturer in the Department of Emergency Medicine within the Rady Faculty of Health Sciences at the University of Manitoba.  

Authors’ Conclusions: “This study shows decreasing SI/SMR treatment and changing patient and practice characteristics. These patterns of care cannot be attributed solely to formal protocol changes. Similar patterns and their possible explanations should be investigated elsewhere.”

Quality Checklist for Observational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes
  3. Was the cohort recruited in an acceptable way? Yes
  4. Was the exposure accurately measured to minimize bias? Yes
  5. Was the outcome accurately measured to minimize bias? Yes
  6. Have the authors identified all-important confounding factors? No
  7. Was the follow up of subjects complete enough? Yes
  8. How precise are the results? Confidence intervals for reported statistics are generally narrow
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Yes
  11. Do the results of this study fit with other available evidence? Yes
  12. Funding of the Study: University of Manitoba Pamela Hardisty Graduate Fellowship

Results: A total of 25,747 patients had SI/SMR with 809 excluded due to incomplete information. The median age was 40 years old, 58% of patients were male and 20% were classified as high acuity.

Key Result: The rate of SI/SMR decreased significantly in the 2009-2012 and 2012-2016 time periods, but not in 2016-2020.

  • Primary Outcome: Rate of spinal immobilization/spinal motion restriction

In July 2012, paramedics were required to record the indications for SI/SMR in all cases. The change was associated with a significant increase in the rate of SI/SMR of 5.8 treatments per 100 trauma calls (95% CI: 4.6 to 7.1). This then decreased over time until the 2016 protocol change.

The 2016 protocol change allowing collar-only treatment was not associated with a significant change in rate of SI/SMR and the final time period.

  • Secondary Outcomes:

Neither wound care nor splinting showed any substantial changes over the study period. In terms of patient characteristics, age and sex did not change significantly over time. The proportion of female patients over age 65 decreased by -2.8% per year (95% CI: -4.0 to -1.5%). A significantly higher proportion were high acuity over time, increasing from 11% in 2009 to 31% in 2020, average annual percent change of 9.6% (95% CI: 8.7% to 10.0%) There were smalls decreases in the proportions of falls, MVCs and assaults over the study period, with corresponding increases in non-reporting.

Regarding collar size, “no-neck” collars were used more frequently than any other size (65%) but their use decreased over time by -3.8% per year to 49% in 2020. This corresponded to a decrease in “short” collars and an increase in “regular” and “tall” size collars.

Prior to the protocol change in 2016 all patients were treated with a collar and board, then immediately after the change 47% of eligible patients were treated with only a cervical collar. This increased by an average of 6.3% per year (95% CI: 3.2% to 9.5%), rising to 60% in 2020.

Positioning changes occurred significantly in all categories, with supine positioning decreasing on average 3.1% per year while all others increased. Semi-fowlers positioning increased 47% per year, rising from 0.8% of all patients in 2009 to 25% in 2020.

Listen to the SGEM podcast to hear Neil respond to our five nerdy questions.

1.Reporting Data: How do you think the lack of mechanism of injury reporting data (37% of cases) affect the results?

2.Big Drop in SI/SMR: One of the big questions from this study is why was there such a big decrease in SI/SMR over time that cannot be explained by protocol changes alone? What questions do you think future studies need to ask to identify the reason for this drop?

3.Multiple Statistical Analysis Tools: The methods section described several tools used to interrogate your data. Can you comment on the need for each of these tools?

4.Size and Type of Collar: There was a lot of discussion on collar sizes and types changing over time. We were a bit unclear from the study how these changes were decided upon and what this reflects.

5. Does it Matter: Where is the high-quality evidence that SI/SMR provides a net patient-oriented outcome? I’m specifically interested in c-spine collars. Those claiming these devices “work” have the burden of proof to provide evidence to support their position.

This has been debated in the pages of AEM with Drs. Serigano and Riscinti give it a colour code of YELLOW(uncertainty) for their NNT blog post based upon the Cochrane 2001 SRMA. In contrast, Drs. Baron and Scalea argue it is not yet time to abandon cervical collars in blunt trauma patients. Where do you currently stand on the issue?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.

SGEM Bottom Line: Patterns of spinal motion restriction are changing over time with reduced use of SMR and changing patient and practice characteristics.

Case Resolution: You decide to place the patient in a cervical collar and transport lying at 30 degrees in semi-fowlers position, corresponding to local guidelines for an ambulatory patient with a potential c-spine injury.

Dr. Chris Bond

Clinical Application: The exact type and benefits of spinal immobilization/spinal motion restriction have not been fully elucidated at this point and you should follow local pre-hospital practices.

What Do I Tell My Patient? You have had head trauma and there is a risk of having a bony neck injury. This risk is lower because you are ambulatory on scene, but to be cautious, we are going to place you in a cervical collar, limit your neck range of motion and transport you to hospital for further assessment as per our current protocol.

Keener Kontest: The winner last episode was Tim Kolosionek. He knew the first paramedic level system in the United States to practice endotracheal intubation was Freedom House Ambulance.

This was a system built in 1968 in very poor neighbourhoods of Pittsburgh that hired and trained chronically unemployed African American men as paramedics. Their first medical director, Dr. Peter Safar, who would later become known as the ‘father of CPR’, took these men and trained them in procedures, such as intubation. He was later replaced by Dr. Nancy Caroline who would later author one of the first paramedic textbooks.

Listen to the SGEM podcast for this weeks’ question. If you know the answer, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on spinal immobilization? Tweet your comments using #SGEMHOP.  What questions do you have for Neil and his team, ask them on the SGEM blog? The best social media feedback will be published in AEM.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References:

  1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. American College of Surgeons; 2018.
  2. PHTLS: Prehospital Trauma Life Support. 9th ed. Jones & Bartlett Learning; 2020.
  3. White CC, Domeier RM, Millin MG. EMS spinal precautions and the use of the long backboard—resource document to the posi- tion statement of the National Association of EMS physicians and the American College of Surgeons Committee on trauma. Prehosp Emerg Care. 2014;18(2):306-314. doi:10.3109/10903127.2014.884 197
  4. Connor D, Greaves I, Porter K, Bloch M. Pre-hospital spinal immobilisation: an initial consensus statement. Emerg Med J. 2013;30(12):1067-1069. doi:10.1136/emermed-2013-203207
  5. Fischer PE, Perina DG, Delbridge TR, et al. Spinal motion restriction in the trauma patient—a joint position statement. Prehosp Emerg Care. 2018;22:659-661. doi:10.1080/10903127.2018.1481476
  6. Maschmann C, Jeppesen E, Rubin MA, Barfod C. New clinical guidelines on the spinal stabilisation of adult trauma patients— consensus and evidence based. Scand J Trauma, Resusc Emerg Med. 2019;27(1):77. doi:10.1186/s13049-019-0655-x
  7. Jennings FL, Mitchell ML, Walsham J, Lockwood DS, Eley RM. Soft collar for acute cervical spine injury immobilisation -patient experiences and outcomes: a single Centre mixed methods study. Int J Orthop Trauma Nurs. 2022;47:100965. doi:10.1016/j. ijotn.2022.100965
  8. Serigano O, Riscinti M. Cervical spine motion restriction after blunt trauma. Acad Emerg Med. 2021;28(4):472-474. doi:10.1111/ acem.14134
  9. Baron BJ, Scalea TM. Not yet time to abandon cervical collars in blunt trauma. Acad Emerg Med. 2021;28(4):475-476. doi:10.1111/ acem.14136
  10. Benchetrit S, Blackham J, Braude P, et al. Emergency manage- ment of older people with cervical spine injuries: an expert prac- tice review. Emerg Med J. 2022;39(4):331-336. doi:10.1136/ emermed-2020-211002
  11. Smith T. Clinical Procedures and Guidelines, Comprehensive Edition 2019–2022. Ambulance New Zealand; 2019.
  12. Morrissey JF, Kusel ER, Sporer KA. Spinal motion restriction: an educational and implementation program to redefine prehospital spinal assessment and care. Prehosp Emerg Care. 2014;18(3):429- 432. doi:10.3109/10903127.2013.869643
  13. Jones Rhodes W, Steinbruner D, Finck L, Flarity K. Community implementation of a prehospital spinal immobilization guideline. Prehosp Emerg Care. 2016;20(6):792-797. doi:10.1080/10903127.2 016.1194932
  14. Nilhas A, Helmer SD, Drake RM, Reyes J, Morriss M, Haan JM. Pre-hospital spinal immobilization: neurological outcomes for spi- nal motion restriction versus spinal immobilization. Kans J Med. 2022;15:119-122. doi:10.17161/kjm.vol15.16213
  15. Asha SE, Curtis K, Healy G, Neuhaus L, Tzannes A, Wright K. Neurologic outcomes following the introduction of a policy for using soft cervical collars in suspected traumatic cervical spine in- jury: a retrospective chart review. Emerg Med Australas. 2020. doi:1 0.1111/1742-6723.13646
  16. Underbrink L, Dalton AT, Leonard J, et al. New immobilization guidelines change EMS critical thinking in older adults with spine trauma. Prehosp Emerg Care. 2018;22:637-644. doi:10.1080/10903 127.2017.1423138
  17. Castro-Marin F, Gaither JB, Rice AD, et al. Prehospital protocols reducing long spinal board use are not associated with a change in incidence of spinal cord injury. Prehosp Emerg Care. 2019;24:401- 410. doi:10.1080/10903127.2019.1645923
  18. Clemency BM, Natalzia P, Innes J, et al. A change from a spinal immo- bilization to a spinal motion restriction protocol was not associated with an increase in disabling spinal cord injuries. Prehosp Disaster Med. 2021;36(6):708-712. doi:10.1017/s1049023x21001187
  19. Hauswald M. Prehospital spinal care: it is time to reconsider and revise. Acad Emerg Med. 2021;28(8):933. doi:10.1111/ acem.14293