214 zyxwv

ACADEMIC EMERGENCY MEDICINE MAR 1998 VOL 5/NO 3

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Out-of-hospital Spinal Immobilization: Its Effect on
Neurologic Injury

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Mark Hauswald, MD, Gracie Ong, MBBS, Dan Tandberg, MD, Zaliha Omal; MBBS

I ABSTRACT
.....................................................................................................................................................

Objective: To examine the effect of emergency immobilization on neurologic outcome of patients who have
blunt traumatic spinal injuries.
Methods: A 5-year retrospective chart review was carried out at 2 university hospitals. All patients with acute
blunt traumatic spinal or spinal cord injuries transported directly from the injury site to the hospital were
entered. None of the 120 patients seen at the University of Malaya had spinal immobilization during transport,
whereas all 334 patients seen at the University of New Mexico did. The 2 hospitals were comparable in

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physician training and clinical resources. Neurologic injuries were assigned to 2 categories, disabling or not
disabling, by 2 physicians acting independently and blinded to the hospital of origin. Data were analyzed
using multivariate logistic regression, with hospital location, patient age, gender, anatomic level of injury, and
injury mechanism serving as explanatory variables.
Results: There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI
1.03-3.99; p = 0.04). This corresponds to a ~ 2 chance
% that immobilization has any beneficial effect. Results
were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p
= 0.34).
Conclusion: Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with
blunt spinal injuries.
Key words: injury; trauma; morbidity; spine; immobilization; back board; emergency medical services; spinal
cord.
Acad. Emerg. Med. 1998; 5:214-219.

I Immobilization of the spine in blunt trauma is thought emergency setting. Much is now known about these is-
to be a crucial intervention almost as essential as man- sues. Immobilization is improved by using a firm surface;
agement of the airway.’ Failure to diagnose and appropri- addition of a hard cervical collar? head blocks? and lat-
ately manage spinal injuries is a major concern for emer- eral provides progressively more stability. The
gency physicians. A large number of papers address clinical importance of immobilization remains unknown.
immobilization and management of spinal injuries in the That is, how much spinal motion is permissible without
harm during transport and during the initial workup re-
..................................................................................
mains unknown.

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Fmm the University of New Mexico. School of Medicine, Albuquerque,
This issue is complex. The definition of instability is

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NM. Department of Emergency Medicine (MH, DT); and the University not standardized. The most conservative view is: “. . . the
of Malaya Faculty of Medicine, Kuala Lumpur; Malaysia, Department loss of the ability of the spine under physiologic condi-
of Anesthesia (GO) and Department of Allied Health Science (ZO). tions to maintain relationships between vertebra in such a
Received: February 19, 1997; revision received: July 10, 1997; ac- way that there is neither damage nor subsequent irritation
cepted: July 17, 1997; updated: October 23. 1997. to the spinal cord or nerve root and, in addition there is
Address for correspondence and reprints: Mark Hauswald, MD, De-
no development of incapacitating deformity or pain from
partment of Emergency Medicine, Ambulatory Care Centec 4-%! Uni- structural changes.”6 This definition, while appropriate to
versity of New Mexico, School of Medicine, Albuquerque, NM 87131- guide long-term management, is of little use in the emer-
5246. Fax: 505-272-6503; e-mail: [email protected] gency setting, where the question generally is: will motion
Spinal Immobilization, Hauswald et al. zyxwvu
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make the neurologic lesion worse? Furthermore, neuro- hospitals with spinal or spinal cord injuries between Jan-
215

logic lesions are dynamic, some deteriorate due to swell- uary 1988 and January 1993 was performed. Permission
ing and microvascular injury?’ and some improve as for the study was provided by the Ethical Sub-committee
edema and neuropraxia resolve, irrespective of immobi- of the Medical Advisory Board of the University Hospital,
lization. Other neurologic injuries are irrevocable at the Kuala Lumpur, Malaysia, and by the institutional review
time of the injury, and not affected by subsequent move- board of the University of New Mexico, School of Med-
ment. In the face of these uncertainties and considerable icine, Albuquerque, NM.
medicolegal pressure, physicians have opted for extraor-

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dinarily conservative management. Patients are fully im- Setting and Population: Study cases were identified by
mobilized at the injury site if there is any suggestion that searching for bony spine or spinal cord injuries by Inter-
the neck or back could be injured.’ Immobilization is usu- national Classification of Disease Version 9 (ICD-9) codes
ally continued in the ED until the spine is “cleared” by contained in hospital computerized databases. Compres-
multiple imaging p r ~ c e d u r e s . ~Authors *’~ have claimed sion fractures due to osteopenia or other disease were ex-
that without adequate long-term immobilization, 10% to cluded. Patients who died were included unless the cause
25% of all patients with spine injuries will deteri~rate.~”’of death was clearly unrelated to the spinal injury; these
These claims, however, have little scientific support. cases were almost exclusively patients with massive head
Conservative treatment is not necessarily benign. Im- or other injuries who died in the first 24 hours.
mobilization is unc~mfortable,l~*’~ takes time, and delays During the period 1988 through 1993, approximately
transport. Immobilized patients are difficult to examine 12,700 trauma patients were admitted to inpatient services
and treat. Immobilization increases the risk of aspiration at the U.S. hospital and 16.600 to the University of Ma-

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and pressure sores. Cervical collars increase intracranial laysia. Both statistics include transfer patients. The U.S.
pressure.14 Given these problems, it would be useful to figures exclude patients with bums, drownings, and iso-
know how often not immobilizing patients would result lated injuries who were admitted to services other than
in increased neurologic injury. A low incidence of these the trauma service. The Malaysian data include the latter
“acutely unstable” injuries would justify more liberal cases. All the patients taken to the U.S.hospital, but none
guidelines for allowable spinal motion following trauma. of those taken to the Malaysian hospital, had their spines
A high incidence of injuries that might benefit from im- immobilized at the injury site. The catchment area of the
mobilization would require more a conservative approach. University of Malaya Hospital lacks emergency ambu-
Some spinal injuries are undoubtedly truly biome- lance coverage. The hospital operates an ambulance, but
chanically and neurologically unstable and will develop it is used almost exclusively for medical patients. Trauma
increased neurologic injury with movement. Others are patients are transported by passersby, police, and cowork-
undoubtedly biomechanically stable but neurologically ers, none of whom have training in spinal immobilization.
fragile; these will suffer more neurologic injury by delay- None of the ED staff could remember any patients who
ing resuscitation. Standard practice assumes that immo- had been immobilized in Malaysia. Other differences be-
bilization is generally protective and that patients with tween our sites are small. The level of training of Malay-
spinal fractures will have a higher incidence of neurologic sian physicians is comparable to that of their counterparts
injuries if immobilization is not carried out. However, this in the United States, particularly in the essential special-
hypothesis has never been tested. It is no longer possible ties where training was commonly outside of Malaysia
to derive a meaningful estimate of effect of spinal im- until recently. The 2 hospitals have similar radiologic, re-
mobilization in the developed world because of the uni- suscitative, and surgical abilities. All patients who were
versal adoption of early, preventive immobilization and admitted to either facility after June 1990 with a neuro-
widespread publicity regarding the “need” to protect the logic deficit were treated with high-dose methylpredni-
spine until ambulance personnel arrive. We derive this es- so~one.’~
timate by comparing the percentages of spine-injured pa-
tients who had neurologic injuries from 2 sites: the Uni- Study Protocol: All patients with blunt injuries to the

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versity Hospital, University of Malaya in Kuala Lumpur, spine or spinal cord who were transported directly from
Malaysia, which is not served by an out-of-hospital emer- the injury scene to a study hospital were entered into the
gency medical services (EMS) system, and the University database. Compression fractures due to osteopenia or dis-
of New Mexico Hospital in Albuquerque, NM, which is ease were excluded. Information regarding hospital, pa-

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served by an extensive EMS system. tient age. gender, level of deficit, mechanism of injury,
and type of neurologic injury was collected. Ages were
METHODS
I .............................................................................. grouped by decade for use in the regression model. The
level of injury was classified into cervical, thoracic, or
Study Design: A retrospective chart review of all pa- lumbosacral depending on the highest vertebra injured.
tients admitted to the inpatient service or ED of our 2 The mechanism of injury was grouped into 1 of 4 cate-
216

I
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TABLE
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1 Anatomic Distribution of Injuries
.......................................................................
ACADEMIC EMERGENCY MEDICINE

RESULTS
MAR 1998 VOL 5/NO 3

I .....................................................................
Disability No Total The anatomic distributions of injuries were similar in the
Cervical 2 sites and to that published in the literature (Table l)."
Immobilized (United 34 (30%) 79 (70%) 113 (100%) Malaysian and US patients were similar in terms of
States) age and level of injury. Patients in Malaysia were more
Unimmobilized 10 (25%) 30 (75%) 40 (100%)
(Malaysia)
likely to be male and to have been injured in a fall rather
than an MVC (Table 2).
Thoracic There were 24 patients who had injuries that required
Immobilized (United 22 (21%) 85 (79%) 107 (100%) physician classification. The 2 physicians grouped these
States) with complete agreement (Table 3), resulting in 21% of
Unimmobilized 2 (6%) 31 (94%) 33 (100%)
(Malaysia)
the patients (70/334) from the United States and 11% of
the Malaysian patients (1 3/120) being classified as having
Lumbosacral disabling injuries.
Immobilized (United 14 (12%) 99 (88%) 113 (100%) The OR for disability was higher for patients in the
States United States (all with spinal immobilization) after ad-
Unimmobilized 1 (2%) 46 (98%) 47 (100%)
(Malaysia)
justment for the effect of all other independent variables
(2.03; 95% CI 1.03-3.99; p = 0.04). The estimated prob-
ability of finding data as extreme as this if immobilization
gories: falls from a height; motor vehicle crashes (MVCs); has an overall beneficial effect is only 2%. Thus, there is
high-velocity-low-mass impacts (primarily patients as- a 98% probability that immobilization is harmful or of no
saulted with blunt objects and those struck by falling value. The level of neurologic deficit was the only inde-
objects): and other. pendent predictor of bad outcome (Table 4). We repeated
The dependent variable, neurologic injury, was clas- this analysis using only the subset of patients with isolated
sified as disabling or not disabling based on the last cervical level deficits. We again failed to show a protec-
hospital note. Patients with complete quadriplegia or par- tive effect of spinal immobilization (OR 1.52; 95% CI
aplegia, inability to ambulate without assistance, incon- 0.64-3.62; p = 0.34).
tinence, or the need for chronic catheterization, and
those who died were classified as having disability. Pa- I ..............................................................................
DISCUSSION
tients with no neurologic injury were classified as not hav-
ing disability. The remaining charts were reviewed by 2 These results undoubtedly seem counterintuitive to most
physicians acting independently and blinded to the hos- physicians who have been taught that spinal motion
pital of origin. These patients were classified into the 2
groups based on whether the physicians thought the injury I TABLE 2 Characteristics of the Patients from the United States
would interfere with normal functioning. and Malaysia

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..............................................................................

Data Analysis: Comparison between patients from the Immobilized Unimmobilized p-value
United States (all who had spinal immobilization) and Number of patients 334 120
Malaysia (none of whom had spinal immobilization) was
performed using x2 and 1-way analysis of variance as ap- Average age 34 yr 35 yr 0.3 1
propriate. Multivariate logistic regression of the associa- Gender-male 256 (77%)* 106 (88%) 0.009
tion between the collected variables and disability was
used for analy~is.'~."The level of deficit and the mecha- Level of injury 0.52
nism of injury were coded as separate binary variables. Cervical 113 (34%) 40 (33%)
Thoracic 107 (32%) 33 (28%)
All of the independent variables were included in the
Lumbosacral 113 (34%) 47 (39%)
model. Odds ratios (ORs) and 2-sided 95% confidence
intervals (CIS) were calculated. We also repeated the anal- Mechanism O.OOO1
ysis using only patients with cervical injuries. Fall 66 (20%) 63 (53%)
Data management was carried out using Quattro Pro Vehicle crash 248 (74%) 45 (38%)

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version 5.00 spreadsheet software (Borland International, Low-mass 9 (3%) 8 (7%)
impact
Scotts Valley, CA). Statistical computations were per-
Other 11 (3%) 4 (3%)
formed with Statgraphics Plus version 7.0 (Manugistics
Inc., Rockville, MD) and LogXact-Turbo version 1.1 (Cy- Significant 70 (21%) 13 (11%) 0.02
tel Software Corporation, Cambridge, MA). We used disabi I i ty
2-tailed tests and an a of 0.05 throughout. *Percentages are relative to each hospital's total.
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Spinal Immobilization, Hauswuld et ul.

causes neurologic injury. However, technically only the I TABLE 3 Physician-classified Patients-Verbatim
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217

Discharge
~

transfer of energy can physically alter material. Acute neu- Diagnosis

..............................................................................
rologic injury occurs when excessive energy is deposited
Neurologic Finding Location
in the spinal cord or its vascular structures. This energy
is a product of force multiplied by time. ”Excessive” en- Injuries judged not disabling

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Moderate leg weakness, ambulatory United States
ergy is directly related to the failure strength of the ma-

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Hypoesthetic thumb United States
terial. Over the length of time experienced during an in- Paresthesias only United States
jurious event, the spine is quite strong and massive Mild hypaesthesia 1/3 right leg United States
amounts of energy are required to fracture or otherwise Mild hand weakness United States
significantly injure it. The cervical spine will fracture Decreased right arm sensation United States
Almost normal at discharge United States
when >2.000-6.000N (Newton or meter-kg/sec2, 1 N =
Weak deltoids United States
0.225 pounds of force)’’ is applied; the lumbar spine re- Weak toe United States
quires >4,200 N to fracture, even in elder individuals.20 Mild diffuse hypaesthesia United States
Muscles and ligaments” reinforce the bone. Even the spi- Paresthesias United States
nal cord itself is capable of absorbing significant energy Mild weakness left leg United States
Sacral 1 root injury United States
without suffering damage.22Energy deposition during an
Right foot drop Malaysia
injury is a complex process. Subjects ejected from vehi- Slight right arm weakness Malaysia
cles, the most common cause of disability in our sample, Right arm partial brachial palsy Malaysia
undergo repetitive impacts. In most cases the maximal Slight left arm weakness Malaysia
impact is early in the event as the victim contacts the Sensory change, no objective findings Malaysia
vehicle structure or the ground. It is presumably at these Injuries judged disabling
times that most of the injury is inflicted. Subsequently, Right arm paralysis and anesthesia United States
multiple impacts occur between the subject and the Severe right arm weakness United States
ground. Even in the simple case of a restrained subject Right hemiparesis United States
and direct linear deceleration while in a sitting position, Anesthetic left leg United States
Severe hypoesthesia left leg United States
the initial acceleration is followed by a series of repetitive Complete left cervical plexus injury United States
oscillatory movement^.'^ In these circumstances the en-
ergy deposited by moving the patient after the event will
be much less than the energy deposited at the scene by TABLE 4 Logistic Regression Analysis
I ..............................................................................
secondary impacts.

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There are good physical and biomechanical reasons 95%

why immobilization immediately after the injurious event Odds Confidence
has little effect. Movement within the spine’s normal Ratio Interval p-value
range of motion requires little energy and is hence un- Spinal immobilization 2.03 1.03-3.99 0.04
likely to result in significant energy deposition to the cord.
Even the force generated across the spine by hanging a Gender-male 1.69 0.86-3.32 1.13
completely unimmobilized 4-kg head off the end of a Age (by decade) 0.96 0.81 - 1.14 0.65
stretcher is only equal to approximately 40 N, which is
orders of magnitude less than that experienced during the Level of injury
original event. Cervical 3.82 1.98-7.37 O.Oo0 1
As the spine is moved, changes in force vectors occur. Thoracic 1.99 0.98-4.00 0.06
Lumbosacral 0.34 0.19-0.62 0.0005
The spinal elements (bone, ligament, muscle, and disc)
interact to transfer energy to all the component parts.24 Mechanism
This serves to minimize energy deposition to any one Fall 0.60 0.14-2.54 0.49
component. When force is applied rapidly, the energy is Vehicle crash 0.91 0.23-3.56 0.90
focused due to wave effects, thus enhancing injury.25 Low-mass impact 0.38 0.03-4.77 0.45
Other 1.32 0.34-5.08 0.69
However, the definition of instability that is used to guide
long-term care of the patient is based on the risk of grad-
ual slippage due to gravity and active motion. It is hardly
surprising that this definition has little relevance in the be that immobilization increases the risk of neurologic
acute setting when the biomechanical factors are com- injury secondary to tissue hypoxia, perhaps by delaying
pletely different. resuscitation or perhaps the benefit of immobilization is
The difference in neurologic disability between im- so small that it is unmeasurable given our sample size.
mobilized patients in the United States and unimmobilized Previous studies have estimated that three fourths of
patients in Malaysia was statistically significant. It may cervical fractures are potentially ~nstable’~.~’
based on ra-
218 zyxwvutsrqpo ACADEMIC EMERGENCY MEDICINE MAR 1998 VOL 5/NO 3

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diographic criteria. The actual percentage of injuries that
are likely to be made worse by lack of immobilization
during the immediate post-injury period is much smaller.
The risk of neurologic deterioration is greatly exagger-
ated.

LIMITATIONS AND FUTURE QUESTIONS

.............................................................................
Our study has several shortcomings. Patients who died at
majority of trauma patients do not have a spinal injury
and hence cannot benefit from spinal immobilization. As
a result, our study design would tend to exaggerate any
potential benefit of current protocols that require the im-
mobilization of almost all trauma patients.
It is doubtful that this study can be duplicated in the
future because Malaysia is now developing an EMS sys-
tem and considerable publicity has recently been given to
spinal immobilization in the mass media. Other popula-
the injury site or during transport are excluded. It is pos- tion-based studies are urgently needed to confirm our data.
sible that some of these died as a result of high cord Current spinal immobilization protocols have been devel-
injuries, attendant loss of diaphragmatic function, and as- oped without supporting clinical efficiency data. They
phyxia. Most of these cord injuries are probably complete may be overly conservative.
at the time of the injury and many of these patients have
other fatal injuries, but it is possible that some partial CONCLUSION
I ..............................................................................
lesions could have been completed during transport in
Malaysia and resulted in death prior to admission. How- Comparison of spine injury patients from 2 study popu-
ever, there were no survivors in Albuquerque with com- lations, one with out-of-hospital spinal immobilization
plete lesions above C, during this period, either. and the other without, showed a higher rate of neurologic
We did not attempt to match patients for the severity injury in the immobilized group. Acute spinal immobili-
of their nonspinal injuries. The University of Malaya does zation may not have significant benefit for the prevention
not routinely use injury severity scores, and retrospective of neurologic deterioration from unstable spinal fractures.
calculation of them would have been difficult. The use of
mechanism of injury in our regression analysis partly cor-
The authors acknowledge the assistance of the late Professor N. Sub-
rects for this omission as does our entry criteria, which ramanian, MBBS (Calc.), Head, Department of Orthopaedic Surgery,
required that adequate energy be deposited to injure the University Hospital, Malaysia, in the planning and data collection for
spine. this study.

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