Manuel Akilov

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY

FACULTY OF MEDICINE

DEPARTMENT OF DISASTER MEDICINE

Manuel Akilov

SHOULD EVERY PATIENT WITH SUSPECTED SPINAL CORD INJURY

AND RISK OF A SECONDARY SPINAL CORD INJURY UNDERGO SPINAL

IMMOBILIZATION IN PREHOSPITAL SETTINGS?

Final Master Thesis of General Medicine

Scientific Supervisor: Prof. Dinas Vaitkaitis

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ABSTRACT

Akilov, Manuel. Should every patient with suspected spinal cord injury and risk of a secondary spinal cord injury undergo spinal immobilization in prehospital settings? A systematic literature review.

Background. Approximately 250-500 thousand people suffer a spinal cord injury in one year globally.

Debates regarding rationale behind routine pre-hospital spinal immobilization of every patient with suspected spinal cord injury were recently raised.

Aim and objectives. The aim was to analyze the recent evidence-based data related to spinal

immobilization in pre-hospital and emergency care settings. The primary research question was raised: should patients with suspected spinal injury and a risk of a secondary spinal cord injury, undergo spinal immobilization in pre-hospital or emergency care? The objectives: 1) to summarize results from available recent medical articles regarding primary management of spinal injuries; 2) to determine advantages and disadvantages of pre-hospital spinal immobilization in trauma patients with risk of a secondary spinal cord injury; 3) to develop recommendations for practice and further research.

Method. PRISMA 2009 statement and checklist were used as the main resource for research

methodology. The main search engine was MEDLINE PubMed, which yielded about 791 research works were per defined inclusion and exclusion criteria and keywords. 20 publications were included in systematic literature review.

Results. 3 studies supported pre-hospital spinal immobilization, 5 recommended not to use it in very

suspected cases, and 12 studies studies agree that the current knowledge is insufficient due to lack of evidence based.

Conclusion. Primary thesis question "Should every patient with suspected spinal cord injury and risk of

a secondary spinal cord injury undergo spinal immobilization in prehospital settings?" could not be answered due to insufficient publications to date. More explicit evidence-based studies are needed to expand knowledge within area.

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CONFLICT OF INTEREST

The author declares no conflict of interest.

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PERMISSION ISSUED BY THE ETHICS COMMITTEE

Permission by the Ethics Committee is not needed for this study.

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ABBREVIATIONS

ATLS – Advanced Trauma Life Support

ETC – European Trauma Course MeSH – medical subject heading

NEXUS – National Emergency X-Radiography Utilization Study PhSI – pre-hospital spinal immobilization

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INTRODUCTION

A spinal cord injury (SCI) is damage to the spinal cord, which causes temporary or permanent changes in its function. Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal cord below the level of the injury, usually affecting predominantly males (1). Spinal cord injury is a dangerous and potentially life-threatening condition, which could result in a variety of complications or co-morbidities, i.e. monoplegia through hemiplegia, paraplegia and to tetraplegia (quadriplegia) (1). These complications can have devastating long-term changes in health, work and social life of the patient.(1)

Approximately 250-500 thousand of population experience SCI in one year globally (up to date information from WHO).

The primary causes of traumatic spinal cord injuries are traffic accidents and falls (1). Per standard trauma management guidelines, SCI is suspected for every trauma patient of first aid care in pre-hospital setting, even though the true SCI cases are relatively rare every year. Spinal immobilization became the standard for pre-hospital primary management approach of suspected spinal cord injury (1). Spinal immobilization has been one of the first steps and recommendations in the management of trauma patients in pre-hospital setting for decades now (2,3). Use of pre-hospital spinal immobilization (PhSI) is based on the premise that immobilization will prevent further sensory and motor neurological complications in patients with a spinal cord injury (2,3).

It is estimated that around 2-6% of all trauma patients in the United States of America have spinal injury. Unstable spinal fractures or injuries of the spinal cord are diagnosed in approximately one third of cases with spinal injuries (4). Precautions including spinal immobilization among other things are taken, when there is a suspicion of spinal injury, until physicians eliminate confirmed diagnosis of spinal injury. Confirmation of spine injury usually includes radiologic imaging and/or applying protocols or recommendations, issued by the Advanced Trauma Life Support (ATLS) training program, the European Trauma Course (ETC), the National Emergency X-Radiography Utilization Study (NEXUS), as well as the algorithm defined in the Canadian Cervical Spine (c-spine) Rule (4).

With the assumed benefits of immobilization and its perceived harmless nature, there is a growing view that this perception has led to a high level of over-treatment. There is, however, growing concern regarding the effectiveness and potential complications of PhSI (5). The main scientific question was raised if every suspected spinal injury should be immobilized in pre-hospital settings?

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AIM AND OBJECTIVES

The aim – to analyze the recent evidence-based data related to spinal immobilization in

pre-hospital and emergency care settings. The primary research question was raised: should patients with suspected spinal injury and a risk of a secondary spinal cord injury, undergo spinal immobilization in pre-hospital or emergency care?

The objectives:

1. to summarize results from available recent medical articles regarding primary management of spinal injuries;

2. to determine advantages and disadvantages of pre-hospital spinal immobilization in trauma patients with risk of a secondary spinal cord injury;

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REASERCH METHODOLOGY AND METHODS

PRISMA 2009 statement and checklist were used as the main research method in this systematic review. The main search engine was MEDLINE PubMed. Randomized clinical trials, retrospective studies, systematic and literature reviews were included per defined inclusion and exclusion criteria and keywords.

Information source:

Online search was performed on a number of databases mainly including PubMed, as well as: UpToDate, Elsevier, CambridgeCore, SpringerLink, ScienceDirect, Google Scholar. Several trauma specific journals were also reviewed: European Journal of trauma, European Spine Journal, The American Journal of Emergency Medicine, Australasian Emergency Nursing Journal.

Inclusion criteria:

Various combinations of MeSH (Medical subject heading) terms were used as keywords for all databases and journals where suitable. Search terms used: Spinal immobilization, Spinal cord immobilization, Immobilization, Spinal injuries, Spinal cord injuries, Guidelines, Pre-hospital.

Sentences used:

- Prehospital management of spinal cord injury

- Prehospital management of suspected spinal cord injury - Prehospital immobilization of spinal cord injury

- Prehospital immobilization of suspected spinal cord injury - New guidelines of prehospital immobilization

Exclusion criteria:

- Works conducted on species other than humans - Works written in language other than English - Not relevant title or abstract

- Publication older than 10 years

Data collection process:

Fig. 1 represents flowchart of literature search and inclusion. The initial search in PubMed yielded 791 results, which were reduced to 199 after applying exclusion filters. Best match function in PubMed assisted for review to select the most suitable, which resulted in 44 articles. 20 research papers were included into this systematic review after review of full text.

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Fig. 1 represents flowchart of literature search and inclusion.

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RESULTS AND THEIR DISCUSSION

Results of literature review are presented in Table 1. Out of 20 studies included in this review, 3 studies supported PhSI, 5 recommended not to use immobilization in pre-hospital setting in very suspected case, and 12 studies agreed that the current knowledge is insufficient due to lack of evidence-based studies to make any conclusions on whether PhSI is necessary or least not harmful in every suspected SCI.

The debate of whether spinal cord immobilization in a pre-hospital care should be done in any suspected spinal cord injury is one of great significance and important implication for the well-being of the traumatic patients. The primary purpose of the spinal immobilization is to prevent mobilization or motion of an unstable spinal cord, which can result in secondary injury that likely to develop into severe neurological and musculoskeletal deficit that extremely limit the patient's lifestyle.

The decision to use the academic articles that was selected were based on the details and whether the study had a conclusion and or suggestions regarding the question of spinal cord immobilization in a suspected spinal cord injury.

To review a range of different findings and opinions, several types of injuries were selected, such as: penetrating trauma, ballistic trauma, blunt trauma and multi-trauma.

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Table 1. Results of systematic literature review No. Publish

year Author Publication name Conclusion

1. 2015 Oteir A.O et al (1) Should suspected cervical spinal cord injury be immobilised?: A systematic review.

Non-conclusive, due to the lack of high-level evidence-base on the effect of phSI on patient outcomes.

Further research is required.

2. 2015 Hood N et al (3) Spinal immobilization in pre-hospital and emergency care: A systematic review of the literature

3. 2018 Brinke J.G et al (4)

Prehospital care of spinal injuries: a historical quest for reasoning and evidence.

4. 2014 Oteir A.O et al (5) The prehospital management of suspected spinal cord injury: an update.

5. 2017 Oosterwold J. T. et al (6)

The characteristics and pre-hospital management of blunt trauma patients with suspected spinal column injuries: a retrospective observational study.

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trauma patients – consensus and evidence based.

By the account that there is weak recommendation against the use of a rigid spinal stabilization trauma by the gridline presented in the study.

7. 2010 Haut E.R et al (7) Spine Immobilization in

Penetrating Trauma: More Harm Than Good?

PhSI is effective but can result in patient morbidity. Spinal

immobilization devices should be used to achieve the goals of spinal stability for safe support and transportation. They should be removed as soon as a conclusive evaluation is achieved and/or definitive management is initiated. Spinal immobilization of trauma patients

with penetrating injuries is not recommended.

8. 2013 Theodore N et al (8)

Prehospital Cervical Spinal Immobilization After Trauma

PhSI is effective but can result in patient morbidity. Spinal

immobilization devices should be used to achieve the goals of spinal stability for safe support and transportation. They should be removed as soon as a conclusive evaluation is achieved and/or definitive management is initiated. Spinal immobilization of trauma patients

with penetrating injuries is not recommended.

9. 2017 Purvisa T.A et al (5)

The definite risks and

questionable benefits of liberal pre-hospital spinal

immobilization.

Non-conclusive,

due to the lack of high-level evidence-base on the effect of phSI on patient outcomes.

10. 2011 Ahn H et al (9) Pre-Hospital Care Management of a Potential Spinal Cord Injured Patient: A Systematic Review of the Literature and Evidence-Based Guidelines.

Supports phSI

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12. 2014 Oteir A.O et al (11)

Should suspected cervical spinal cord injuries be immobilised? A systematic review protocol.

Non-conclusive,

13. 2017 Kornhall D.K et al (12)

The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury.

Supports phSI

(NEXUS) 14. 2013 Moss R et al (13) Minimal patient handling: a

faculty of prehospital care consensus statement.

The consensus no longer supports the routine use of phSI for patient transportation. In its place the scoop stretcher should be the preferred device

15. 2009 Ramasamy A et al (14)

Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma.

recommend that phSI not be used routinely for adult patients with penetrating trauma or ballistic neck trauma.

16. 2018 Velopulos C.G et al (15)

Prehospital spine

immobilization/spinal motion restriction in penetrating trauma: A practice management

guideline from the Eastern Association for the Surgery of Trauma (EAST).

recommend that phSI not be used routinely for adult patients with penetrating trauma.

17. 2016 Clemency B.M et al (16)

Patients Immobilized with a Long Spine Board Rarely Have Unstable Thoracolumbar Injuries.

Non-conclusive,

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18. 2009 Brown J.B et al (17)

Prehospital Spinal

Immobilization Does Not Appear to Be Beneficial and May Complicate Care Following Gunshot Injury to the Torso.

Non-conclusive,

19. 2011 Care P et al (18) Cervical Collars are Insufficient for Immobilizing an Unstable Cervical Spine Injury.

Non-conclusive,

20. 2016 Ham WHW et al

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Pressure ulcers, indentation marks and pain from cervical spine immobilization with extrication collars and.

Non-conclusive,

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In this systematic literature review 20 academic articles were taken according to their title, main subject, key word and conclusion. From 20 studies, 3 support PhSI and recommended to continue using this method of transference with preventing secondary spinal cord damage in and already unstable spine (7)(11)(14). Furthermore 5 studies do not support and recommend discontinuing the application of SCI in every suspected spinal cord injury, most of the studies give penetrating injury to the spine like stab wound, gunshot wound or even ballistic debris wound as an example for a case of injury to the spinal cord with very low incidence of unstable spine. Moreover, those studies show that the time that immobilization consumes, and the position may increase morbidity and mortality due to interference with resuscitation (8)(9)(16)(17). One study says that the consensus no longer supports the routine usage of pre hospital spinal cord immobilization (long spinal board for spinal immobilization) and patient transportation and instead recommends the scoop stretcher device (15).

Even though most of sources agree that there is not enough data on immobilization in prehospital settings in general, the majority of studies, conducted specifically on penetrating trauma, acknowledge that immobilization in penetrating trauma does more harm than good.

Haut et al (8) conducted a retrospective analysis comparing patients with and without applying pre-hospital spine immobilization under circumstances of penetrating injury (knife stab and gunshot). Their study informs that patients with penetrating injuries to the spine seldom have spinal instability even once the penetrating trauma specifically injures the spine which spine-immobilized penetrating trauma patients were two times more likely to die than patients who were not treated with spinal immobilization. It was estimated that only 1 from 1032 patients with a penetrating spinal injury required spinal immobilization and had benefit from it. Also, 1 patient was harmed by the application of spinal immobilization, and for 66 patients spinal immobilization potentially could have contributed to death. The time needed for the proper application of spinal immobilization devices in patients who have been stabbed and suffered gunshot wounds delays patient resuscitation, resulting in increased morbidity and mortality.

The main question of this systematic literature review was whether PhSI was needed in every case of suspected SCI. The answers that were expected were both for or against, however the vast majority (even studies that have recommendation only) agree that there is not enough data from evidence-based studies to decide on further guidelines. 12 out of 20 articles reveal that there is no sufficient information and suggest further studies in the field (1)(3)(4)(5)(6)(10)(12)(13)(18)(19)(20)(21).

Ala'a O. Oteir et al (1) criticize the lack of high-level evidence-based studies which address the effect of PhSI on the outcome of the patient. Thomas Adam Purvisa et al (10) were concerned that some literature supports the Consensus Guidelines. but questions if they are deep enough as there is strong

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evidence that suggest that PhSI is not only a harmful procedure, but also has no proven benefits. Their results testify to an urgent need for further studies to determine the effect of the PhSI treatment.

Another systematic review that composed a similar conclusion as this systematic literature review was done by Natalie Hood et al (3) that resulted with 15 supportive, 13 neutral, and 19 studies opposing spinal immobilization out of 47 analyzed and concluded that further research is needed.

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CONCLUSION

1. From 20 studies analyzed, 3 supported pre-hospital spinal immobilization and recommended to continue this method of transference in order to prevent secondary spinal cord damage in and already unstable spine. 5 studies did not support or recommended to keep this standard practice in every suspected spinal cord injury. 12 studies did not make any determined conclusions due to lack of available evidence-based data. Primary thesis question "Should every patient with suspected spinal cord injury and risk of a secondary spinal cord injury undergo spinal immobilization in prehospital settings?" could not be answered due to insufficient publications to date.

2. Advantages of pre-hospital spinal immobizilation were obvious in cases with confirmed spine instability, but in most cases of spinal immobilization this was not an issue. Most of literature concluded that advantages and disadvantages were not possible to determine due to lack of evidence or proper documentation, as well as could evaluate risk-benefit ratio of pre-hospital spinal immobizilation. 3. More explicit evidence-based studies are needed to expand knowledge within area.Routine healthcare practices and documentations should be pursued to further investigate pre-hospital care of suspected spinal cord injury. It is recommended to develop case reporting strategies by emergency or healthcare providers.

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RECOMENDATIONS

A systematic literature review revealed a problematic situation that there is not enough evidence to answer primary aim. Therefore, we came up with a method to increase the cases reported by first aid providers, physicians and healthcare providers in the community and in turn to increase dramatically the evidence.

A suggested example can be presented to first aid providers, physicians and healthcare providers in the community in a form of a questionnaire that can be platformed on a website or even a mobile application that will include:

Pre-hospital part:

- Was there a suspicion for spinal cord injury? If yes, why?

- Was it decided to implement spinal cord immobilization of sort? Is yes, why? - How long did the application take?

In hospital part:

- Whether the patient arrived with spinal cord immobilization? - How much time passed before the immobilization was removed? - After imaging, was there an indication for the immobilization? Why? - In conclusion was the immobilization beneficial or not? Why? In outpatient/ community:

-Was the patient immobilized in prehospital setting?

-Is there noticeable benefit or deficiency in the patient lifestyle that can be correlated to immobilization?

Demanding to fill up this type of questionnaire can help to document the outcome of immobilization and in turn provide information for potential better guidelines in the future.

Any type of outcome measure following the application or non-application of c-collars will be included. This may include pain, psychological effects, neurological outcome, functional outcome, health-related quality of life or adverse effects.

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REFERENCES

1. Oteir AO, Smith K, Stoelwinder JU, Middleton J, Jennings PA. Should suspected cervical spinal cord injury be immobilised?: A systematic review. Injury. 2015;46(4):528–35.

2. Kaups KL. Editorial comment. J Trauma - Inj Infect Crit Care. 2011;71(3):769–70.

3. Hood N, Considine J. Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature. Australas Emerg Nurs J [Internet]. 2015;18(3):118–37. Available from: http://dx.doi.org/10.1016/j.aenj.2015.03.003

4. ten Brinke JG, Groen SR, Dehnad M, Saltzherr TP, Hogervorst M, Goslings JC. Prehospital care of spinal injuries: a historical quest for reasoning and evidence. Eur Spine J [Internet]. 2018;27(12):2999–3006. Available from: https://doi.org/10.1007/s00586-018-5762-2 5. Purvis TA, Carlin B, Driscoll P. The definite risks and questionable benefits of liberal

pre-hospital spinal immobilisation. Am J Emerg Med [Internet]. 2017;35(6):860–6. Available from: http://dx.doi.org/10.1016/j.ajem.2017.01.045

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):1–10.

7. Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, et al. Spine

immobilization in penetrating trauma: More harm than good? J Trauma - Inj Infect Crit Care. 2010;68(1):115–20.

8. Theodore N, Hadley MN, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, et al. Prehospital cervical spinal immobilization after trauma. Neurosurgery. 2013;72(SUPPL.2):22–34.

9. Ahn H, Singh J, Nathens A, MacDonald RD, Travers A, Tallon J, et al. Pre-Hospital care management of a potential spinal cord injured patient: A systematic review of the literature and evidence-based guidelines. J Neurotrauma. 2011;28(8):1341–61.

10. Connor D, Greaves I, Porter K, Bloch M. Pre-hospital spinal immobilisation : an initial consensus statement. 2013;30(12).

11. Oteir AO, Jennings PA, Smith K, Stoelwinder J. Should suspected cervical spinal cord injuries be immobilised ? A systematic review protocol. 2014;2013–5.

12. Kornhall DK, Jørgensen JJ, Brommeland T, Hyldmo PK, Asbjørnsen H. The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury. Scand J Trauma Resusc Emerg Med [Internet]. 2017;1–11. Available from:

http://dx.doi.org/10.1186/s13049-016-0345-x

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14. Ramasamy A, Midwinter M, Mahoney P, Clasper J. Learning the lessons from conflict : Pre-hospital cervical spine stabilisation following ballistic neck trauma. 2009;40:1342–5.

15. Velopulos CG, Shihab HM, Lottenberg L, Feinman M, Raja A, Salomone J, et al. Prehospital spine immobilization / spinal motion restriction in penetrating trauma : A practice management guideline from the Eastern Association for the Surgery of Trauma ( EAST ). 2018;84(5). 16. Clemency BM, Bart JA, Malhotra A, Klun T, Lindstrom HA, Clemency BM, et al. 1. Clemency

BM, Bart JA, Malhotra A, Klun T, Lindstrom HA, Clemency BM, et al. P ATIENTS I MMOBILIZED WITH A L ONG S PINE B OARD R ARELY H AVE U NSTABLE. 2016;3127. P ATIENTS I MMOBILIZED WITH A L ONG S PINE B OARD R ARELY H AVE U NSTABLE. 2016;3127.

17. Brown JB, Bankey PE, Sangosanya AT, Cheng JD, Stassen NA, Gestring ML. Prehospital Spinal Immobilization Does Not Appear to Be Beneficial and May Complicate Care Following Gunshot Injury to the Torso. 2009;67(4):0–4.

18. Care P. Selected Topics : JEM [Internet]. 2011;41(5):513–9. Available from: http://dx.doi.org/10.1016/j.jemermed.2011.02.001

19. Ham WHW, Schoonhoven L, Schuurmans MJ, Leenen LPH. Pressure ulcers , indentation marks and pain from cervical spine immobilization with extrication collars and headblocks : An

observational study. Injury [Internet]. 2016;47(9):1924–31. Available from: http://dx.doi.org/10.1016/j.injury.2016.03.032

Manuel Akilov

Manuel Akilov

SHOULD EVERY PATIENT WITH SUSPECTED SPINAL CORD INJURY

AND RISK OF A SECONDARY SPINAL CORD INJURY UNDERGO SPINAL

IMMOBILIZATION IN PREHOSPITAL SETTINGS?

TABLE OF CONTENTS

ABSTRACT

CONFLICT OF INTEREST

PERMISSION ISSUED BY THE ETHICS COMMITTEE

ABBREVIATIONS

INTRODUCTION

AIM AND OBJECTIVES

REASERCH METHODOLOGY AND METHODS

RESULTS AND THEIR DISCUSSION

CONCLUSION

RECOMENDATIONS

REFERENCES