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Spine Immobilization for Penetrating Trauma Can Be Harmful

Summary and Comment |
January 29, 2010

Spine Immobilization for Penetrating Trauma Can Be Harmful

  1. John A. Marx, MD, FAAEM

Patients who underwent immobilization were twice as likely to die as those who did not.

  1. John A. Marx, MD, FAAEM

Despite a lack of supportive evidence for the practice, prehospital providers often apply spine immobilization to patients who have penetrating trauma to the head, neck, or torso without neurological symptoms or deficit. These authors retrospectively assessed the effect of prehospital spine immobilization on mortality in patients with penetrating trauma using data from the American College of Surgeons National Trauma Data Bank between 2001 and 2004.

Of 45,284 patients (median age, 29), 4.3% received cervical collars, spinal backboards, or both. The overall mortality rate was 8.1%. Multiple logistic regression analysis that controlled for confounders, including Injury Severity Score and Revised Trauma Score, showed that immobilized patients had significantly increased mortality (odds ratio, 2.06); this finding held true in subgroups of patients with gunshot wounds (OR, 2.12), hypotension (OR, 2.42), and gunshot wounds and hypotension (OR, 3.19). Complete data on in-hospital procedures were available for about 31,000 patients. Only 30 patients (0.1%) underwent operative spine stabilizing procedures for incomplete spinal-cord injury. The number needed to treat with spine immobilization to potentially benefit 1 patient was 1032. The number needed to harm with spine immobilization to potentially contribute to 1 death was 66.

Comment

Increasing evidence indicates that limited intervention at the scene allows trauma patients to receive definitive care at a trauma center more rapidly. This study indicates that prehospital spine immobilization is associated with increased mortality in patients with penetrating trauma. Trying to assign cause and effect in a retrospective study is risky, but possibly increased scene time or interference with later care (e.g., intubation, radiography, examination of the patient's back) contribute to worse outcomes. Spine immobilization might be applied more wisely to patients with altered mental status, spine tenderness, or sensorimotor dysfunction.

Citation(s):

Reader Comments (2)

Robert R. Cesario

Although the comments made about prehosital care providers (EMS), and spinal immobilization for patients who have penetrating trauma to the head, neck, or torso without neurological symptoms or deficit is generally true, that is not the case in many areas, particularly in Southeast Michigan. Our protocol driven system uses criteria to safely rule out the need for spinal immobilization when a mechanism of injury exists. If the patient is neurologically unaffected, has no loss or altered level of consciousness, extremity fracture, or spinal tenderness of any kind, the immobilization can be withheld. I hope this information is helpful.

Competing interests: None declared

Kevin A Klassen

How can the authors make any conclusions when there is no control group of patients who did not get spinal immobilization? Considering almost all major trauma patients end up with cervical immobilization, I would question the credibility of saying someone with the same Injurity Severity Score was a good control if they did not require immobilization.

Competing interests: None declared

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