Pre-Hospital Care Management of a Potential Spinal Cord ... · PDF fileDavies et al., 1996; De...
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Pre-Hospital Care Management of a Potential Spinal Cord Injured Patient: A Systematic Review of the Literature and Evidence-Based Guidelines Henry Ahn, 1 Jeffrey Singh, 2 Avery Nathens, 3 Russell D. MacDonald, 4 Andrew Travers, 5 John Tallon, 6 Michael G. Fehlings, 1 and Albert Yee 1 Abstract An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury. Key words: pre-hospital care; spinal cord injury; systematic review Introduction G reat care must be taken when providing medical care to an acutely injured patient prior to arrival at hospital. About 2% of all blunt trauma patients will have sustained a spinal cord injury, and these rates are higher in the setting of severe closed head injury (Crosby, 1992, 2006). Patients with acute spinal cord injury (SCI) are at risk of neurologic dete- rioration due to secondary injury to the spinal cord (Fehlings and Louw, 1996). A potential cause of secondary injury is through inadvertent manipulation of the spinal cord in the setting of an unstable spinal column injury (Crosby, 1992; Eismont et al., 2004; Fehlings and Louw, 1996; Fenstermaker, 1993). Minimizing the chances of secondary injury can be challenging in the pre-hospital setting due to the local and transport environment, a lack of resources, and heterogeneity in health care providers and their skill sets (Hauswald et al., 2000). Furthermore, treatments initiated prior to arrival in the hospital can lead to significant morbidity in other body re- gions, such as sacral and occipital ulcers (Cordell et al., 1995; 1 Department of Surgery, 2 Department of Interdepartmental Medicine, Division of Critical Care, 3 Department of Surgery, Health Policy, Management and Evaluation, and 4 Department of Research and Development, Ornge Transport Medicine and Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada. 5 Department of Emergency Medicine, and 6 Department of Emergency Medicine, Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada. JOURNAL OF NEUROTRAUMA 28:1341–1361 (August 2011) ª Mary Ann Liebert, Inc. DOI: 10.1089=neu.2009.1168 1341
Transcript of Pre-Hospital Care Management of a Potential Spinal Cord ... · PDF fileDavies et al., 1996; De...
Pre-Hospital Care Management of a PotentialSpinal Cord Injured Patient: A Systematic Reviewof the Literature and Evidence-Based Guidelines
Henry Ahn,1 Jeffrey Singh,2 Avery Nathens,3 Russell D. MacDonald,4 Andrew Travers,5
John Tallon,6 Michael G. Fehlings,1 and Albert Yee1
Abstract
An interdisciplinary expert panel of medical and surgical specialists involved in the management of patientswith potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significantinterest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patientswith acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinalimmobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes ofpatients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spineclearance and immobilization? A systematic review utilizing multiple databases was performed to determine thecurrent evidence about the specific questions, and each article was independently reviewed and assessed by tworeviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by anational Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines abouteach question. Recommendations about the key questions included: the pre-hospital immobilization of patientsusing a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable beanbag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer ofpatients off spinal boards while awaiting transfer from one hospital institution to another hospital center fordefinitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiringintubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospitalcenter for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting toapply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervicalspinal injury.
Key words: pre-hospital care; spinal cord injury; systematic review
Introduction
Great care must be taken when providing medical careto an acutely injured patient prior to arrival at hospital.
About 2% of all blunt trauma patients will have sustained aspinal cord injury, and these rates are higher in the setting ofsevere closed head injury (Crosby, 1992, 2006). Patients withacute spinal cord injury (SCI) are at risk of neurologic dete-rioration due to secondary injury to the spinal cord (Fehlingsand Louw, 1996). A potential cause of secondary injury is
through inadvertent manipulation of the spinal cord in thesetting of an unstable spinal column injury (Crosby, 1992;Eismont et al., 2004; Fehlings and Louw, 1996; Fenstermaker,1993). Minimizing the chances of secondary injury can bechallenging in the pre-hospital setting due to the local andtransport environment, a lack of resources, and heterogeneityin health care providers and their skill sets (Hauswald et al.,2000). Furthermore, treatments initiated prior to arrival in thehospital can lead to significant morbidity in other body re-gions, such as sacral and occipital ulcers (Cordell et al., 1995;
1Department of Surgery, 2Department of Interdepartmental Medicine, Division of Critical Care, 3Department of Surgery, Health Policy,Management and Evaluation, and 4Department of Research and Development, Ornge Transport Medicine and Division of EmergencyMedicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
5Department of Emergency Medicine, and 6Department of Emergency Medicine, Surgery and Community Health and Epidemiology,Dalhousie University, Halifax, Nova Scotia, Canada.
JOURNAL OF NEUROTRAUMA 28:1341–1361 (August 2011)ª Mary Ann Liebert, Inc.DOI: 10.1089=neu.2009.1168
1341
Davies et al., 1996; De Lorenzo et al., 1996; Hamilton andPons, 1996; Hauswald et al., 2000; Johnson et al., 1996; Krellet al., 2006; Luscombe and Williams, 2003; Main and Lovell,1996; Sheerin and de Frein, 2007; Walton et al., 1995). There istremendous variation in how care is administered prior toarrival at the hospital and during transport from one hospitalto another (Armitage et al., 1990; Burney et al., 1989; Fla-bouris, 2001). Some care models and treatments may providepatients with improved safety and reduce morbidity, andthus improve efficiency of care delivery. These variations ofpractice served as the impetus to perform a systematic review,in conjunction with a series of other systematic reviews re-lated to SCI care. The purpose of this study was to provideevidence-based guidelines agreed upon by a multi-disciplin-ary expert panel to identify optimal care in key areas in thepre-hospital setting for patients with potential SCI.
Four questions that were of clinical relevance and thatcould have significant impact on patient care were deter-mined by a multidisciplinary expert panel. These four ques-tions posed for the systematic review were:
1. What is the optimal type and duration of spinal im-mobilization in patients with acute SCI?
2. During airway manipulation in the pre-hospital setting,what is the ideal method of spinal immobilization?
3. What is the impact of pre-hospital transport time todefinitive care on the outcomes of patients with acuteSCI?
4. What is the role of pre-hospital care providers in cer-vical spine clearance and immobilization?
These four questions then served as the basis of oursystematic review of pre-hospital care of potential spinal-cord-injured patients. The systematic review method wasutilized to systematically collate and assess the literature,while minimizing bias in the assembly and interpretation ofthe evidence. Following an exhaustive search of the literatureand collation of the identified studies into evidentiary tables,the evidence was graded and synthesized into guidelines thatwere refined through consensus using Delphi methodology(Hasson et al., 2000; Keeney et al., 2001; Kennedy, 2004).
Methods
Four questions of pertinent interest to a multi-disciplinarycommittee with expertise in the management of SCI wereagreed upon to form the basis of the systematic review. Eachof the four questions was amenable to a systematic review.Members of this committee included a traumatologist (AveryNathens), three trauma triage specialists in emergency med-icine (Russell MacDonald, Andrew Tavers, and John Tallon),three spine surgeons (Henry Ahn, Michael Fehlings, and Al-bert Yee), a critical care intensivist ( Jeffrey Singh), and afundamental scientist in SCI research (Darryl Baptiste).
A primary literature search was performed using theMEDLINE, CINAHL, Embase, and Cochrane databases. Asecondary search strategy incorporated articles referred to inmeta-analyses, systematic and non-systematic review articlesthat were found in the primary search. Additional articles thatwere listed in the references of retrieved original articles couldbe also included in the secondary search strategy. The litera-ture searches addressed publications produced from 1966 toApril 2008. Two reviewers independently selected the articles
based on the inclusion and exclusion criteria, determined theirlevel of evidence, and assessed their methodological qualityaccording to the Downs and Black criteria (Downs and Black,1998). Disagreement between the reviewers was reconciled bya third reviewer. All articles were directly related to pre-hospital care, and limited to human studies by excluding the‘‘animal’’ Medical Subject Heading (MeSH). The MeSH searchterms used were: ‘‘pre-hospital care,’’ ‘‘spinal trauma,’’ and‘‘spinal cord injury.’’
Based on this methodology 66 articles were screened, and47 were eligible based upon criteria utilized for pre-hospitalcare. These were scored according to the Downs and Blackcriteria (Downs and Black, 1998). The main results of eacharticle and the reviewers’ assessments were summarized in anevidentiary table (Table 1).
Evidence-based responses were then composed for the fourquestions. A panel of 5 to 10 multi-disciplinary experts (fromthe Solutions Network [Acute Practice Network]) using theDelphi method scrutinized the evidence-based statements forthe specific questions. A level of consensus of 80% or higherwas considered to be a strong agreement. Based on the level ofagreement and the comments from the expert panel, recom-mendations were formulated for each question related to pre-hospital care.
Findings from the systematic review
Question 1. What is the optimal type and duration ofspinal immobilization in patients with acute SCI?
In all, 25 studies were reviewed for this particular question(Chan et al., 1996; Chandler et al., 1992; Cordell et al., 1995;Cornwell et al., 2001; Davies et al., 1996, De Lorenzo et al.,1996; Gerling et al., 2000; Graziano et al., 1987; Hamilton andPons, 1996; Hauswald et al., 2000, 1998; Huerta et al., 1987;Johnson et al., 1996; Krell et al., 2006; Luscombe and Williams,2003; Main and Lovell, 1996; Mazolewski and Manix, 1994;Nypaver and Treloar, 1994; Peery et al., 2007; Perry et al., 1999;Schafermeyer et al., 1991; Schriger et al., 1991; Sheerin and deFrein, 2007; Walton et al., 1995; Waninger et al., 2001). Mostevidence in the literature was based on biomechanical studieswith volunteers. The studies showed that immobilization witha board and collar and head immobilization between towels orfoam wedges provided the most stable biomechanical immo-bilization (Huerta et al., 1987; Perry et al., 1999). The additionof the board to the cervical collar provided statistically sig-nificantly more immobilization than a collar by itself(Chandler et al., 1992; Graziano et al., 1987). There were notenough studies to recommend exact types of collars. Certainforms of strapping, if applied appropriately in terms of loca-tion and tightness may further reduce lateral thoraco-lumbarspinal movement, but the clinical relevance of this reduction isnot known (Mazolewski and Manix, 1994; Peery et al., 2007).
The use of rigid boards can lead to discomfort at the occiputand sacrum and increased pressures that can lead to tissuenecrosis (Chan et al., 1996; Hauswald et al., 2000; Main andLovell, 1996; Sheerin and de Frein, 2007; Walton et al., 1995).Cushioning the board can lead to increased comfort and de-crease the amount of pressure at the occiput and sacrumwithout compromising biomechanical immobilization (Chanet al., 1996; Hauswald et al., 2000; Main and Lovell, 1996;Sheerin and de Frein, 2007; Walton et al., 1995). Severalstudies examined the effects of duration of immobilization on
1342 AHN ET AL.
Ta
bl
e1.
Ev
id
en
ce
Ta
bl
e(P
re
-H
osp
it
al
Ca
re
in
Sp
in
al
Co
rd
In
ju
ry
)
Ref
eren
ceJo
urn
alT
itle
Des
ign
Pu
rpos
e=h
yp
oth
esis
Sac
kett
rati
ng
aD
&B
scor
e(o
ut
of4
4)
Res
ult
s
Arm
itag
eet
al.,
1990
BM
JR
esp
irat
ory
pro
ble
ms
of
air
trav
elin
pa-
tien
tsw
ith
SC
I
(Cas
ere
por
ts)
Po
pu
lati
on
:A
ge¼
50.8
y(2
4–69
y);
lev
elo
fin
jury
:C¼
3,T¼
2.T
rea
tme
nt:
spo
nta
neo
us
resp
irat
ion
thro
ug
htr
ach
eost
om
y,
or
inte
rmit
ten
tp
osi
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ress
ure
ven
tila
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nth
rou
gh
trac
heo
sto
my
To
rep
ort
reco
mm
end
a-ti
on
sfo
rp
atie
nts
atri
skd
uri
ng
airp
lan
etr
ans-
po
rt
48
See
text
Arm
stro
ng
etal
.,20
07E
mer
g.
Med
.J.
Pre
-ho
spit
alcl
eara
nce
of
the
cerv
ical
spin
e:d
oes
itn
eed
tob
ea
pai
nin
the
nec
k?
(Obs
ervat
ion
alca
sese
ries
)T
rea
tme
nt:
Am
bu
lan
cep
erso
nn
elw
ere
giv
en3
ho
fed
uca
tio
nan
dtr
ain
ing
inp
re-h
os-
pit
alC
-sp
ine
clea
ran
cean
dp
atie
nt
info
rmat
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usi
ng
the
alg
ori
thm
de-
sig
ned
by
afa
cult
yo
fem
erg
ency
care
pra
ctit
ion
ers.
Aft
ertr
ain
ing
they
wer
eal
low
edto
use
the
alg
ori
thm
wit
hth
ep
atie
nts
and
retu
rnan
aud
itfo
rm.
Ou
tco
me
me
asu
res:
pat
ien
td
ata.
To
intr
od
uce
acl
inic
ald
e-ci
sio
nal
go
rith
mal
low
-in
gam
bu
lan
cep
erso
nn
elto
det
erm
ine
wh
ore
qu
ires
cerv
ical
imm
ob
iliz
atio
n
412
See
text
Ben
ner
,et
al.,
2006
Air
Med
.J.
Dis
agre
emen
tb
e-tw
een
tran
spo
rtte
aman
dE
Dst
aff
reg
ard
ing
the
pre
-h
osp
ital
asse
ssm
ent
of
air
med
ical
lyev
acu
ated
scen
ep
atie
nts
(Cas
ese
ries
)T
rea
tme
nt:
Pat
ien
tre
cord
sw
ere
rev
iew
edfo
rtr
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team
s’as
sess
men
tan
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efi
nal
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s.A
ny
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etw
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ato
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Dw
asca
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ori
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asa
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fere
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tran
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ated
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or
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D,
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eas
any
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Dn
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ted
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the
tran
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amw
asm
ark
edu
nd
eras
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om
em
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art
dat
a
To
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ine
the
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agre
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ent
inas
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men
to
fsi
gn
ifica
nt
illn
ess
or
in-
jury
bet
wee
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rm
edic
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ansp
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team
and
ED
dia
gn
osi
sin
pat
ien
tstr
ansf
erre
dfr
om
the
scen
e
415
Th
etr
ansp
ort
team
as-
sess
ed84
po
ten
tial
spi-
nal
cord
inju
ries
,an
d81
inju
ries
wer
en
ote
das
no
tp
rese
nt
and
3w
ere
no
ted
asp
rese
nt.
Th
eE
D’s
fin
ald
iag
no
sis
con
firm
edth
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as-
sess
men
tin
81o
ccu
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s(9
6.4%
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dd
isag
reed
wit
has
sess
-m
ent
inth
ree
occ
ur-
ren
ces
(3.6
%).
Of
the
thre
ed
iffe
ren
ces,
all
wer
eu
nd
eras
sess
men
tb
yth
etr
ansp
ort
team
.
Bro
wn
etal
.,19
98E
mer
g.
Med
.J.
Can
EM
Sp
rov
ider
sad
equ
atel
yas
sess
trau
ma
pat
ien
tsfo
rce
rvic
alsp
inal
inju
ry?
(Cas
ese
ries
)T
rea
tme
nt:
EM
Sp
erso
nn
elw
ere
inst
ruct
edto
com
ple
tea
form
bas
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nth
eir
init
ial
scen
ere
vie
w.E
Ps
wer
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stru
cted
toco
mp
lete
the
form
bas
edo
nth
eir
ED
asse
ssm
ent.
Par
ti-
cip
ants
did
n’t
dis
cuss
.N
otr
ain
ing
was
giv
enb
ut
par
tici
pan
tsw
ere
in-
stru
cted
that
vag
ue
fin
din
gs
sho
uld
be
reco
rded
asp
osi
tiv
efi
nd
ing
s.A
fter
the
EM
Sas
sess
men
tw
asp
erfo
rmed
all
the
pat
ien
tsw
ere
imm
ob
iliz
edan
dtr
ansp
ort
edto
the
ED
.
To
det
erm
ine
wh
eth
erE
MS
pro
vid
ers
can
accu
rate
lyap
ply
the
clin
ical
crit
eria
for
clea
rin
gce
rvic
alsp
ines
intr
aum
ap
a-ti
ents
415
See
text (C
onti
nu
ed)
1343
Ta
bl
e1.
Ev
id
en
ce
Ta
bl
e(C
on
tin
ue
d)
Ref
eren
ceJo
urn
alT
itle
Des
ign
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rpos
e=h
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oth
esis
Sac
kett
rati
ng
aD
&B
scor
e(o
ut
of44
)R
esu
lts
Bu
rney
etal
.,19
89J.
Tra
um
aS
tab
iliz
atio
no
fsp
inal
inju
ryfo
rea
rly
tran
sfer
(Cas
ese
ries
)P
op
ula
tio
n:
Ag
e¼
34y
(13–
83y
);M=F¼
47=14
;le
vel
of
inju
ry:
C¼
70.5
%;
T¼
18%
;L¼
11.5
%.
Tre
at-
me
nt:
Th
eam
bu
lan
ce,
refe
rral
ho
spi-
tal,
tran
sfer
,ac
ute
ho
spit
al,
and
reh
abil
itat
ion
ho
spit
alre
cord
so
fp
a-ti
ents
wer
ere
vie
wed
and
dat
aw
ere
ob
tain
ed.
Ou
tco
me
me
asu
res:
Dat
afr
om
pat
ien
tre
cord
s:m
od
eo
ftr
ansf
er,
dis
tan
ce,
and
met
ho
do
fsp
inal
stab
i-li
zati
on
du
rin
gtr
ansf
er.
Als
oco
mp
li-
cati
on
sd
uri
ng
tran
sfer
and
typ
eo
fd
efin
itiv
etr
eatm
ent.
Th
eh
yp
oth
esis
was
that
pat
ien
tsw
ith
spin
alfr
actu
res
and
par
tial
or
com
ple
ten
euro
log
ical
defi
cits
cou
ldu
nd
erg
osa
feea
rly
tran
spo
rtto
asp
inal
cord
cen
ter
usi
ng
bas
iceq
uip
men
tfo
rsp
ine
stab
iliz
atio
n
418
See
text
Bu
rto
net
al.,
2005
Pre
ho
sp.
Em
erg
.C
are
EM
Sp
rov
ider
fin
d-
ing
san
din
terv
en-
tio
ns
wit
ha
stat
e-w
ide
EM
Ssp
ine-
asse
ssm
ent
pro
toco
l
Po
pu
lati
on
:A
ge¼
43.1
y(0
–102
y);
%M¼
46T
rea
tme
nt:
Are
vis
edsp
ine-
asse
ssm
ent
pro
toco
lw
asim
ple
men
ted
July
1,20
02,
ou
tlin
ing
afo
ur-
step
seq
uen
ceb
ased
on
pat
ien
tas
sess
-m
ents
.T
each
ing
beg
an*
12m
on
ths
pri
or
toim
ple
men
tati
on
for
bo
thA
LS
and
BL
SE
MS
pro
vid
ers.
Tea
chin
gsl
ides
,st
ud
ent
lear
nin
gm
ater
ials
,an
da
FA
Qs
wer
ep
lace
do
nli
ne
and
inte
-g
rate
din
toE
MS
edu
cati
on
acti
vit
ies.
Th
ecu
rric
ulu
mco
nsi
sts
of
pre
sen
ta-
tio
ns
and
pat
ien
t-b
ased
scen
ario
trai
nin
g.
Ou
tco
me
me
asu
res:
EM
Sp
rov
ider
fin
din
gs,
nu
mb
ero
fsp
ine
imm
ob
iliz
atio
ns,
and
inci
den
cean
dtr
eatm
ent
of
spin
efr
actu
rep
atie
nts
.
To
des
crib
eth
eu
tili
zati
on
and
fin
din
gs
wit
ha
stat
e-w
ide,
pre
-ho
spit
alsp
ine-
asse
ssm
ent
pro
to-
col
for
EM
Sp
rov
ider
sin
aru
ral
stat
e
421
Pro
vid
ers
rep
ort
eda
dec
isio
nto
imm
o-
bil
ize
59%
of
pat
ien
ts.T
he
inci
den
ceo
fac
ute
spin
efr
actu
res
for
the
stu
dy
po
pu
lati
on
was
0.3%
.T
his
spin
eas
-se
ssm
ent
pro
toco
lfo
rim
mo
bil
izat
ion
of
trau
ma
pat
ien
tsw
ith
acu
tesp
ine
frac
ture
du
rin
gth
ein
ves
tig
atio
nal
pe-
rio
d,
ren
der
eda
sen
siti
vit
yo
f10
0.0
(95%
CI¼
77.2
,10
0),
an
egat
ive
pre
-d
icti
ve
val
ue
of
100
(95%
CI¼
99.7
,10
0),
asp
ecifi
city
of
41.5
(95%
CI¼
38.5
,43
.5),
and
ap
osi
tiv
e-p
red
icti
ve
val
ue
of
0.5
(95%
CI¼
0.1,
0.9)
.
Bu
rto
net
al.,
2006
J.T
rau
ma
Ast
ate-
wid
e,p
re-
ho
spit
alE
MS
sele
c-ti
ve
pat
ien
tsp
ine
imm
ob
iliz
atio
np
roto
col
Po
pu
lati
on
:31
,885
pat
ien
tsw
ith
mea
nag
eo
f48
.1�
26.7
y(0
–109
y),
45.2
%m
ale.
Tre
atm
ent:
Pre
-ho
spit
alp
rov
id-
ers
do
cum
ente
dE
MS
pat
ien
ten
cou
n-
ters
.F
or
spin
em
anag
emen
t,d
ata
incl
ud
edin
dic
ato
rsfo
rsp
ine
imm
ob
ili-
zati
on
.D
atab
ase
was
qu
erie
dfo
rp
a-ti
ent
enco
un
ters
wit
hIC
D-9
cod
ing
spec
ific
for
the
pre
sen
ceo
fsp
inal
inju
ry.
Ou
tco
me
mea
sure
s:T
he
inci
den
ceo
fsp
ine
frac
ture
sam
on
gE
MS-
asse
ssed
pat
ien
tsan
dco
rrel
atio
nb
etw
een
im-
mo
bil
izat
ion
and
spin
efr
actu
re.
To
eval
uat
eth
ep
ract
ices
and
ou
tco
mes
asso
ciat
edw
ith
ast
ate-
wid
eE
MS
pro
toco
lfo
rtr
aum
ap
a-ti
ent
spin
eas
sess
men
tan
dse
lect
ive
pat
ien
tim
-m
ob
iliz
atio
n
330
12,9
88(4
1%)
tran
spo
rted
wit
hE
MS
spin
eim
mo
bil
izat
ion
.D
ata
lin
kag
eid
enti
-fi
ed15
4sp
ine
frac
ture
sw
ith
20(1
3%)
tran
spo
rted
wit
ho
ut
imm
ob
iliz
atio
n;
19o
fth
ese
wer
est
able
spin
efr
actu
res.
Th
ep
roto
col
sen
siti
vit
yfo
rim
mo
bil
i-za
tio
no
fan
yac
ute
spin
efr
actu
rew
as87
%.
Pre
sen
ceo
fth
ep
roto
col
affe
cted
the
dec
isio
nn
ot
toim
mo
bil
ize
inm
ore
than
hal
fo
fth
eas
sess
edp
atie
nts
.
Ch
an,
etal
.,19
96J.
Em
erg
.M
ed.
Bac
kb
oar
dv
s.m
attr
ess
spli
nt
imm
ob
iliz
a-ti
on
:a
com
par
iso
no
fsy
mp
tom
sg
ener
-at
ed
(Pro
spec
tiv
eR
CT
)P
op
ula
tio
n:
n¼
37h
ealt
hy
vo
lun
teer
s.T
rea
tme
nt:
nec
kco
llarþ
bac
kb
oar
dv
ersu
sn
eck
coll
arv
ersu
sv
acu
um
spli
nt.
Ou
tco
me
me
a-
sure
s:se
lf-r
epo
rted
pai
nle
vel
s.
To
com
par
ep
ain
lev
els
be-
twee
nn
eck
col-
larþ
bac
kb
oar
dv
ersu
sn
eck
coll
arþ
vac
uu
msp
lin
t
1B21
Sig
nifi
can
tly
mo
rep
ain
inth
eb
ack
bo
ard
gro
up
(p<
0.00
1),
inp
arti
cula
rin
the
occ
ipit
alre
gio
nan
dth
elu
mb
osa
cral
reg
ion
.
1344
Ch
and
ler
etal
.,19
92A
nn
.E
mer
g.
Med
.E
mer
gen
cyce
rvic
al-
spin
eim
mo
bil
iza-
tio
n
(Exp
erim
enta
l)P
op
ula
tio
n:
Ag
e¼
29.6
;%
M¼
100.
Tre
atm
ent:
Un
rest
rain
edce
rvic
alm
oti
on
was
com
par
edw
ith
mo
tio
nin
ace
rvic
alex
tric
atio
nco
llar
and
anA
mm
erm
anh
alo
ort
ho
sis
wit
han
dw
ith
ou
ta
spin
eb
oar
d.
In10
sub
ject
sth
era
ng
eo
fm
oti
on
was
mea
-su
red
inth
eA
mm
erm
anh
alo
ort
ho
sis
and
cerv
ical
extr
icat
ion
coll
aral
on
e.In
the
oth
er10
sub
ject
sth
era
ng
eo
fm
oti
on
was
det
erm
ined
wit
hth
ece
r-v
ical
extr
icat
ion
coll
arin
pla
cean
dth
eh
ead
tap
edto
asu
pin
esp
ine
bo
ard
,an
dal
sow
ith
the
Am
mer
man
hal
oo
rth
osi
sat
tach
edto
asu
pin
esp
ine
bo
ard
.O
utc
om
em
easu
res:
Ph
oto
-g
rap
hic
mea
sure
men
to
fh
ead
and
nec
km
oti
on
du
rin
gm
axim
alfl
exio
nex
ten
-si
on=la
tera
lb
end
ing=ro
tati
on
.R
adi-
olo
gic
alm
easu
rem
ent
of
max
imal
inte
rver
teb
ral
flex
ion
-ext
ensi
on
.
To
det
erm
ine
the
effe
ctiv
e-n
ess
of
ace
rvic
alsp
ine
imm
ob
iliz
atio
nu
sin
ga
rig
idce
rvic
alex
tric
atio
nco
llar
and
anA
mm
er-
man
hal
oo
rth
osi
sw
ith
and
wit
ho
ut
spin
eb
oar
ds
Ben
ch-s
ide
ex-
per
imen
tal
stu
dy
17B
oth
the
cerv
ical
extr
icat
ion
coll
aran
dth
eA
mm
erm
anh
alo
ort
ho
sis
sig
nifi
-ca
ntl
yre
du
ced
mo
tio
nin
all
pla
nes
(p<
0.00
1),
wit
hth
eA
mm
erm
anh
alo
ort
ho
sis
red
uci
ng
thes
em
oti
on
ssi
g-
nifi
can
tly
mo
re(p<
0.00
1).
Th
eu
seo
fa
spin
eb
oar
dre
stri
cted
mo
tio
ns
even
mo
re(p<
0.00
1).
Th
eA
mm
erm
anh
alo
ort
ho
sis
wit
ha
spin
eb
oar
dp
ro-
vid
edth
eg
reat
est
imm
ob
iliz
atio
n,
equ
ival
ent
toth
atp
rov
ided
by
ah
alo
-v
est.
Ari
gid
cerv
ical
coll
aran
da
spin
eb
oar
dp
rov
ided
sig
nifi
can
tly
bet
ter
imm
ob
iliz
atio
nth
anth
eco
llar
alo
ne.
Fu
rth
erim
mo
bil
izat
ion
was
pro
vid
edb
yan
Am
mer
man
hal
oo
rth
osi
s.
Co
rdel
let
al.,
1995
An
n.
Em
erg
.M
ed.
Pai
nan
dti
ssu
ein
ter-
face
pre
ssu
res
du
r-in
gsp
ine
bo
ard
imm
ob
iliz
atio
n
(Ex
per
imen
tal
RC
T)
Po
pu
lati
on
:M=F¼
8=12
;A
ge¼
29.9
y(1
6–50
y);
Hei
gh
t¼66
.2in
;W
eig
ht¼
165.
7lb
;A
ver
age
po
un
d-t
o-i
nch
rati
o¼
2.5
Tre
atm
en
t:P
re-h
osp
ital
tran
spo
rtco
nd
itio
ns
wer
esi
mu
late
db
yim
mo
-b
iliz
ing
hea
lth
yv
olu
nte
ers
wit
hh
ard
cerv
ical
coll
ars
and
sin
gle
-bu
ckle
ches
tst
rap
so
nw
oo
den
spin
eb
oar
ds
wit
ho
rw
ith
ou
tco
mm
erci
ally
avai
lab
lem
edic
alai
rm
attr
esse
s.T
he
cro
sso
ver
ord
erw
asra
nd
om
ized
.A
fter
80m
in,
the
sub
ject
sw
ere
allo
wed
tog
eto
ffth
eb
oar
ds
for
are
cov
ery
per
iod
of
60m
in.
Su
bje
cts
wer
eth
enst
ud
ied
for
ase
c-o
nd
80-m
inp
erio
dw
ith
the
op
po
site
inte
rven
tio
n.
To
stan
dar
diz
e,v
olu
n-
teer
sw
ere
inst
ruct
edto
wea
rco
m-
fort
able
,lo
ose
-fitt
ing
clo
thin
g.
Bel
ts,
sho
es,
and
all
ob
ject
sin
po
cket
sw
ere
rem
ov
ed.
At
bas
elin
ean
dat
20-m
inin
terv
als,
the
lev
elo
fp
ain
was
rate
dw
ith
a10
0-m
mv
isu
alan
alo
gsc
ale.
Tis
sue
inte
rfac
ep
ress
ure
sw
ere
mea
-su
red
atth
eo
ccip
ut,
sacr
um
,an
dle
fth
eel.
Ou
tco
me
me
asu
res:
Dif
fere
nce
sin
pai
nan
dp
ress
ure
lev
els
bet
wee
nth
etw
otr
eatm
ents
.
To
inv
esti
gat
eth
ele
vel
of
pai
nan
dti
ssu
e-in
terf
ace
pre
ssu
res
inv
olu
nte
ers
imm
ob
iliz
edo
nsp
ine
bo
ard
sw
ith
and
wit
ho
ut
inte
rpo
sed
air
mat
tres
ses
1B28
Th
etw
otr
eatm
ent
typ
esd
idn
ot
dif
fer
sig
nifi
can
tly
inag
e(p¼
0.30
),h
eig
ht
(p¼
0.88
),w
eig
ht
(p¼
0.68
),o
rp
ou
nd
s-to
-in
chra
tio
(p¼
0.5)
.P
ain
lev
els
chan
ged
sig
nifi
can
tly
ov
erti
me
(p¼
0.00
01)
and
the
two
trea
tmen
tsd
iffe
red
inam
ou
nt
of
pai
n(p¼
0.00
01)
and
pat
tern
of
pai
nch
ang
eo
ver
tim
e(p¼
0.00
09).
No
sig
nifi
can
td
iffe
ren
cein
pai
nb
etw
een
the
two
trea
tmen
tsat
tim
e-p
oin
t0;
sub
ject
sre
po
rted
sig
nifi
-ca
ntl
ym
ore
pai
nd
uri
ng
the
no
-m
attr
ess
per
iod
at20
(p¼
0.00
3),
40(p¼
0.00
01),
60(p¼
0.00
01),
and
80m
in(p¼
0.00
01).
Inte
rfac
ep
ress
ure
lev
els
wer
esi
gn
ifica
ntl
yle
ssfo
rm
at-
tres
sth
ann
o-m
attr
ess
atth
eo
ccip
ut
(p¼
0.00
01),
sacr
um
(p¼
0.00
01),
and
hee
l(p¼
0.00
01).
Pre
ssu
rew
assi
gn
ifi-
can
tly
less
du
rin
gth
em
attr
ess
per
iod
atal
lti
me
po
ints
(p¼
0.00
01).
Pai
nle
vel
sfo
rth
em
attr
ess
and
no
-mat
tres
sg
rou
ps
wer
en
ot
sig
nifi
can
tly
dif
fere
nt
on
the
bas
iso
fo
rder
of
trea
tmen
tg
rou
pas
-si
gn
men
t(p¼
0.41
and
p¼
0.93
).T
ota
lp
ress
ure
was
rela
ted
toh
eig
ht
(p¼
0.00
8),
and
no
tsi
gn
ifica
ntl
yre
-la
ted
tow
eig
ht
(p¼
0.11
).T
ota
lp
res-
sure
was
no
tsi
gn
ifica
ntl
yre
late
dto
pai
n(p¼
0.76
).
(Con
tin
ued
)
1345
Ta
bl
e1.
Ev
id
en
ce
Ta
bl
e(C
on
tin
ue
d)
Ref
eren
ceJo
urn
alT
itle
Des
ign
Pu
rpos
e=h
yp
oth
esis
Sac
kett
rati
ng
aD
&B
scor
e(o
ut
of44
)R
esu
lts
Co
rnw
ell
etal
.,20
01A
rch
.S
urg
.T
ho
raco
lum
bar
im-
mo
bil
izat
ion
for
trau
ma
pat
ien
tsw
ith
tors
og
un
sho
tw
ou
nd
s
(Obs
erv
atio
nal
case
rep
orts
)P
op
ula
tio
n:
Med
ian
age¼<
25y
;M
ale¼
90.8
%.
Tre
atm
en
t:P
atie
nts
wh
oco
uld
hav
eth
eore
tica
lly
ben
efite
dfr
om
spin
alim
mo
bil
izat
ion
wer
eth
ose
wh
od
idn
ot
hav
eco
mp
lete
neu
rolo
gic
ald
efi-
cits
,an
dw
ho
req
uir
eda
ver
teb
ral
colu
mn
stab
iliz
atio
np
roce
du
rew
hil
ein
the
ho
spit
al.
Pat
ien
ts(1
)w
ith
no
ver
teb
ral
colu
mn
inju
ry,
(2)
wit
hle
ss-
than
-co
mp
lete
neu
rolo
gic
ald
efici
tsb
ut
wit
hst
able
ver
teb
ral
colu
mn
san
dw
ho
did
no
tre
qu
ire
ver
teb
ral
colu
mn
stab
iliz
atio
nw
hil
ein
the
ho
spit
al,
or
(3)
wit
hco
mp
lete
neu
ro-
log
ical
defi
cits
wh
ow
ere
con
sid
ered
ton
ot
hav
eb
enefi
ted
fro
mth
ora
co-
lum
bar
imm
ob
iliz
atio
n.
Ou
tco
me
me
asu
res:
Ap
atie
nt
was
con
sid
ered
toh
ave
ben
efite
dfr
om
imm
ob
iliz
a-ti
on
ifh
eo
rsh
eh
adle
ss-t
han
-co
mp
lete
neu
rolo
gic
ald
efici
tsin
the
pre
sen
ceo
fan
un
stab
lev
erte
bra
lco
lum
n,
assh
ow
nb
yth
en
eed
for
op
erat
ive
stab
iliz
atio
no
fth
ev
erte
bra
lco
lum
n;
mo
rtal
ity
.
To
loo
kat
the
po
ten
tial
ben
efits
and
neg
ativ
eef
-fe
cts
of
tim
ere
qu
ired
for
EM
Sp
roto
col
inp
atie
nts
wit
hto
rso
gu
nsh
ot
wo
un
ds
419
In10
00p
atie
nts
wit
hto
rso
gu
nsh
ot
wo
un
ds,
141
pat
ien
tsh
adv
erte
bra
lco
lum
no
rsp
inal
cord
inju
ry.
Tw
op
atie
nts
req
uir
edo
per
ativ
ev
erte
bra
lco
lum
nst
abil
izat
ion
,w
hil
esi
xo
ther
sre
qu
ired
oth
ersp
inal
op
erat
ion
s(d
e-co
mp
ress
ion=fo
reig
nb
od
yre
mo
val
).T
he
two
pat
ien
tsar
eth
eo
nly
on
esw
ho
wo
uld
hav
eb
enefi
ted
fro
mth
or-
aco
lum
bar
imm
ob
iliz
atio
nin
the
fiel
d.
Pla
cem
ent
on
alo
ng
bo
ard
wit
ho
ut
form
alfo
ur-
po
int
fix
atio
nfo
rp
atie
nts
inth
isca
teg
ory
wo
uld
allo
wa
sho
rter
inju
ry-t
o-t
reat
men
tti
me,
wh
ile
pre
-se
rvin
gth
eb
enefi
tto
thes
etw
op
a-ti
ents
.F
orm
alim
mo
bil
izat
ion
wo
uld
no
th
ave
ben
efite
dth
e73
surv
ivo
rsw
ho
had
com
ple
tele
sio
ns
of
thei
rsp
inal
cord
sn
or
the
859
pat
ien
tsw
ho
had
no
ver
teb
ral
colu
mn
inju
ry.
Th
ep
rese
nce
of
ver
teb
ral
colu
mn
inju
ryw
asac
tual
lyas
soci
ated
wit
hlo
wer
mo
rtal
ity
(7.1
%,
p<
0.02
)th
anp
atie
nts
wit
hn
ov
erte
bra
lco
lum
nin
jury
(14.
8%,
p<
0.02
).
Dav
ies
etal
.,19
96In
jury
Th
eef
fect
of
ari
gid
coll
aro
nin
trac
ra-
nia
lp
ress
ure
(IC
P)
(Obs
erv
atio
nal
case
seri
es)
Tre
atm
en
t:T
he
asse
ssm
ent
of
coll
arfi
tmen
tw
asd
on
eb
ya
sin
gle
op
erat
or
fam
ilia
rw
ith
spin
alim
mo
bil
izat
ion
and
wit
hth
em
anu
fact
ure
r’s
reco
mm
end
edg
uid
e-li
nes
.M
easu
rem
ents
of
intr
acra
nia
lp
ress
ure
,m
ean
arte
rial
pre
ssu
re(M
AP
),h
eart
rate
(HR
),an
dce
ntr
alv
eno
us
pre
ssu
re(C
VP
)w
ere
mad
e20
min
bef
ore
the
coll
arw
asap
pli
ed,
20m
inaf
ter,
and
20m
inaf
ter
itw
asre
mo
ved
.O
utc
om
em
ea
sure
s:p
atie
nt
rep
ort
dat
a.
To
mea
sure
chan
ges
inIC
Pin
pat
ien
tsw
ho
req
uir
edsp
inal
imm
ob
iliz
atio
nb
yp
roto
col,
and
wh
oco
uld
hav
ed
istu
rbed
cere
bra
lau
tore
gu
lati
on
419
Am
ean
ICP
rise
of
4.5
mm
Hg
(SD
4.1
mm
Hg
)w
asfo
un
d.
Ap
aire
dan
aly
sis
of
ICP
read
ing
sw
ith
and
wit
ho
ut
the
coll
arsh
ow
eda
sig
nifi
-ca
nt
rise
wh
enth
eco
llar
was
use
d(p¼<
0.00
1).
Pai
red
anal
ysi
so
fH
R,
CV
P,
and
MA
Pw
ith
and
wit
ho
ut
the
coll
arsh
ow
edn
osi
gn
ifica
nt
dif
fer-
ence
.T
her
ew
asn
oco
rrel
atio
nb
e-tw
een
chan
ges
inIC
Pan
dM
AP
(r¼
0.17
),st
arti
ng
ICP
(r¼
0.03
),ch
ang
ein
CV
P(r¼
0.06
),o
rch
ang
ein
HR
(r¼
0.02
).
1346
De
Lo
ren
zoet
al.,
1996
An
n.
Em
erg
.M
ed.
Op
tim
alp
osi
tio
nin
gfo
rce
rvic
alim
mo
-b
iliz
atio
n
(Ex
per
imen
tal
non
-RC
T)
Po
pu
lati
on
:M=F¼
8=11
;A
ge¼
33.6
y(2
0–54
y).
Tre
atm
en
t:S
ub
ject
sw
ere
ask
edto
lie
on
ari
gid
pla
stic
bo
ard
.T
he
nec
kw
asfl
exed
and
exte
nd
edb
yra
isin
gan
dlo
wer
ing
the
hea
dre
lati
ve
toth
eco
ccy
x-s
cap
ula
rp
lan
ein
2-cm
incr
e-m
ents
.T
he
mag
net
icfi
eld
iso
cen
ter
was
alig
ned
wit
hth
esu
bje
ct’s
cric
oid
mem
bra
ne.
On
ceth
esu
bje
ctw
asin
po
siti
on
,im
agin
gw
aso
bta
ined
wit
ha
Ph
illi
ps
1.5
Tsc
ann
er.
Tra
nsv
erse
im-
ages
thro
ug
hth
ece
nte
ro
fth
ev
erte
-b
ral
bo
die
sfr
om
C2
toT
2w
ere
ob
tain
ed.
Th
eim
agin
gp
roce
ssw
asre
pea
ted
wit
hth
eo
ccip
ut
seq
uen
tial
lyel
evat
edan
dlo
wer
edb
y2
and
4cm
toth
ep
lan
eo
fth
ep
last
icb
oar
d.
Ou
t-co
me
me
asu
res:
Th
era
tio
of
spin
alca
nal
and
spin
alco
rdar
eas
atea
chsp
inal
lev
elC
2to
T1
was
calc
ula
ted
for
each
po
siti
on
of
flex
ion
and
ex-
ten
sio
n.
Th
ecr
oss
-sec
tio
nal
area
was
det
erm
ined
.
To
det
erm
ine
the
op
tim
alp
osi
tio
nfo
rce
rvic
alsp
ine
imm
ob
iliz
atio
nu
sin
gm
agn
etic
reso
-n
ance
imag
ing
(MR
I),
and
tod
efin
eth
iso
pti
-m
alp
osi
tio
nin
acl
ini-
call
yre
pro
du
cib
lefa
shio
n
419
Th
em
ean
rati
oo
fsp
inal
can
alan
dsp
inal
cord
cro
ss-s
ecti
on
alar
eas
was
smal
lest
atC
6,b
ut
exce
eded
2.0
atal
lle
vel
sfr
om
C2
toT
1(p<
0.05
).A
tC
4–C
7th
eze
rop
osi
tio
nra
tio
of
spi-
nal
can
alar
eato
spin
alco
rdar
eaw
asm
inim
um
for
78%
of
sub
ject
s.S
mal
lca
nal
-to
-co
rdra
tio
sre
pre
sen
tth
elo
wes
tm
arg
ino
fsa
fety
for
inju
ryto
the
spin
alco
rdp
ote
nti
ally
swo
llen
by
inju
ryo
ris
chem
ia,
or
imp
ing
edo
nb
yd
isp
lace
dv
erte
bra
lst
ruct
ure
s.A
tth
eC
5an
dC
6le
vel
sth
em
axim
alar
eara
tio
was
mo
stco
nsi
sten
tly
ob
tain
edw
ith
slig
ht
flex
ion
(cer
vic
al-t
ho
raci
can
gle
of
148;
p<
0.05
).F
or
ap
atie
nt
lyin
gfl
ato
na
bac
kb
oar
d,
this
corr
e-sp
on
ds
tora
isin
gth
eo
ccip
ut
2cm
.A
tþ4
elev
atio
nsi
gn
ifica
nt
var
iab
ilit
yw
aso
bta
ined
amo
ng
the
sub
ject
ssu
chth
atat
this
extr
eme
deg
ree
of
flex
ion
,so
me
ind
ivid
ual
sh
adm
axim
alsp
inal
can
al=sp
inal
cord
area
rati
os
ata
giv
enle
vel
,w
her
eas
oth
ers
had
min
-im
alsp
inal
can
al=sp
inal
cord
area
rati
os.
Inh
ealt
hy
adu
lts,
asl
igh
td
egre
eo
ffl
exio
neq
uiv
alen
tto
2cm
of
occ
ipu
tel
evat
ion
pro
du
ces
afa
vo
r-ab
lein
crea
sein
spin
alca
nal=sp
inal
cord
rati
oat
lev
els
C5
and
C6,
are
gio
no
ffr
equ
ent
un
stab
lesp
ine
inju
ries
.
Do
mei
eret
al.,
1997
Aca
d.
Em
erg
.M
ed.
Pro
spec
tiv
ev
alid
atio
no
fo
ut
of
ho
spit
alsp
inal
clea
ran
cecr
iter
ia:
ap
reli
mi-
nar
yre
po
rt
(Obs
erva
tion
alst
udy
)P
op
ula
tio
n:
M=F¼
1035=10
61;
Lev
elo
fin
jury
:C¼
19;
T¼
22;
L¼
25.
Tre
atm
en
t:O
ut
of
ho
spit
altr
ansp
ort
amb
ula
nce
per
son
nel
com
ple
ted
aq
ues
tio
nn
aire
for
pat
ien
ts.
All
par
tici
pat
ing
per
-so
nn
elw
ere
trai
ned
on
the
stu
dy
and
qu
esti
on
nai
res.
Th
eyw
ere
told
tov
erif
yth
ep
rese
nce
or
abse
nce
of
each
dat
ap
oin
tb
ased
on
the
init
ial
pat
ien
tev
alu
atio
n.
Th
ep
erso
nn
elw
ere
inst
ruct
edto
det
ail
any
po
ten
-ti
alD
PI.
Ou
tco
me
dat
ap
oin
tsw
ere
det
erm
ined
by
med
ical
reco
rdre
-v
iew
.O
utc
om
em
easu
res:
Pre
sen
ceo
rab
sen
ceo
fa
spin
alfr
actu
reo
rS
CI,
loca
tio
no
ffr
actu
rean
dtr
eat-
men
t.
To
pro
spec
tiv
ely
asse
ssw
het
her
the
abse
nce
of
all
of
the
abo
ve
retr
o-
spec
tiv
ely
iden
tifi
edcr
i-te
ria
can
be
use
dto
iden
tify
ou
to
fh
osp
ital
trau
ma
pat
ien
tsw
ith
ou
tsi
gn
ifica
nt
spin
alfr
actu
re
417
See
text
(Con
tin
ued
)
1347
Ta
bl
e1.
Ev
id
en
ce
Ta
bl
e(C
on
tin
ue
d)
Ref
eren
ceJo
urn
alT
itle
Des
ign
Pu
rpos
e=h
yp
oth
esis
Sac
kett
rati
ng
aD
&B
scor
e(o
ut
of44
)R
esu
lts
Do
mei
eret
al.,
1999
Pre
ho
sp.
Em
erg
.C
are
Th
ere
liab
ilit
yo
fp
re-
ho
spit
alcl
inic
alev
alu
atio
nfo
rp
o-
ten
tial
spin
alin
jury
isn
ot
affe
cted
by
the
mec
han
ism
of
inju
ry
(Cas
ese
ries
)T
rea
tme
nt:
Pre
-ho
spit
altr
ansp
ort
ing
amb
ula
nce
pro
vid
ers
com
ple
ted
ad
ata
qu
esti
on
nai
refo
ral
lth
ep
atie
nts
wh
om
etth
est
ud
yp
op
-u
lati
on
incl
usi
on
crit
eria
.A
llp
arti
ci-
pat
ing
pre
-ho
spit
alp
erso
nn
elw
ere
pro
vid
edb
rief
did
acti
ctr
ain
ing
de-
sig
ned
for
ori
enta
tio
nto
the
stu
dy
and
dat
aco
llec
tio
nsh
eet.
Par
tici
pan
tsw
ere
inst
ruct
edto
det
erm
ine
the
pre
sen
ceo
rab
sen
ceo
fea
chd
ata
po
int
bas
edo
nth
ein
itia
lp
atie
nt
eval
uat
ion
.T
he
dat
aq
ues
tio
nn
aire
sw
ere
left
inth
eE
Do
fth
ere
ceiv
ing
faci
lity
,o
rg
iven
toth
eam
bu
lan
cesu
per
vis
or
for
dis
trib
uti
on
and
ou
tco
me
det
erm
inat
ion
.O
utc
om
em
easu
res:
Pre
sen
ceo
rab
sen
ceo
fsp
i-n
alfr
actu
reo
rS
CI,
loca
tio
no
ffr
actu
rean
dtr
eatm
ent.
To
exam
ine
the
effe
cto
fth
ese
ver
ity
of
the
mec
ha-
nis
mo
fin
jury
on
the
abil
ity
of
clin
ical
crit
eria
tose
lect
pat
ien
tsw
ith
spin
alin
jury
427
See
tex
t
Do
mei
er,
etal
.,20
02J.
Tra
um
aM
ult
icen
ter
pro
spec
tiv
ev
alid
a-ti
on
of
pre
-ho
spit
alcl
inic
alsp
inal
clea
ran
cecr
iter
ia
(Cas
ese
ries
)P
op
ula
tio
n:
%M=F¼
49.5=50
.5;
Ag
e¼
39.3
y;
Lev
elo
fin
jury
:C¼
109;
T¼
86;
L¼
100.
Tre
atm
en
t:P
re-h
osp
ital
tran
spo
rtin
gam
bu
lan
cep
rov
ider
sw
ere
inst
ruct
edto
com
ple
tea
stan
dar
diz
edd
ata
qu
esti
on
nai
refo
ral
lp
atie
nts
wh
om
etin
clu
sio
ncr
iter
ia.
All
par
tici
pat
ing
pre
-ho
spit
alp
erso
nn
elw
ere
pro
vid
eda
bri
efd
idac
tic
trai
nin
gse
ssio
nd
e-si
gn
edfo
ro
rien
tati
on
toth
est
ud
yan
dd
ata
coll
ecti
on
shee
tb
efo
reen
roll
ing
pat
ien
ts.
Ou
tco
me
me
asu
res:
Pat
ien
tre
po
rtd
ata.
To
pro
spec
tiv
ely
val
idat
eth
atth
eab
sen
ceo
fsp
e-ci
fic
crit
eria
can
be
use
dto
iden
tify
pre
-ho
spit
altr
aum
ap
atie
nts
wit
ho
ut
asp
inal
inju
ry,
and
wh
od
on
ot
req
uir
ep
re-
ho
spit
alri
gid
imm
ob
ili-
zati
on
415
See
tex
t
Do
mei
eret
al.,
2005
An
n.
Em
erg
.M
ed.
Pro
spec
tiv
ep
erfo
r-m
ance
asse
ssm
ent
of
ano
ut
of
ho
spi-
tal
pro
toco
lfo
rse
-le
ctiv
esp
ine
imm
ob
iliz
atio
nu
s-in
gcl
inic
alsp
ine
clea
ran
cecr
iter
ia
(Cas
ese
ries
)P
op
ula
tio
n:
Ag
e¼<
1–10
4y
;L
evel
of
inju
ry:
27%
C,
10%
T,
2.5%
L.
Tre
atm
en
t:E
MS
per
son
nel
wer
etr
ain
edto
per
form
and
do
cum
ent
asp
ine
inju
ryas
sess
men
tfo
ro
ut-
of-
ho
spit
altr
aum
ap
atie
nts
wit
ha
mec
han
ism
of
inju
ryju
dg
edsu
ffici
ent
toca
use
asp
ine
inju
ry.
Ou
tco
me
me
asu
res:
Bas
edo
nh
osp
ital
reco
rds
and
spin
ein
jury
asse
ssm
ent
tab
leco
mp
lete
db
yE
MS
per
son
nel
.O
ut-
com
ech
arac
teri
stic
sin
clu
ded
the
pre
sen
ceo
rab
sen
ceo
fsp
ine
inju
ryan
dsp
ine
inju
rym
anag
emen
t.
To
det
erm
ine
wh
eth
erth
eu
seo
fan
EM
Sp
roto
col
for
sele
ctiv
esp
ine
im-
mo
bil
izat
ion
wo
uld
resu
ltin
app
rop
riat
eim
mo
bil
izat
ion
wit
ho
ut
SC
Ias
soci
ated
wit
hn
oim
mo
bil
izat
ion
415
See
tex
t
1348
Do
ran
etal
.,19
95P
reh
osp
.D
isas
-te
rM
ed.
Fac
tors
infl
uen
cin
gsu
cces
sfu
lin
tub
a-ti
on
inth
ep
re-
ho
spit
alse
ttin
g
(Pro
spec
tiv
ere
vie
w)
Po
pu
lati
on
:46
91p
a-ti
ents
tran
spo
rted
;23
6w
ith
intu
bat
ion
atte
mp
ts;
78%
mal
e,m
ean
age
51.4�
22.1
0y
.T
rea
tme
nt:
Dat
aab
-st
ract
edfr
om
run
rep
ort
san
dp
ara-
med
ics
ask
edin
stru
ctu
red
inte
rvie
ws
tod
escr
ibe
dif
ficu
ltie
sin
OE
TI=
ET
I.O
utc
om
em
easu
res:
Su
cces
so
rfa
ilu
reo
fp
re-h
osp
ital
intu
bat
ion
To
exp
lore
the
det
erm
i-n
ants
infl
uen
cin
go
ral=
nas
alen
do
trac
hea
lin
tub
atio
n;
tod
eter
min
ew
hic
hco
gn
itiv
e,th
era-
peu
tic,
and
tech
nic
alin
-te
rven
tio
ns
may
assi
stp
re-h
osp
ital
airw
aym
anag
emen
t
2B25
88%
succ
essf
ul
intu
bat
ion
;p
osi
tio
nan
dsp
inal
imm
ob
iliz
atio
nw
ere
rep
ort
edto
incr
ease
dif
ficu
lty
in39
.6%
of
trau
ma
pat
ien
ts.
Fla
bo
uri
s,20
01In
jury
Cli
nic
alfe
atu
res,
pat
-te
rns
of
refe
rral
and
ou
to
fh
osp
ital
tran
spo
rtev
ents
for
pat
ien
tsw
ith
sus-
pec
ted
iso
late
dsp
i-n
alin
jury
(Cas
ese
ries
)P
op
ula
tio
n:
Ag
e¼
31y
;%
M¼
68;
Lev
elo
fin
jury
:C¼
41%
;L¼
10%
;T¼
8%;
mix
ed¼
2%;
no
r-m
al¼
39%
.T
rea
tme
nt:
Med
ical
tran
s-p
ort
reco
rds
of
pat
ien
tstr
ansp
ort
edw
ere
rev
iew
ed.
Rel
evan
td
ata
wer
eco
llat
edo
nto
ast
ud
y-s
pec
ific
dat
a-b
ase.
Ou
tco
me
me
asu
res:
Pat
ien
td
emo
gra
ph
ics,
typ
ean
dm
od
eo
ftr
ansp
ort
,an
dtr
ansp
ort
inci
den
ts.
Sce
ne,
pre
-ref
erra
l,an
do
utc
om
ecl
in-
ical
dat
a.
To
des
crib
eth
ep
atte
rno
fu
tili
zati
on
of
ap
atie
nt
tran
spo
rtat
ion
serv
ice
by
pat
ien
tsw
ith
susp
ecte
dis
ola
ted
spin
alin
juri
esw
ho
are
tran
spo
rted
fro
mh
osp
ital=sc
ene,
do
cum
ent
the
imp
act
of
the
serv
ice
on
scen
em
anag
emen
tan
dth
ecl
inic
alco
sto
fm
od
eso
ftr
ansp
ort
atio
n
419
See
text
Ger
lin
get
al.,
2000
An
n.
Em
erg
.M
ed.
Eff
ects
of
cerv
ical
spin
eim
mo
bil
iza-
tio
nte
chn
iqu
ean
dla
ryn
go
sco
pe
bla
de
sele
ctio
no
nan
un
-st
able
cerv
ical
spin
ein
aca
dav
erm
od
elo
fin
tub
atio
n
(Ex
per
imen
tal)
Tre
atm
en
t:A
C5–
C6
sur-
gic
altr
anse
ctio
nw
ascr
eate
dto
stan
dar
diz
eth
em
od
elo
fin
jury
.A
nan
teri
or
app
roac
hw
asse
lect
ed,
wit
ha
ver
tica
lin
cisi
on
mad
eal
on
gth
em
e-d
ial
asp
ect
of
the
clav
icu
lar
hea
do
fth
est
ern
ocl
eid
om
asto
idm
usc
le.C
om
ple
tein
stab
ilit
yo
fth
ein
jury
was
con
firm
edth
rou
gh
flu
oro
sco
py
asd
efin
edb
yan
gu
lar
dis
pla
cem
ent>
118
and
AP
dis
pla
cem
ent>
20%
of
C5
ver
teb
ral
bo
dy
wid
thd
uri
ng
man
ipu
lati
on
.A
nO
TI
was
per
form
edw
ith
each
of
the
thre
ela
ryn
go
sco
pe
bla
des
.E
ach
of
the
two
dif
fere
nt
imm
ob
iliz
atio
nte
ch-
niq
ues
(man
ual
in-l
ine
stab
iliz
atio
nan
dce
rvic
alco
llar
imm
ob
iliz
atio
n)
wer
eal
sou
sed
.A
cro
ss-o
ver
des
ign
was
use
din
wh
ich
thre
eb
lad
esan
db
oth
imm
ob
iliz
atio
nte
chn
iqu
esw
ere
use
din
ran
do
mo
rder
for
each
ca-
dav
er.
Intu
bat
ors
wer
en
ot
bli
nd
edto
eith
erth
eb
lad
ety
pe
or
imm
ob
iliz
a-ti
on
tech
niq
ue.
Ou
tco
me
me
asu
res:
Am
ou
nt
of
mo
vem
ent
acro
ssth
eu
n-
stab
lece
rvic
alsp
ine
lesi
on
inth
ree
pla
nes
,ax
ial
dis
trac
tio
n,
and
ang
ula
rro
tati
on
To
eval
uat
eth
eef
fect
so
fm
anu
alin
-lin
est
abil
iza-
tio
nan
dce
rvic
alco
llar
imm
ob
iliz
atio
nan
dth
ree
dif
fere
nt
lary
ng
o-
sco
pe
bla
des
on
cerv
ical
spin
em
ov
emen
td
uri
ng
OT
Iin
aca
dav
erm
od
elo
fce
rvic
alsp
ine
inju
ry
Bio
mec
han
ical
stu
dy
,n
ot
app
lica
ble
16S
ign
ifica
ntl
yle
ssm
ov
emen
td
uri
ng
OT
Iw
aso
bse
rved
wit
hth
eu
seo
fm
anu
alin
-lin
est
abil
izat
ion
than
cerv
ical
coll
arim
mo
bil
izat
ion
wit
hre
gar
dto
AP
dis
pla
cem
ent
into
the
spin
alca
nal
(7.5
%v
ersu
s13
.7%
of
C5
bo
dy
wid
th;
p¼
0.03
).T
her
ew
ere
no
sig
nifi
can
td
iffe
ren
ces
inax
ial
dis
trac
tio
n=
ang
ula
rro
tati
on
;S
ign
ifica
ntl
yle
ssm
ov
emen
td
uri
ng
OT
Iw
ith
the
use
of
the
Mil
ler
stra
igh
tb
lad
ev
ersu
sth
eM
cIn
tosh
or
CL
Mb
lad
esin
axia
ld
istr
acti
on
(p¼
0.00
9).
Th
ere
wer
en
od
iffe
ren
ces
amo
ng
the
bla
des
inA
Pd
isp
lace
men
to
ran
gu
lar
rota
tio
n.
Th
eC
orm
ack
-Leh
ane
gra
de
ob
tain
edd
ur-
ing
lary
ng
osc
op
yw
assi
gn
ifica
ntl
yb
ette
rw
ith
man
ual
in-l
ine
stab
iliz
a-ti
on
ver
sus
cerv
ical
coll
arim
mo
bil
i-za
tio
n(p<
0.05
),b
ut
no
dif
fere
nce
ing
rad
eb
etw
een
the
Mil
ler,
Mac
into
sh,
and
CL
Mla
ryn
go
sco
pe
bla
des
.
(Con
tin
ued
)
1349
Ta
bl
e1.
Ev
id
en
ce
Ta
bl
e(C
on
tin
ue
d)
Ref
eren
ceJo
urn
alT
itle
Des
ign
Pu
rpos
e=h
yp
oth
esis
Sac
kett
rati
ng
aD
&B
scor
e(o
ut
of44
)R
esu
lts
Gra
zian
oet
al.,
1987
An
n.
Em
erg
.M
ed.
Ara
dio
gra
ph
icco
m-
par
iso
no
fp
re-
ho
spit
alce
rvic
alim
mo
bil
izat
ion
met
ho
ds
(Ex
per
imen
tal
RC
T)
Po
pu
lati
on
:A
ge¼
25y
(18–
61y
)T
rea
tme
nt:
All
vo
lun
teer
sw
ere
test
edin
the
sitt
ing
po
siti
on
toap
pro
xim
ate
the
con
dit
ion
freq
uen
tly
enco
un
tere
din
the
pre
-h
osp
ital
sett
ing
.A
llim
mo
bil
izat
ion
tech
niq
ues
wer
ead
min
iste
red
acco
rd-
ing
toth
em
anu
fact
ure
r’s
reco
m-
men
ded
pro
ced
ure
.E
ach
vo
lun
teer
un
der
wen
tn
ine
rad
iog
rap
hic
vie
ws.
Th
ree
vie
ws
wer
eo
bta
ined
inea
cho
fth
efo
llo
win
gco
nd
itio
ns
stu
die
d:
un
-re
stri
cted
for
bas
elin
eco
mp
aris
on
,th
esh
ort
-bo
ard
tech
niq
ue,
and
on
eo
fth
eth
ree
test
dev
ices
tow
hic
hth
esu
bje
ctw
asra
nd
om
lyas
sig
ned
.T
he
effi
caci
eso
fth
ese
tech
niq
ues
wer
eco
mp
ared
.O
utc
om
em
easu
res:
Effi
cacy
of
the
dif
fere
nt
test
dev
ices
To
eval
uat
eth
eef
fica
cyo
fth
ree
new
erco
mm
on
lyu
sed
cerv
ical
imm
ob
ili-
zati
on
dev
ices
(CS
C,
ao
ne-
pie
cew
rap
-aro
un
dco
llar
;K
ED
,a
fact
ory
-fa
bri
cate
dsh
ort
bo
ard
;an
dX
P-O
ne,
afa
cto
ry-
fab
rica
ted
sho
rtb
oar
d-
coll
arco
mb
inat
ion
)fo
rw
hic
hth
ere
are
no
ob
-je
ctiv
ed
ata
pu
bli
shed
inth
em
edic
alli
tera
ture
420
Th
esh
ort
bo
ard
tech
niq
ue
(SB
T)
was
sup
erio
rto
the
CS
Cin
rota
tio
nan
dth
eK
ED
inex
ten
sio
n;
the
KE
Dw
assu
-p
erio
rto
the
SB
Tin
flex
ion
.F
or
tota
lra
ng
eo
fm
oti
on
inth
esa
git
tal
pla
ne
the
SB
Tp
rov
edsi
gn
ifica
ntl
yb
ette
r(p<
0.05
)th
anth
eC
SC
,w
hil
eth
eK
ED
and
XP
-On
eap
pro
ach
edS
BT
effi
cacy
.T
he
SB
Tw
assi
gn
ifica
ntl
yd
iffe
ren
tth
anth
eco
ntr
ols
(p<
0.00
1)in
all
pla
nes
.T
hu
sw
her
ed
iffe
ren
ces
wer
esi
gn
ifica
nt
(p<
0.05
)th
eS
BT
was
sup
erio
rw
hen
com
par
edto
all
test
dev
ices
.T
he
SB
Tw
assu
per
ior
inal
lp
lan
eso
fce
rvic
alsp
ine
mo
tio
n.
Of
the
thre
ed
evic
esco
mp
ared
agai
nst
the
SB
T,
the
sho
rt-b
oar
dd
evic
es(K
ED
and
XP
-On
e)p
rov
ided
the
gre
ates
tim
mo
bil
izat
ion
wit
hlo
gis
tica
lad
van
-ta
ges
ov
erth
eS
BT
.H
amil
ton
and
Po
ns,
1996
J.E
mer
g.
Med
.T
he
effi
cacy
and
com
fort
of
full
bo
dy
vac
uu
msp
lin
tsfo
rce
rvic
al-
spin
eim
mo
bil
iza-
tio
n
Po
pu
lati
on
:A
ge¼
28.9
y;
M=F¼
22=4;
Hei
gh
t¼17
4.5
cm;
Wei
gh
t¼75
.6k
g.
Tre
atm
en
t:E
ach
mea
sure
men
tw
asre
pea
ted
thre
eti
mes
and
the
aver
age
was
use
d.
Su
bje
cts
wer
eas
ked
top
erfo
rmth
ed
esir
edm
oti
on
by
mo
v-
ing
asfa
ras
po
ssib
lew
ith
ou
tca
usi
ng
pai
n=d
isco
mfo
rt.
C-s
pin
eR
OM
was
reco
rded
,aS
tifn
eck
cerv
ical
coll
arw
asap
pli
ed,
and
RO
Mw
asre
pea
ted
.S
ub
ject
sw
ere
then
ran
do
miz
edto
be
imm
ob
iliz
edo
na
stan
dar
dlo
ng
spin
eb
oar
do
ro
nth
eV
acB
oar
d,
bo
thw
ith
and
wit
ho
ut
ace
rvic
alco
llar
.E
ach
sub
ject
was
then
cro
ssed
ov
erto
the
oth
erd
evic
e.D
uri
ng
each
imm
ob
ili-
zati
on
,a
full
set
of
cerv
ical
spin
eR
OM
mea
sure
men
tsw
asm
ade,
and
afte
r10
min
of
imm
ob
iliz
atio
n,
each
sub
ject
was
ask
edto
gra
de
ov
eral
lim
mo
bil
i-za
tio
no
na
10-p
oin
tv
isu
alan
alo
gsc
ale,
wit
h0
as‘‘n
ore
stri
ctio
n’’
and
10as
‘‘co
mp
lete
lyim
mo
bil
ized
.’’S
ub
ject
sw
ere
also
ask
edto
gra
de
dis
com
fort
bo
tho
ver
all
and
inse
ven
spec
ific
bo
dy
reg
ion
so
na
10-p
oin
tv
isu
alan
alo
gsc
ale,
wit
h0
as‘‘n
od
isco
mfo
rt’’
and
10as
‘‘sev
ere
pai
n.’’
Ou
tco
me
me
asu
res:
Sig
nifi
can
ceo
fea
chim
mo
-b
iliz
atio
nsy
stem
on
mo
tio
n,
ov
eral
lim
mo
bil
izat
ion
,an
dd
isco
mfo
rt
To
det
erm
ine
wh
eth
ero
rn
ot
vac
uu
msp
lin
tsp
ro-
vid
ece
rvic
alsp
ine
im-
mo
bil
izat
ion
com
par
able
toth
ato
bta
ined
wit
hth
eri
gid
bac
kb
oar
d,
and
toco
mp
are
the
sub
ject
ive
com
fort
bet
wee
nth
etw
osy
stem
s
2B16
Infl
exio
n,
ther
ew
asn
osi
gn
ifica
nt
dif
-fe
ren
ceb
etw
een
the
VSþ
CC
(vac
uu
msp
lin
tan
dce
rvic
alco
llar
)an
dth
eB
Bþ
CC
(bac
kb
oar
dan
dce
rvic
alco
llar
),an
db
oth
thes
esy
stem
sp
ro-
vid
edb
ette
rim
mo
bil
izat
ion
than
ei-
ther
wit
ho
ut
the
CC
.W
ith
ou
tth
eC
C,
the
VS
pro
vid
edsi
gn
ifica
ntl
yb
ette
rim
mo
bil
izat
ion
for
flex
ion
than
the
BB
.F
or
exte
nsi
on
,th
eB
Bal
on
ean
dth
eV
Sw
ith
or
wit
ho
ut
aC
Cp
rov
ided
com
-p
arab
leim
mo
bil
izat
ion
,an
dal
lth
ree
com
bo
sw
ere
bet
ter
than
the
BBþ
CC
.In
late
ral
ben
din
g,
the
vac
uu
msp
lin
tin
gen
eral
pro
vid
edb
ette
rim
mo
bil
i-za
tio
nth
anth
eb
ack
bo
ard
,w
ith
or
wit
ho
ut
aC
C.
Inro
tati
on
,th
ere
wer
en
osi
gn
ifica
nt
dif
fere
nce
sin
imm
o-
bil
izat
ion
.S
ign
ifica
nt
dif
fere
nce
sin
sub
ject
per
cep
tio
no
fo
ver
all
imm
ob
i-li
zati
on
wer
efo
un
d,
wit
hth
eV
Sþ
CC
pro
vid
ing
the
bes
tim
mo
bil
izat
ion
,fo
llo
wed
by
the
BBþ
CC
and
VS
alo
ne,
foll
ow
edb
yth
eB
Bal
on
e.T
he
vac
uu
msp
lin
tw
asal
sofo
un
dto
be
sig
nifi
can
tly
mo
reco
mfo
rtab
leth
anth
eb
ack
bo
ard
,b
oth
insu
bje
ctiv
ep
er-
cep
tio
no
fo
ver
all
and
occ
ipit
alre
gio
nco
mfo
rt,
wit
ho
rw
ith
ou
ta
CC
.
1350
Hau
swal
det
al.,
1998
Aca
d.
Em
erg
.M
ed.
Ou
to
fh
osp
ital
spin
alim
mo
bil
izat
ion
:it
sef
fect
on
neu
rolo
gic
inju
ry
(Obs
ervat
ion
alca
sese
ries
)P
op
ula
tio
n:
Ag
e:¼
34y
(US
A),
(Mal
aysi
a)¼
35y
;%
M(U
SA)¼
77,
(Mal
aysi
a)¼
88;
Lev
elo
fin
jury
:(U
SA)
C¼
34%
,T¼
32%
,L¼
34%
;M
alay
sia:
C¼
33%
,T¼
28%
,L¼
39%
.T
reatm
ent:
Are
tro
spec
tiv
ech
art
rev
iew
was
con
du
cted
on
all
pat
ien
tsad
mit
ted
toth
ein
pat
ien
tse
rvic
eo
rE
Dfo
rth
etw
oh
osp
ital
s.N
on
eo
fth
ep
atie
nts
seen
atth
eU
niv
ersi
tyo
fM
alay
ah
adsp
inal
imm
ob
iliz
atio
nd
uri
ng
tran
spo
rt,
wh
erea
sal
lth
ep
a-ti
ents
seen
atth
eU
niv
ersi
tyo
fN
ewM
exic
od
id.
Neu
rolo
gic
alin
juri
esw
ere
assi
gn
edto
two
cate
go
ries
(dis
abli
ng
or
no
td
isab
lin
g),
by
two
ph
ysi
cian
sac
t-in
gin
dep
end
entl
yan
db
lin
ded
toth
eh
osp
ital
of
ori
gin
.D
ata
wer
ean
aly
zed
usi
ng
mu
ltiv
aria
telo
gis
tic
reg
ress
ion
.O
utc
om
em
easu
res:
Ch
art
dat
a
To
exam
ine
the
effe
cto
fem
erg
ency
imm
ob
iliz
a-ti
on
on
neu
rolo
gic
alo
utc
om
eo
fp
atie
nts
wh
oh
ave
blu
nt
trau
mat
icsp
inal
inju
ries
423
OR
for
dis
abil
ity
was
hig
her
for
pat
ien
tsin
the
US
Aaf
ter
adju
stm
ent
for
the
effe
cto
fin
dep
end
ent
var
iab
les
(p¼
0.04
).T
he
lev
elo
fn
euro
log
ical
defi
cit
was
the
on
lyin
dep
end
ent
pre
-d
icto
ro
fb
ado
utc
om
e.T
her
ew
asle
ssn
euro
log
ical
dis
abil
ity
inth
eu
nim
-m
ob
iliz
edM
alay
sian
pat
ien
ts(O
R2.
03;
95%
CI
1.03
,3.
99;
p¼
0.04
).T
his
corr
esp
on
ds
toa<
2%ch
ance
that
imm
ob
iliz
atio
nis
ben
efici
al.
Res
ult
sw
ere
sim
ilar
wh
enli
mit
edto
pat
ien
tsw
ith
cerv
ical
inju
ries
(OR
1.52
;95
%C
I0.
64,
3.62
;p¼
0.34
).O
ut-
of-
ho
spit
alim
mo
bil
izat
ion
has
litt
leo
rn
oef
fect
on
neu
rolo
gic
alo
utc
om
ein
pat
ien
tsw
ith
blu
nt
spin
alin
juri
es.
Hau
swal
det
al.,
2000
Pre
ho
sp.
Em
erg
.C
are
Max
imiz
ing
com
fort
and
min
imiz
ing
isch
emia
:A
com
-p
aris
on
of
fou
rm
eth
od
so
fsp
inal
imm
ob
iliz
atio
n
(Ex
per
imen
tal
RC
T)
Tre
atm
ent:
Stu
den
tsw
ere
ask
edto
lay
sup
ine
on
fou
rd
iffe
ren
tsu
rfac
esw
ith
ou
tb
ein
gse
cure
dw
ith
stra
ps.
Dev
ices
(tra
dit
ion
alb
ack
-b
oar
d;b
ack
bo
ard
pad
ded
wit
ha
fold
edb
lan
ket
;b
ack
bo
ard
pad
ded
wit
ha
3-cm
gu
rney
mat
tres
s;an
da
bac
kb
oar
dan
dm
attr
ess
pad
ded
wit
ha
6-cm
egg
crat
efo
amp
ad)
wer
eas
sig
ned
inra
nd
om
ord
er.
Aft
erly
ing
for
10m
in,
stu
den
tsra
ted
com
fort
.A
llfo
ur
met
ho
ds
wer
eev
alu
ated
usi
ng
the
sam
esc
ale
toal
low
com
par
iso
no
fre
spo
nse
s.E
ach
par
tici
-p
ant
eval
uat
edal
lfo
ur
dev
ices
and
was
giv
ena
15-m
inre
stin
terv
alb
etw
een
tria
ls.
Eac
hm
ark
ed10
-cm
vis
ual
anal
og
scal
ew
asm
easu
red
on
two
sep
arat
eo
ccas
ion
sto
the
clo
sest
0.1
cmb
yth
esa
me
ob
serv
eran
dth
em
ean
of
thes
etw
oes
tim
ates
was
reco
rded
.O
utc
om
em
easu
res:
Dev
ice
com
fort
sco
res
To
det
erm
ine
wh
ich
of
fou
rm
eth
od
so
fsp
inal
im-
mo
bil
izat
ion
cau
ses
the
leas
tis
chem
icp
ain
2B29
Co
mfo
rtsc
ore
sw
ere
sig
nifi
can
tly
dif
fer-
ent
for
all
met
ho
ds
(F¼
101,
p<
0.00
1).
Ab
ack
bo
ard
pad
ded
wit
ha
gu
rney
mat
tres
san
deg
gcr
ate
foam
cau
sed
the
leas
tis
chem
icp
ain
(9.6
cm,
95%
CI
8.9,
9.8
cm).
Ab
ack
bo
ard
pad
ded
wit
ha
gu
rney
mat
tres
sw
asth
ese
con
dm
ost
com
fort
able
dev
ice
(7.0
cm,
95%
CI
6.4,
7.4
cm).
Ab
ack
bo
ard
pad
ded
wit
ha
fold
edb
lan
ket
was
the
thir
dm
ost
com
fort
able
(3.3
cm,
95%
CI
2.6,
4.9
cm).
Th
eb
ack
bo
ard
alo
ne
cau
sed
the
mo
stp
ain
(0.8
cm,
95%
CI,
0.7
to2.
1cm
).In
crea
sin
gth
eam
ou
nt
of
pad
din
go
na
bac
kb
oar
dd
ecre
ased
the
amo
un
to
fis
chem
icp
ain
cau
sed
by
imm
ob
iliz
atio
n.
Hu
erta
etal
.,19
87A
nn
.E
mer
g.
Med
.C
erv
ical
spin
est
abil
i-za
tio
nin
pae
dia
tric
pat
ien
ts:
eval
uat
ion
of
curr
ent
tech
-n
iqu
es
(Ex
per
imen
tal
Non
-RC
T)
Po
pu
lati
on
:A
ge¼
5–9
y.
Tre
atm
ent:
Eac
hch
ild
was
inst
ruct
edto
exer
tm
axim
um
pre
ssu
rew
ith
his
or
her
hea
dag
ain
sta
stat
ion
ary
han
d-h
eld
blo
od
pre
ssu
recu
ffin
flat
edto
ab
asel
ine
pre
ssu
reo
f20
mm
Hg
.A
ver
age
pre
ssu
res
wer
ed
eter
min
edfo
rea
chd
irec
tio
nan
dth
ese
pre
ssu
res
wer
esu
bse
qu
entl
yre
pro
du
ced
the
man
ne-
qu
ins.
Wit
hth
em
ann
equ
inin
the
sup
ine
po
siti
on
,eac
hce
rvic
alco
llar
was
pla
ced
wit
hm
anu
alax
ial
trac
tio
nan
dim
mo
bil
izat
ion
was
mai
nta
ined
.O
ut-
com
em
easu
res:
Pre
ssu
res
wer
ere
-co
rded
info
ur
dir
ecti
on
s:fl
exio
n,
exte
nsi
on
,to
rsio
n,
and
late
rall
y.
Ov
eral
lef
fect
iven
ess
of
the
coll
arw
asas
sess
ed
Th
isst
ud
yw
asco
nd
uct
edto
eval
uat
eth
eef
fica
cyo
fco
mm
erci
ally
avai
l-ab
lece
rvic
alsp
ine
stab
i-li
zati
on
dev
ices
des
ign
edfo
rp
aed
iatr
icp
atie
nts
417
Co
llar
so
fri
gid
pla
stic
con
stru
ctio
np
er-
form
edb
ette
rth
anfo
am.
Wh
enu
sed
alo
ne
no
ne
of
the
coll
ars
pro
vid
edac
cep
tab
leim
mo
bil
izat
ion
;th
eb
est
allo
wed
178
of
flex
ion
,198
of
exte
n-
sio
n,
48o
fro
tati
on
,an
d68
of
late
ral
mo
tio
n,
bu
tco
mb
ined
wit
ho
ther
de-
vic
es,
imm
ob
iliz
atio
nto
38o
rle
ssin
any
dir
ecti
on
was
ach
iev
ed.
Ov
eral
l,co
mb
inat
ion
met
ho
ds
wer
eb
ette
rth
ance
rvic
alco
llar
sal
on
e(p<
0.00
1)o
rsu
pp
lem
enta
ld
evic
esal
on
e(p<
0.05
).T
he
mo
difi
edh
alf
spin
eb
oar
du
sed
wit
ha
rig
idco
llar
and
tap
ew
asth
em
ost
effe
ctiv
eco
mb
inat
ion
met
ho
d.
(Con
tin
ued
)
1351
Ta
bl
e1.
Ev
id
en
ce
Ta
bl
e(C
on
tin
ue
d)
Ref
eren
ceJo
urn
alT
itle
Des
ign
Pu
rpos
e=h
yp
oth
esis
Sac
kett
rati
ng
aD
&B
scor
e(o
ut
of44
)R
esu
lts
Joh
nso
net
al.,
1996
Am
.J.
Em
erg
.M
ed.
Co
mp
aris
on
of
av
ac-
uu
msp
lin
td
evic
eto
ari
gid
bac
k-
bo
ard
for
spin
alim
mo
bil
izat
ion
(Ex
per
imen
tal)
Tre
atm
en
t:T
oev
alu
ate
the
com
fort=
spee
do
fap
pli
cati
on
of
each
dev
ice,
stu
den
tsw
ere
giv
entr
ain
ing
inth
eu
seo
fea
chd
evic
ean
dal
low
ed4–
6h
of
pra
ctic
e.A
nin
stru
c-to
rti
med
each
pro
ced
ure
and
stu
den
tsw
ere
ran
do
mly
assi
gn
edfo
rp
lace
-m
ent
on
the
vac
uu
msp
lin
to
rth
ew
oo
db
ack
bo
ard
firs
t.A
fter
lyin
go
nea
chd
evic
efo
r30
min
the
stu
den
tsra
ted
com
fort
.E
ach
par
tici
pan
th
adth
eo
pp
ort
un
ity
toev
alu
ate
bo
thd
e-v
ices
.T
he
seco
nd
ph
ase
com
par
edim
mo
bil
izat
ion
of
sub
ject
sin
each
of
the
dev
ices
.Wh
enim
mo
bil
izat
ion
was
mea
sure
d,
each
dev
ice
was
eval
uat
edb
oth
wit
han
dw
ith
ou
tth
eap
pli
cati
on
of
ari
gid
cerv
ical
coll
ar.
Ou
tco
me
me
asu
res:
Co
mfo
rt,
late
ral
tilt
,m
ov
e-m
ent
To
com
par
ea
vac
uu
msp
lin
tm
attr
ess
toa
stan
dar
dw
oo
den
bac
k-
bo
ard
wit
hre
spec
tto
pat
ien
tco
mfo
rt;
also
toco
mp
are
the
two
dev
ices
wit
hre
gar
dto
the
ade-
qu
acy
of
imm
ob
iliz
atio
nan
dsp
eed
of
app
lica
tio
nu
sin
gh
um
anv
olu
nte
ers
417
Th
ev
acu
um
spli
nt
was
sig
nifi
can
tly
mo
reco
mfo
rtab
leo
na
10-p
oin
tsc
ale
than
the
rig
idb
ack
bo
ard
afte
rsu
bje
cts
had
bee
nly
ing
on
each
dev
ice
for
30m
in(p<
0.00
1).
Th
ev
acu
um
spli
nt
was
also
fast
erto
app
ly(p<
0.00
1).
Vac
uu
msp
lin
tsp
rov
ided
bet
ter
im-
mo
bil
izat
ion
of
the
tors
oan
dle
sssl
ipp
age
on
ag
rad
ual
late
ral
tilt
.T
he
rig
idb
ack
bo
ard
wit
hh
ead
blo
cks
was
slig
htl
yb
ette
rat
imm
ob
iliz
ing
the
hea
d;
Vac
uu
msp
lin
tso
ffer
asi
gn
ifi-
can
tim
pro
vem
ent
inco
mfo
rto
ver
the
trad
itio
nal
bac
kb
oar
dfo
rth
ep
atie
nt
wit
hp
oss
ible
spin
alin
jury
.
Kre
llet
al.,
2006
Pre
ho
sp.
Em
erg
.C
are
Co
mp
aris
on
of
the
Fer
no
Sco
op
stre
tch
erw
ith
the
lon
gb
ack
bo
ard
for
spin
alim
mo
bil
iza-
tio
n
(Ex
per
imen
tal)
Po
pu
lati
on
:A
ge¼
26y
(18–
47y
);H
eig
ht¼
175
cm(1
55–
196
cm);
Wei
gh
t¼79
kg
(48–
121
kg
).T
rea
tme
nt:
Th
em
ov
emen
to
fth
esp
ine
du
rin
gim
mo
bil
izat
ion
and
lift
ing
bet
wee
nth
eF
ern
oS
coo
pS
tret
cher
Mo
del
65E
XL
(FS
S)
and
the
lon
gb
ack
bo
ard
(LB
B)
wer
eev
al-
uat
ed.
Eac
hd
evic
ew
asal
soev
alu
-at
edfo
rco
mfo
rtan
dse
nse
of
secu
rity
.O
utc
om
em
easu
res:
Sag
itta
l=la
tera
lfl
exio
nan
dax
ial
ro-
tati
on
RO
Mw
ere
mea
sure
do
nb
oth
the
LB
Ban
dF
SS
To
com
par
eth
etr
adit
ion
alL
BB
wit
hth
eF
SS
420
Th
ere
was
abo
ut
6–88
gre
ater
mo
tio
nin
the
sag
itta
l,la
tera
l,an
dax
ial
pla
nes
du
rin
gth
eap
pli
cati
on
of
the
LB
Bco
mp
ared
wit
hth
eF
SS
(p<
0.00
1).N
osi
gn
ifica
nt
dif
fere
nce
was
fou
nd
du
r-in
ga
secu
red
log
roll
man
euv
er.
Th
eF
SS
ind
uce
dm
ore
sag
itta
lfl
exio
nd
uri
ng
the
lift
than
the
LB
B(p<
0.00
1).
Th
eF
SS
sho
wed
sup
erio
rco
mfo
rtan
dp
erce
ived
secu
rity
ov
erth
eL
BB
.
Lu
sco
mb
ean
dW
illi
ams,
2003
Em
erg
.M
ed.
J.C
om
par
iso
no
fa
lon
gsp
inal
bo
ard
and
vac
uu
mm
attr
ess
for
spin
alim
mo
bi-
lisa
tio
n
(Ex
per
imen
tal)
Po
pu
lati
on
:M=F¼
8=1;
Wei
gh
tM=F¼
79k
g=58
kg
.T
rea
t-m
en
t:V
olu
nte
ers
wo
rea
Wiz
loc
rig
idce
rvic
alco
llar
and
stan
dar
d-
ized
clo
thin
g.
Eac
hw
asth
enp
lace
do
nb
oth
the
bac
kb
oar
dan
dth
ev
acu
um
mat
tres
san
dse
cure
lyst
rap
ped
toth
ed
evic
e.B
od
ym
ov
emen
tsan
dco
mfo
rtle
vel
sw
ere
det
erm
ined
.O
utc
om
em
easu
res:
Mea
nb
od
ym
ov
emen
tsan
dco
mfo
rtle
vel
s
To
com
par
eth
est
abil
ity
and
com
fort
affo
rded
by
the
lon
gsp
inal
bo
ard
and
the
vac
uu
mm
at-
tres
s
421
Th
em
ean
bo
dy
mo
vem
ents
inth
eh
ead
-u
pp
osi
tio
n,
hea
d-d
ow
np
osi
tio
n,
and
late
ral
tilt
wer
esi
gn
ifica
ntl
yg
reat
ero
nth
eb
ack
bo
ard
than
on
the
vac
uu
mm
attr
ess
(p<
0.01
).T
he
vac
uu
mm
at-
tres
sw
assi
gn
ifica
ntl
ym
ore
com
fort
-ab
leth
anth
eb
ack
bo
ard
(p<
0.01
).
1352
Mai
nan
dL
ov
ell,
1996
J.A
ccid
ent
Em
erg
.M
ed.
Are
vie
wo
fse
ven
sup
po
rtsu
rfac
esw
ith
emp
has
iso
nth
eir
pro
tect
ion
of
the
spin
ally
in-
jure
d.
(Ex
per
imen
tal
RC
T)
Tre
atm
en
t:S
ub
ject
sw
ere
ran
do
mly
pla
ced
on
six
wel
l-es
tab
lish
edsu
pp
ort
surf
aces
and
the
pro
toty
pe
sup
po
rtsu
rfac
e.R
ead
ing
sfo
rea
chsu
rfac
ew
ere
tak
enan
dth
em
ean
pre
ssu
res=
stan
dar
dd
evia
tio
ns
wer
eca
lcu
late
dto
mea
sure
the
var
i-ab
ilit
yo
fsa
cral
and
tho
raci
cp
ress
ure
sb
etw
een
the
sub
ject
san
dsu
rfac
es.
Th
esu
bje
cts
wer
eas
ked
abo
ut
com
fort
and
acce
pta
bil
ity
of
the
surf
aces
.O
utc
om
em
easu
res:
Mea
nsa
cral
and
tho
raci
cp
ress
ure
read
ing
s
To
eval
uat
ese
ven
evac
ua-
tio
nsu
pp
ort
surf
aces
:co
nv
enti
on
alsp
inal
bo
ard
,tw
ov
acu
um
stre
tch
ers,
ap
roto
typ
e(c
om
bin
atio
no
fb
oth
pri
nci
ple
s),
and
thre
eco
nv
enti
on
alst
retc
her
s
1B15
See
tex
t
Mar
uy
ama
etal
.,20
08B
r.J.
An
aes-
thes
iaR
and
om
ized
cro
ss-
ov
erco
mp
aris
on
of
cerv
ical
-sp
ine
mo
-ti
on
wit
hA
irw
ayS
cop
eo
rM
acin
tosh
lary
ng
osc
op
ew
ith
in-l
ine
stab
iliz
atio
n:
av
ideo
flu
oro
-sc
op
icst
ud
y
(Pro
spec
tiv
eR
CT
)P
op
ula
tio
n:
13p
atie
nts
wit
hn
orm
alce
rvic
alsp
ines
.T
rea
t-m
en
t:P
atie
nts
un
der
wen
tla
ryn
go
s-co
py
wit
ha
Mac
into
shb
lad
eo
ran
Air
way
sco
pe,
then
vic
ev
ersa
.O
ut-
com
em
easu
res:
Up
per
cerv
ical
spin
em
oti
on
asse
ssed
wit
hli
ve
vid
eofl
uo
-ro
sco
py
inth
ela
tera
lp
lan
e
To
com
par
eth
eC
-sp
ine
mo
vem
ent
req
uir
edfo
rla
ryn
go
sco
py
and
intu
-b
atio
nw
ith
the
Air
way
Sco
pe
and
the
Mac
into
shla
ryn
go
sco
pe
1B30
C-s
pin
em
oti
on
was
sig
nifi
can
tly
less
wit
hu
seo
fth
eA
irw
ayS
cop
eco
m-
par
edto
dir
ect
lary
ng
osc
op
yw
ith
the
Mac
into
shb
lad
e.T
ime
toin
tub
atio
nw
assi
mil
ar.
Maz
ole
wsk
ian
dM
anix
,19
94
An
n.
Em
erg
.M
ed.
Th
eef
fect
iven
ess
of
stra
pp
ing
tech
-n
iqu
esin
spin
alim
mo
bil
izat
ion
(Ex
per
imen
tal)
Po
pu
lati
on
:H
eig
ht:
70.2
0in
;W
eig
ht:
171.
74lb
;%
M¼
100.
Tre
atm
en
t:S
ub
ject
sre
stra
ined
on
aw
oo
den
bac
kb
oar
du
sin
ga
con
tro
lan
dth
ree
stra
pp
ing
tech
niq
ues
:#1
(co
ntr
ol)
—tw
ost
rap
so
ver
the
ches
tw
ith
ath
ird
stra
pp
lace
dju
stb
elo
wth
eax
illa
;#2
—th
esa
me
stra
ps
as#1
wit
han
abd
om
inal
stra
pac
ross
the
um
bil
icu
s;#3
—th
esa
me
stra
ps
as#2
,w
ith
ast
rap
aro
un
dth
ech
est=
arm
s;#4
—n
ocr
oss
stra
ps,
bu
tab
do
mi-
nal=ar
mst
rap
s.T
he
bac
kb
oar
dw
asro
lled
908
and
late
ral
mo
tio
no
fth
eto
rso
was
mea
sure
d.
Vo
lun
teer
sju
dg
edea
seo
fb
reat
hin
go
nce
the
stra
ps
wer
eti
gh
ten
ed,
and
each
was
ask
edw
hic
hm
eth
od
they
tho
ug
ht
allo
wed
the
leas
tam
ou
nt
of
late
ral
mo
tio
n.
Ou
tco
me
me
asu
res:
late
ral
mo
tio
n
To
test
the
effe
ctiv
enes
so
fst
rap
pin
gte
chn
iqu
esin
red
uci
ng
late
ral
mo
tio
no
fv
olu
nte
ers
rest
rain
edo
na
bac
kb
oar
d
1B15
Tec
hn
iqu
e#2
,w
hic
had
ded
anab
do
mi-
nal
stra
pto
the
con
tro
lte
chn
iqu
e,re
du
ced
26%
of
the
late
ral
mo
tio
n.
Tec
hn
iqu
es#2
,#3
,an
d#4
wer
efo
un
dto
be
stat
isti
call
ysi
gn
ifica
ntl
yd
iffe
ren
tth
ante
chn
iqu
e#1
,b
ut
no
tfr
om
each
oth
er(p<
0.05
).W
hen
ask
edw
hic
hte
chn
iqu
eth
eyth
ou
gh
tre
du
ced
late
ral
mo
tio
nb
est,
6%o
fv
olu
nte
ers
cho
sete
chn
iqu
e#1
,6%
tech
niq
ue
#2,
73%
tech
niq
ue
#,an
d15
%te
chn
iqu
e#4
.
McG
uir
eet
al.,
1987
J.T
rau
ma
Sp
inal
inst
abil
ity
and
the
log
roll
ing
ma-
no
euv
re
(Cas
ere
por
ts)
Tre
atm
en
t:T
he
mo
tio
no
fth
eth
ora
colu
mb
arsp
ine
ina
vo
lun
teer
wit
ha
stab
lesp
ine,
aca
dav
erw
ith
au
nst
able
tho
raco
lum
bar
spin
e,an
da
pat
ien
tw
ith
aT
12–L
1fr
actu
red
islo
-ca
tio
nw
ere
rad
iog
rap
hic
ally
exam
-in
ed.
Ou
tco
me
me
asu
res:
Sta
bil
izat
ion
effi
cien
cy
To
eval
uat
eth
em
oti
on
of
the
tho
raco
lum
bar
spin
ein
var
iou
sin
div
idu
als
412
Bo
thth
eb
ack
bo
ard
and
the
sco
op
stre
tch
ero
ffer
edad
equ
ate
stab
iliz
a-ti
on
for
thro
raco
lum
bar
spin
ein
sta-
bil
ity
.T
he
log
roll
man
euv
erp
rese
nte
dth
eg
reat
est
po
ssib
ilit
yfo
rm
ov
emen
to
fth
esp
ine
atth
eu
nst
able
tho
raco
-lu
mb
arse
gm
ent.
(Con
tin
ued
)
1353
Ta
bl
e1.
Ev
id
en
ce
Ta
bl
e(C
on
tin
ue
d)
Ref
eren
ceJo
urn
alT
itle
Des
ign
Pu
rpos
e=h
yp
oth
esis
Sac
kett
rati
ng
aD
&B
scor
e(o
ut
of44
)R
esu
lts
Mel
do
net
al.,
1998
J.T
rau
ma
Ou
to
fh
osp
ital
cerv
i-ca
lsp
ine
clea
ran
ce:
Ag
reem
ent
be-
twee
nem
erg
ency
med
ical
tech
nic
ian
san
dem
erg
ency
ph
ysi
cian
s
(Cas
ese
ries
)P
op
ula
tio
n:
Ag
e¼
34y
(6–9
8y
);%
M¼
59.
Tre
atm
en
t:P
atie
nt
dat
aw
ere
pro
spec
tiv
ely
coll
ecte
din
ord
erto
det
erm
ine
inte
r-ra
ter
agre
e-m
ent
bet
wee
nE
MT
san
dE
Ps
reg
ard
-in
go
ut-
of-
ho
spit
alcl
inic
alC
SI
clea
ran
ce.
Ou
tco
me
me
asu
res:
Inte
r-ra
ter
agre
emen
tb
etw
een
EM
Ts
and
EP
s
To
det
erm
ine
agre
emen
tb
etw
een
EM
Ts
and
EP
sw
hen
app
lyin
gan
EM
S=fi
red
epar
tmen
tp
roto
col
for
ou
t-o
f-h
os-
pit
alC
SI
clea
ran
cein
blu
nt
trau
ma
pat
ien
ts
427
Ov
eral
ld
isag
reem
ent
bet
wee
nE
MT
san
dE
Ps
reg
ard
ing
CS
Ip
re-h
osp
ital
clea
r-an
ceo
ccu
rred
in23
%o
fp
atie
nts
(kap
pa¼
0.29
;95
%C
I0.
15,
0.43
;p<
0.01
).C
SI
was
det
ecte
din
2.6%
of
pat
ien
ts,
and
all
of
them
wer
eim
mo
-b
iliz
edin
the
ou
t-o
f-h
osp
ital
sett
ing
.
Mu
hr
etal
.,19
98P
reh
osp
.E
mer
g.
Car
eP
aram
edic
use
of
asp
inal
inju
rycl
ear-
ance
alg
ori
thm
re-
du
ces
spin
alim
mo
bil
izat
ion
inth
eo
ut
of
ho
spit
alse
ttin
g
(Cas
ese
ries
)P
op
ula
tio
n:
Ag
e:st
an-
dar
d¼
34.1
y;
%M=F
:st
an-
dar
d¼
48=52
.T
rea
tme
nt:
Par
amed
ics
rece
ived
trai
nin
go
nth
eal
go
rith
m.
Th
eyw
ere
inst
ruct
edto
asse
ssp
a-ti
ent
lev
elo
fco
nsc
iou
snes
s,d
rug=
alco
ho
lu
se,
loss
of
con
scio
usn
ess,
spin
alp
ain=te
nd
ern
ess,
neu
rolo
gic
ald
efici
t,co
nco
mit
ant
seri
ou
sin
jury
,an
dp
ain
wit
hR
OM
.If
all
crit
eria
wer
en
egat
ive,
the
alg
ori
thm
ind
i-ca
ted
that
pat
ien
tsd
idn
’tn
eed
spin
alim
mo
bil
izat
ion
(SI)
.P
aram
edic
sco
mp
lete
da
trac
kin
gfo
rman
dfo
l-lo
wed
the
pat
ien
tto
the
ED
.D
ata
wer
eth
eng
ath
ered
tod
eter
min
eth
ep
rese
nce
of
spin
alfr
actu
re,
neu
ro-
log
ical
defi
cit,
or
aco
mb
inat
ion
of
the
two
To
det
erm
ine
wh
eth
erp
aram
edic
sca
nsa
fely
use
asp
inal
clea
ran
ceal
go
rith
mto
red
uce
un
-n
eces
sary
SI
inth
eo
ut-
of-
ho
spit
alse
ttin
g
421
11.7
%o
fp
atie
nts
wer
eim
mo
bil
ized
de-
spit
eth
eir
no
tm
eeti
ng
imm
ob
iliz
atio
ncr
iter
ia.
No
ne
of
thes
ep
atie
nts
wer
ed
iag
no
sed
ash
avin
gsp
inal
inju
ry.
Co
mp
aris
on
of
pre
-stu
dy
dat
aan
dst
ud
yd
ata
ind
icat
eda
33%
red
uct
ion
inu
tili
zati
on
of
SI
(95%
CI
27.2
,38
.8).
An
ou
t-o
f-h
osp
ital
spin
alcl
eara
nce
alg
ori
thm
adm
inis
tere
db
yp
aram
ed-
ics
can
red
uce
SI
by
on
e-th
ird
.
Ny
pav
eran
dT
relo
ar,
1993
An
n.
Em
erg
.M
ed.
Neu
tral
cerv
ical
spin
ep
osi
tio
nin
gin
chil
-d
ren
(Ex
per
imen
tal)
Po
pu
lati
on
:A
ge¼
33m
on
ths
(1m
on
th–7
y).
Tre
atm
en
t:T
he
two
ob
serv
ers
ind
epen
den
tly
pla
ced
chil
dre
nin
an
eutr
alp
osi
tio
nu
sin
gst
and
ard
-siz
edp
add
ing
wit
ho
rw
ith
-o
ut
shim
sto
rais
eth
eb
ack
off
ab
ack
bo
ard
.O
utc
om
em
easu
res:
Inte
r-o
bse
rver
agre
emen
t,h
eig
ht
of
elev
a-ti
on
To
det
erm
ine
the
elev
atio
no
fb
ack=sh
ou
lder
sn
eed
edto
pu
tch
ild
ren
inn
eutr
alce
rvic
alsp
ine
po
siti
on
,an
dd
eter
min
eif
ob
serv
ers
cou
ldag
ree
on
the
hei
gh
tre
qu
ired
420
Th
ein
ter-
ob
serv
erag
reem
ent
kap
-p
a¼
0.56
.N
oco
rrel
atio
nw
asn
ote
db
etw
een
the
age
and
hei
gh
to
fel
eva-
tio
n(r¼
0.11
4,p>
0.05
).W
hen
chil
-d
ren>
4y
old
wer
eco
mp
ared
wit
hth
ose�
4y
old
,it
was
fou
nd
that
the
yo
un
ger
gro
up
req
uir
edm
ore
elev
a-ti
on
for
corr
ect
po
siti
on
ing
than
old
erch
ild
ren
(p<
0.05
).
Pee
ryet
al.,
2007
Pre
ho
sp.
Em
erg
.C
are
Pre
-ho
spit
alsp
inal
imm
ob
iliz
atio
nan
dth
eB
ack
bo
ard
Qu
alit
yA
sses
s-m
ent
Stu
dy
(Cas
ese
ries
)P
op
ula
tio
n:
M=F¼
23=26
;W
eig
ht¼
172
lb;
Hei
gh
t¼68
in.
Tre
atm
en
t:P
atie
nts
wh
ow
ere
spi-
nal
lyim
mo
bil
ized
wer
eev
alu
ated
for
the
nu
mb
eran
do
ccas
ion
of
rest
rain
-in
gst
rap
san
dth
eir
deg
ree
of
tig
htn
ess
toas
sess
qu
alit
yo
fim
mo
bil
izat
ion
.O
utc
om
em
easu
res:
Nu
mb
eran
dlo
-ca
tio
no
fre
stra
inin
gst
rap
san
dth
eir
deg
ree
of
tig
htn
ess
To
qu
anti
fyh
ow
oft
enim
-m
ob
iliz
atio
nis
inad
e-q
uat
e
425
30%
had
atle
ast
on
eu
nat
tach
edst
rap
or
pie
ceo
fta
pe
that
sho
uld
hav
eat
tach
edth
eir
hea
dto
the
bo
ard
;88
%w
ere
fou
nd
toh
ave>
2cm
of
slac
kb
etw
een
thei
rb
od
yan
dat
leas
to
ne
stra
p;
amo
ng
tho
sew
ith
any
stra
ps
loo
ser
than
2cm
,th
eav
erag
en
um
ber
of
loo
sest
rap
sw
as3.
4.
1354
Per
ryet
al.,
1999
Sp
ine
Th
eef
fica
cyo
fh
ead
imm
ob
iliz
atio
nte
chn
iqu
esd
uri
ng
sim
ula
ted
veh
icle
mo
tio
n
(Ex
per
imen
tal)
Po
pu
lati
on
:A
ge¼
25y
;H
eig
ht¼
168
cm;
Wei
gh
t¼69
kg
.T
rea
tme
nt:
Th
ree
dif
fere
nt
hea
d-
imm
ob
iliz
atio
nm
eth
od
sw
ere
com
par
edin
six
hea
lth
yad
ult
su
sin
ga
com
pu
ter-
con
tro
lled
pla
tfo
rmto
sim
ula
tem
ov
emen
tsth
ato
ccu
rd
uri
ng
tran
spo
rt;
5=6
vo
lun
teer
sw
ere
test
edu
sin
gea
cho
fth
eth
ree
dif
fere
nt
met
ho
ds:
(1)
tow
els,
(2)
wed
ges
,an
d(3
)h
ead
bed
;1
vo
lun
teer
was
test
edo
nth
efi
rst
two
met
ho
ds;
3v
olu
nte
ers
wer
ete
sted
for
8m
in(4
exp
osu
res
for
2m
inea
ch),
and
the
oth
erth
ree
for
14m
in(7
exp
osu
res
for
2m
inea
ch).
Ou
tco
me
me
asu
res:
Effi
cacy
of
hea
dim
mo
bil
izat
ion
To
com
par
eth
eef
fica
cyo
fd
iffe
ren
th
ead
-im
mo
bil
i-za
tio
nte
chn
iqu
esd
uri
ng
mo
tio
nsi
mu
lati
ng
am-
bu
lan
cetr
ansp
ort
430
Th
era
ng
eo
fla
tera
lb
end
ing
was
sig
nif
-ic
antl
yla
rger
wh
enth
ism
oti
on
was
refe
ren
ced
toth
etr
un
kra
ther
than
toth
efr
actu
reb
oar
d(p<
0.00
1);
Sty
ro-
foam
wed
ges
led
toco
nsi
sten
tly
low
erra
ng
eso
fm
oti
on
for
abso
lute
axia
lro
tati
on
(p¼
0.00
04)
and
abso
lute
lat-
eral
ben
din
g(p¼
0.01
6)th
anth
eH
ead
bed
;T
her
ew
ere
no
stat
isti
call
ysi
gn
ifica
nt
dif
fere
nce
sb
etw
een
the
tech
niq
ues
inte
rms
of
rela
tiv
em
oti
on
occ
urr
ing
acro
ssth
en
eck
(ax
ial
rota
-ti
on
p¼
0.13
;la
tera
lb
end
ing
p¼
0.31
).
Sah
ni
etal
.,19
97P
reh
osp
.E
mer
g.
Car
eP
aram
edic
eval
uat
ion
of
clin
ical
ind
ica-
tors
of
cerv
ical
spi-
nal
inju
ry
(Ex
per
imen
tal)
Po
pu
lati
on
:H
ealt
hy
vo
l-u
nte
ers.
Tre
atm
en
t:T
he
EP
san
dE
MS
sw
ere
pai
red
.E
ach
pai
rev
alu
-at
edfi
ve
ran
do
mly
assi
gn
edp
atie
nts
for
six
clin
ical
crit
eria
:al
tera
tio
nin
con
scio
usn
ess,
evid
ence
of
into
xic
a-ti
on
,co
mp
lain
to
fn
eck
pai
n,
cerv
ical
ten
der
nes
s,n
euro
log
icd
efici
t=co
mp
lain
t,an
dd
istr
acti
ng
inju
ry.
Ifan
ycr
iter
ion
was
po
siti
ve,
clin
ical
clea
ran
cew
asco
nsi
der
edto
hav
efa
iled
and
the
pat
ien
tw
ou
ldh
ave
bee
nim
mo
bil
ized
.O
utc
om
em
ea
-su
res:
Kap
pa
coef
fici
ents
To
com
par
ep
aram
edic
as-
sess
men
tso
fin
dic
ato
rso
fce
rvic
alsp
inal
inju
ryw
ith
tho
seo
fat
ten
din
gem
erg
ency
ph
ysi
cian
s
416
Kap
pas
for
the
six
crit
eria
wer
e:al
tere
dco
nsc
iou
snes
s¼
0.77
;in
tox
ica-
tio
n¼
0.68
;n
eck
pai
n¼
0.62
;ce
rvic
alte
nd
ern
ess¼
0.73
;n
euro
log
icd
efi-
cit¼
0.68
;an
dd
istr
acti
ng
inju
ry¼
0.62
.K
app
a¼
0.90
for
the
imm
ob
iliz
atio
nd
ecis
ion
.In
on
eca
seth
ed
ecis
ion
sd
iffe
red
:th
ep
aram
edic
ind
icat
edim
-m
ob
iliz
atio
n,
wh
erea
sth
ep
hy
sici
ans
did
no
t.N
op
atie
nt
req
uir
ing
imm
o-
bil
izat
ion
wo
uld
hav
eb
een
clin
ical
lycl
eare
db
yth
ep
aram
edic
s.
Sca
nn
ell
etal
.,19
93A
rch
.S
urg
.O
rotr
ach
eal
intu
ba-
tio
nin
trau
ma
pa-
tien
tsw
ith
cerv
ical
frac
ture
s
(Cas
ese
ries
)T
rea
tme
nt:
Sen
ior
resi
den
to
rfa
cult
yan
esth
esio
log
ists
per
form
edin
tub
atio
ns.
Per
iph
eral
neu
rolo
gic
alex
amin
atio
nw
asp
erfo
rmed
bef
ore
and
afte
rea
chin
tub
atio
n,
and
neu
ro-
log
ical
defi
cits
wer
ed
ocu
men
ted
Ou
tco
me
me
asu
res:
Nu
mb
ero
fn
eu-
rolo
gic
defi
cits
To
eval
uat
eo
rotr
ach
eal
in-
tub
atio
nw
ith
in-l
ine
stab
iliz
atio
no
fth
ece
r-v
ical
spin
efo
rem
er-
gen
cyai
rway
trea
tmen
to
fp
atie
nts
48
Th
ere
wer
eu
nst
able
cerv
ical
frac
ture
sin
38p
atie
nts
wit
hn
on
euro
log
ical
def
-ic
its,
and
23p
atie
nts
wer
en
euro
log
i-ca
lly
inta
ctw
ith
frac
ture
sth
atw
ere
late
rju
dg
edst
able
.In
no
inst
ance
was
ther
ea
det
erio
rati
on
of
neu
rolo
gic
alst
atu
sfo
llo
win
gin
tub
atio
n.
Per
iph
eral
neu
rolo
gic
ald
efici
tsim
pro
ved
afte
rin
tub
atio
nin
fou
rp
atie
nts
.
Sch
aefe
rmey
er,
etal
.,19
91A
nn
.E
mer
g.
Med
.R
esp
irat
ory
effe
cts
of
spin
alim
mo
bil
iza-
tio
nin
chil
dre
n
(Ex
per
imen
tal)
Po
pu
lati
on
:A
ge¼
10.6
y;
M=F¼
22=29
;H
eig
ht¼
57.5
in.
Tre
at-
me
nt:
Par
tici
pan
ts’
forc
edv
ital
cap
ac-
ity
(FV
C)
mea
sure
men
tsw
ere
firs
to
bta
ined
wit
hch
ild
ren
stan
din
gan
dly
ing
sup
ine,
and
then
infu
llsp
inal
imm
ob
iliz
atio
nu
sin
gtw
od
iffe
ren
tst
rap
pin
gco
nfi
gu
rati
on
s:cr
oss
stra
ps
and
late
ral
stra
ps.
Str
aps
wer
eti
gh
t-en
edto
allo
wo
ne
han
dto
fit
snu
gly
bet
wee
nth
est
rap
and
the
chil
d.
Ou
t-co
me
me
asu
res:
Su
pin
eF
VC
To
asse
ssth
ere
stri
ctiv
eef
-fe
cts
of
two
spin
alim
-m
ob
iliz
atio
nst
rap
pin
gte
chn
iqu
eso
nth
ere
spi-
rato
ryca
pac
ity
of
no
r-m
alh
ealt
hy
chil
dre
n
419
Su
pin
eF
VC
was
less
than
up
rig
ht
FV
C(p<
0.00
1).
FV
Cin
spin
alim
mo
bil
i-za
tio
nra
ng
edfr
om
41–9
6%o
fsu
pin
eF
VC
.T
her
ew
asn
od
iffe
ren
cein
FV
Cb
etw
een
stra
pp
ing
tech
niq
ues
(p¼
0.83
).S
pin
alim
mo
bil
izat
ion
sig
-n
ifica
ntl
yre
du
ced
resp
irat
ory
cap
acit
yas
mea
sure
db
yF
VC
inh
ealt
hy
pa-
tien
ts6–
15y
old
.T
her
ew
asn
osi
gn
if-
ican
tb
enefi
to
fo
ne
stra
pp
ing
tech
niq
ue
ov
erth
eo
ther
.
(Con
tin
ued
)
1355
Ta
bl
e1.
Ev
id
en
ce
Ta
bl
e(C
on
tin
ue
d)
Ref
eren
ceJo
urn
alT
itle
Des
ign
Pu
rpos
e=h
yp
oth
esis
Sac
kett
rati
ng
aD
&B
scor
e(o
ut
of44
)R
esu
lts
Sch
rig
eret
al.,
1991
An
n.
Em
erg
.M
ed.
Sp
inal
imm
ob
iliz
atio
no
na
flat
bac
kb
oar
d:
Do
esit
resu
ltin
neu
tral
po
siti
on
of
the
cerv
ical
spin
e?
(Ex
per
imen
tal)
Po
pu
lati
on
:M=
F¼
50=50
;A
ge¼
24.4
y.
Tre
atm
en
t:N
eutr
alp
osi
tio
nw
asd
efin
edas
the
no
rmal
anat
om
icp
osi
tio
no
fth
eh
ead
and
tors
oth
ato
ne
assu
mes
wh
enst
and
ing
loo
kin
gst
raig
ht
ahea
dO
utc
om
em
easu
res:
Intr
a-o
bse
rver
reli
abil
ity
,o
ccip
ital
off
set
To
det
erm
ine
the
amo
un
to
fo
ccip
ital
pad
din
gre
-q
uir
edto
ach
iev
en
eutr
alp
osi
tio
no
fth
ece
rvic
alsp
ine
wh
enim
mo
bil
ized
on
afl
atb
ack
bo
ard
423
Intr
a-o
bse
rver
reli
abil
ity
sho
wed
am
ult
i-o
bse
rver
kap
pa¼
0.99
and
intr
a-cl
ass
corr
elat
ion
coef
fici
ent
of
0.98
.T
he
amo
un
to
fo
ccip
ital
off
set
req
uir
edfo
rn
eutr
alp
osi
tio
nv
arie
dfr
om
0–3.
75in
(mea
n¼
1.49
in;
95%
CI
1.37
,1.
60).
Mea
no
ccip
ital
off
set
for
men
(1.6
7in
)w
assi
gn
ifica
ntl
yg
reat
erth
anth
atfo
rw
om
en(1
.31
in;
p¼
0.00
16).
Mea
no
ccip
ital
off
set
sig
nifi
can
tly
dif
-fe
red
fro
mze
ro(p<
0.00
01).
Bo
dy
mea
sure
men
tsd
idn
ot
accu
rate
lyp
red
ict
occ
ipit
alo
ffse
t.Im
mo
bil
izat
ion
on
afl
atb
ack
bo
ard
wo
uld
pla
ce98
%o
fsu
bje
cts
ince
rvic
alex
ten
sio
n.
Occ
i-p
ital
pad
din
gw
ou
ldp
lace
ag
reat
erp
erce
nta
ge
of
pat
ien
tsin
neu
tral
po
si-
tio
nan
din
crea
sep
atie
nt
com
fort
.
Sh
eeri
nan
dd
eF
rein
,20
07J.
Em
erg
.N
urs
.T
he
occ
ipit
alan
dsa
-cr
alp
ress
ure
sex
-p
erie
nce
db
yh
ealt
hy
vo
lun
teer
su
nd
ersp
inal
im-
mo
bil
izat
ion
:a
tria
lo
fth
ree
surf
aces
(RC
T)
Po
pu
lati
on
:A
ge¼
41an
d23
y;
M¼
2;W
eig
ht¼
82an
d67
kg
;H
eig
ht¼
1.68
and
1.77
m;
BM
I¼29
.05
and
21.3
9k
g=m
2.
Tre
atm
en
t:T
he
two
vo
lun
teer
sw
ere
imm
ob
iliz
edo
nth
ree
spin
alsu
pp
ort
surf
aces
toas
sess
the
dif
fere
nce
sin
occ
ipit
alan
dsa
cral
tiss
ue
inte
rfac
ep
ress
ure
.Ou
tco
me
me
asu
res:
Red
uct
ion
of
pre
ssu
reex
per
ien
ced
atth
eo
ccip
ital
and
sacr
alre
gio
ns
To
iden
tify
wh
eth
ero
rn
ot
the
pre
ssu
reex
per
ien
ced
by
ind
ivid
ual
sat
two
anat
om
ical
loca
tio
ns
wer
ed
epen
den
to
nth
esu
pp
ort
surf
ace
use
d
2B20
See
tex
t
Str
oh
and
Bra
ud
e,20
01A
nn
.E
mer
g.
Med
.C
anan
ou
t-o
f-h
osp
i-ta
lce
rvic
alsp
ine
clea
ran
cep
roto
col
iden
tify
all
pat
ien
tsw
ith
inju
ries
?A
nar
gu
men
tfo
rse
lec-
tiv
eim
mo
bil
izat
ion
(Ret
rosp
ecti
ve
char
tre
vie
w)
Po
pu
lati
on
:86
1p
atie
nts
wit
hsi
gn
ifica
nt
cerv
ical
inju
ries
dis
char
ged
fro
mfi
ve
trau
ma
ho
spit
als
bet
wee
nJu
ly1,
1990
and
Jun
e30
,19
96
To
det
erm
ine
the
sen
siti
v-
ity
of
anE
MS
spin
eim
-m
ob
iliz
atio
np
roto
col
inid
enti
fyin
gp
atie
nts
wit
hce
rvic
alin
juri
es,
and
tod
eter
min
ew
het
her
itw
assa
fein
ano
ut-
of-
ho
spit
alse
ttin
g
423
Of
the
861
tota
lpat
ien
ts,5
04w
ere
bro
ug
ht
toh
osp
ital
by
EM
S,w
ith
495
arri
vin
gin
spin
eim
mo
bil
izat
ion
.T
he
EM
Ssp
inal
imm
ob
iliz
atio
np
roto
col
was
99%
sen
-si
tiv
ein
iden
tify
ing
pat
ien
tsw
ith
sig
-n
ifica
nt
cerv
ical
inju
ries
for
imm
ob
iliz
atio
n.
Pro
spec
tiv
ev
alid
atio
nad
dre
ssin
gli
mit
atio
ns
isn
eed
ed.
Tu
rkst
raet
al.,
2005
An
esth
.A
nal
g.
Cer
vic
alsp
ine
mo
-ti
on
:a
flu
oro
sco
pic
com
par
iso
nd
uri
ng
intu
bat
ion
wit
hli
gh
ted
sty
let,
Gli
deS
cop
e,an
dM
acin
tosh
lary
ng
osc
op
e
(Pro
spec
tive
RC
Tcr
oss-
over
)P
op
ula
tio
n:
AS
AI–
III,
elec
tiv
en
on
card
iac
surg
ery
,w
ith
ou
td
iffi
cult
airw
ayo
ru
nst
able
C-
spin
e.T
rea
tme
nt:
Lig
htw
and
ver
sus
Mac
into
sh(n¼
18),
and
Gli
deS
cop
ev
ersu
sM
acin
tosh
(n¼
18),
all
wit
hsi
mu
late
dm
anu
alin
-lin
eim
mo
bil
iza-
tio
n.
Ou
tco
me
me
asu
res:
Ex
ten
sio
n-
flex
ion
of
nec
ku
nd
erd
igit
alv
ideo
flu
oro
sco
py
To
det
erm
ine
C-s
pin
em
ov
emen
td
uri
ng
use
of
the
Gli
deS
cop
eo
rL
igh
t-w
and
ver
sus
dir
ect
lar-
yn
go
sco
py
wit
hth
eM
acin
tosh
bla
de
1B30
C-s
pin
em
oti
on
was
sig
nifi
can
tly
less
du
rin
gb
ag-a
nd
-mas
kv
enti
lati
on
than
dir
ect
lary
ng
osc
op
y.
Lig
htw
and
use
resu
lted
insi
gn
ifica
ntl
yle
ssC
-sp
ine
mo
tio
nal
on
gal
lse
gm
ents
,fr
om
occ
ipit
al-c
erv
ical
toce
rvic
oth
ora
cic
reg
ion
s(p<
0.03
).G
lid
eSco
pe
use
resu
lted
inre
du
ced
mo
tio
nfr
om
C2–
C5,
bu
tn
och
ang
ein
mo
tio
nat
oth
erre
gio
ns
ver
sus
the
Mac
into
shb
lad
e.T
ime
toin
tub
atio
nw
assi
mil
arfo
rth
eL
igh
twan
dan
dth
eb
lad
e,b
ut
was
incr
ease
dw
ith
the
use
of
the
Gli
de-
Sco
pe
ver
sus
the
bla
de
(p<
0.01
).
1356
Wal
ton
etal
.,19
94A
cad
.E
mer
g.
Med
.P
add
edv
s.u
np
add
edsp
ine
bo
ard
for
cerv
ical
spin
eim
-m
ob
iliz
atio
n
(RC
T)
Po
pu
lati
on
:A
ge¼
32.5
y;
M=F¼
26=4;
Wei
gh
t¼72
kg
.T
rea
t-m
en
t:S
ub
ject
sw
ere
ran
do
miz
edto
eith
erp
add
edo
ru
np
add
edlo
ng
spin
eb
oar
dim
mo
bil
izat
ion
wit
hse
rial
mea
sure
men
tso
fd
isco
mfo
rtan
dtr
ansc
uta
neo
us
tiss
ue
ox
yg
ente
nsi
on
.T
he
sub
ject
sw
ere
then
ask
edto
retu
rnaf
ter
atle
ast
3d
ays
tob
eim
mo
bil
ized
wit
hth
eo
ther
spin
eb
oar
d.
Ou
tco
me
me
asu
re:
Dis
com
fort
,fl
exio
n,
exte
n-
sio
n,
rota
tio
n,
late
ral
ben
din
g,
and
sacr
altr
ansc
uta
neo
us
ox
yg
ente
nsi
on
To
det
erm
ine
wh
eth
erp
add
ing
the
lon
gsp
ine
bo
ard
imp
rov
esp
atie
nt
com
fort
,af
fect
sce
rvic
alsp
ine
imm
ob
iliz
atio
n,
or
incr
ease
ssa
cral
tran
scu
-ta
neo
us
ox
yg
ente
nsi
on
2B23
Su
bje
ctd
isco
mfo
rtw
assi
gn
ifica
ntl
yre
-d
uce
din
the
pad
ded
gro
up
com
par
edw
ith
the
un
pad
ded
gro
up
(p¼
0.02
4).
Th
ere
was
no
sig
nifi
can
td
iffe
ren
cein
flex
ion
(p¼
0.41
0),
exte
nsi
on
(p¼
0.23
1),
rota
tio
n(p¼
0.89
1),
or
late
ral
ben
din
g(p¼
0.23
0)fo
rth
etw
og
rou
ps.
Th
ere
was
no
sig
nifi
can
td
if-
fere
nce
inth
eac
tual
dro
pin
sacr
altr
ansc
uta
neo
us
ox
yg
ente
nsi
on
fro
mti
me
zero
to30
min
for
the
pad
ded
and
the
un
pad
ded
gro
up
s(p¼
0.90
6).
Wan
ing
eret
al.,
2001
Cli
n.
J.S
po
rtM
ed.
An
eval
uat
ion
of
hea
dm
ov
emen
tin
bac
k-
bo
ard
-im
mo
bil
ized
hel
met
edfo
otb
all,
lacr
oss
e,an
dic
eh
ock
eyp
lay
ers
(Pro
spec
tiv
e)P
op
ula
tio
n:
30v
olu
nte
erco
lleg
iate
ath
lete
s(1
2ic
eh
ock
ey,
9fo
otb
all,
9la
cro
sse)
wit
hn
oh
isto
ryo
fce
rvic
alsp
ine
inju
ryo
rp
ath
olo
gy
.T
rea
tme
nt:
Ath
lete
sw
ere
imm
ob
i-li
zed
on
bac
kb
oar
ds
per
pro
toco
l.T
hre
ere
tro
-refl
ecti
ve
mar
ker
sw
ere
atta
ched
toth
eh
elm
et.
Mea
sure
men
tsw
ere
ob
tain
edd
uri
ng
ap
erio
dw
hen
the
bac
kb
oar
dw
asp
ertu
rbed
ino
rder
tost
imu
late
jost
lin
gd
uri
ng
tran
spo
r-ta
tio
n.
Ou
tco
me
me
asu
res:
Hel
ical
ang
les
det
erm
ine
the
rela
tiv
era
ng
eo
fm
oti
on
of
the
hea
din
sid
eth
eh
elm
et
Co
mp
ares
the
amo
un
to
fh
ead
mo
vem
ent
inA
mer
ican
foo
tbal
l,la
-cr
oss
e,an
dic
eh
ock
eyh
elm
ets
du
rin
gh
ead
and
nec
kst
abil
izat
ion
pro
ced
ure
s
416
Mea
nra
ng
eo
fh
ead
mo
tio
nfo
rfo
otb
all
pla
yer
sw
as4.
888
(n¼
9,S
D2.
07),
lacr
oss
ep
lay
ers
6.568
(n¼
9,S
D1.
61),
and
ice
ho
ckey
pla
yer
s5.
548
(n¼
12,
SD
1.19
).R
esu
lts
wer
en
ot
sig
nifi
can
tly
dif
fere
nt
(p>
0.05
).S
up
po
rts
the
po
l-ic
yo
fst
abil
izat
ion
wit
hh
elm
etan
dsh
ou
lder
pad
sin
pla
ce.
Th
eam
ou
nt
of
mo
vem
ent
that
issa
feto
pre
ven
tia
tro
gen
icin
jury
has
yet
tob
ed
eter
-m
ined
.
Sou
rce:
Sac
ket
tet
al.,
2000
.aS
ack
ett
rati
ng
.E
MS
,em
erg
ency
med
ical
serv
ices
;E
D,
emer
gen
cyd
epar
tmen
t;E
P,
emer
gen
cyp
hy
sici
ans;
C,
cerv
ical
;T
,th
ora
cic;
M,
mal
e;F
,fe
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body tissue pressure (Chan et al., 1996; Hauswald et al., 2000;Main and Lovell, 1996; Sheerin and de Frein, 2007; Waltonet al., 1995); however, no study evaluated what constitutes asafe duration of immobilization on a hard board, althoughtissue interface pressures were elevated even after short pe-riods of rigid immobilization (Main and Lovell, 1996; Sheerinand de Frein, 2007; Walton et al., 1995). None of the studiesassessed time on hard board and the clinical outcome ofpressure sores. As a result, there is no firm time point citedin the literature after which immobilization should be dis-continued.
Main and Lovell (1996) performed an experimental ran-domized controlled trial in which subjects laid on six dif-ferent support surfaces and surface pressure readings wereobtained both at the sacral region and the thoracic region.Results showed that the traditional spinal board had thehighest sacral reading of 233.5 mm Hg and the highest tho-racic reading of 82.9 mm Hg, versus other forms of stretcherssuch as the York Two stretcher, for which readings of 46 mmHg and 21 mm Hg, respectively, were obtained. The studyalso found that the traditional board lacked support forthe lumbar lordosis. Differences in pressure readings inthe various board surfaces and designs may lead to differ-ences in the occurrence of pressure sores in the setting ofprolonged transportation times and SCI (Main and Lovell,1996).
Sheerin and de Frein (2007) conducted an experimentalstudy examining volunteers on different support surfaces andassessed occipital and sacral tissue interface pressures. Thehighest pressure readings were seen with the traditionalunpadded spinal board. They observed that occipital andsacral pressures were lowest with a vacuum mattress device(Sheerin and de Frein, 2007).
Mazolewski and Manix examined different techniques ofstrapping in spinal immobilization using an experimentalstudy in which subjects were restrained on a spine board.Four different techniques were evaluated and lateral spinemotion was measured as the backboard was rolled 908 fromside to side. Motion was most reduced by placing two strapsthat cross over at the chest, with a third strap placed across theumbilicus (Mazolewski and Manix, 1994).
Krell and colleagues compared the scoop stretcher to thelong backboard for spinal immobilization in terms of mo-tion and comfort. There were 6–88 more of sagittal motionduring the application of the long backboard compared to thescoop board. The scoop board was also perceived to be morecomfortable compared to the traditional board (Krell et al.,2006).
There are few published studies evaluating spinal immo-bilization for children. Only two of the identified publicationsstudied pediatric spinal immobilization (Nypaver and Tre-loar, 1994; Schafermeyer et al., 1991). There are anatomicdifferences between adults and children that may preventvalid generalizations of the adult literature to spinal immo-bilization in a pediatric population. These include increasedhead:body size ratio, as well as a more posterior occiput rel-ative to the spinal plumb line in children than in adults. Withthe relative paucity of literature evaluating pediatric immo-bilization, and the concerns regarding generalizability ofadult findings to this population, the group decided to restrictrecommendations made in this review to individuals over theage of 12 years.
Question 2. During airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobi-lization?
Most studies examining airway management were per-formed in the hospital rather than in the pre-hospital setting(Doran et al., 1995; Maruyama et al., 2008; Scannell et al., 1993;Turkstra et al., 2005). Intubations in the studies were done bysenior anesthesia residents or fully-trained anesthesiologists.The studies did not assess intubations done by emergencymedical technicians in the field, and there was only one articleexamining pre-hospital intubation and factors influencingsuccessful intubation in the pre-hospital setting. This pro-spective study evaluated 4691 transported patients, of which236 required intubation. The intubation success rate was 88%,and was considered to be technically more challenging, es-pecially in the setting of spinal immobilization (Doran et al.,1995).
The available clinical studies evaluating the impact of air-way control using in-line cervical stabilization did not findworsening of neurologic status after airway management(Maruyama et al., 2008; Scannell et al., 1993). Anatomicalstudies of in-line stabilization with a Miller blade showed lesscervical movement compared to use of a cervical collar alone(Gerling et al., 2000).
Several randomized cross-over trials were performedassessing newer forms of indirect intubation in patients un-dergoing general anesthesia for elective surgeries with livefluoroscopy (Maruyama et al., 2008; Turkstra et al., 2005).Indirect methods of intubation such as the Lightwand withmanual in-line immobilization were found to cause less cer-vical motion than direct laryngoscopy with a Miller bladeand in-line immobilization (Maruyama et al., 2008; Turkstraet al., 2005).
Question 3. What is the impact of pre-hospital transporttime to definitive care on the outcomes of patients withacute SCI?
There is little evidence regarding the impact of pre-hospitaltransport time to definitive care on the outcomes of patientswith acute SCI. However, patients transported within 24 h fortreatment fared better than those transported after 24 h. It isunknown if there were confounding factors in those patientstransported after 24 h that negatively affected outcomes,such as medical comorbidities or concurrent injuries thathindered earlier transportation, and thus negatively impactedthe results of spinal cord injury treatment. Air and groundtransport are both safe when spinal precautions are taken fortransport (Armitage et al., 1990; Burney et al., 1989; Flabouris,2001), and these studies did not document the developmentof any ascending neurological deficits with transport (Armi-tage et al., 1990; Burney et al., 1989; Flabouris, 2001).
Burney and associates reviewed patients with spinal col-umn fractures with SCI (complete or incomplete) to assesswhether these patients could undergo safe early transport toan SCI center using basic equipment for spine stabilization.Transportation was achieved both by ground ambulance(41%) , helicopter (54%), and fixed-wing aircraft (5%), and84% were transferred within 24 h of injury. No patients suf-fered ascending injury levels as a result of transfer. There wasno significant difference found in the probability of im-provement between ground and air transportation (Burneyet al., 1989).
1358 AHN ET AL.
Flabouris and colleagues reviewed the pattern of utilizationof a medically-staffed transportation service by patients withsuspected spinal injuries from a hospital or from a scene ofan accident and documented the impact of differentmodes of transportation. The majority (93%) of transferswere by helicopter, followed by fixed-wing aircraft (3.5%),and lastly road vehicles. Mean duration of inter-hospitaltransport (42� 28 min) was longer than from scene transfers(19� 12 min), but this was similar to road vehicle transfers(45� 26 min). Rural hospitals were the referral source for 55%of inter-hospital transports. The reason for 18% of all inter-hospital transfers was to exclude a spinal injury that could nototherwise be excluded at the referral hospital. No worseneurological outcomes occurred as a result of transportation(Flabouris, 2001).
Question 4. What is the role for pre-hospital care pro-viders in cervical spine clearance and immobilization?
Clinical evidence reveals that pre-hospital emergencymedical technicians can be trained to apply criteria to clearpatients of cervical spinal injuries and immobilize patientssuspected of having a cervical spinal injury to a level similar tothat of emergency physicians (Armstrong et al., 2007; Benneret al., 2006; Brown et al., 1998; Burton et al., 2005, 2006;Campbell, 1987; Domeier et al., 1997, 1999, 2002, 2005; Meldonet al., 1998; Muhr et al., 1999; Sahni et al., 1997; Stroh andBraude, 2001). There was no universal tool or triage indexused in the studies.
In some series up to 8% of vertebral column injuries werenot immobilized (Armstrong et al., 2007; Brown et al., 1998;Domeier et al., 2002, 2005; Stroh and Braude, 2001). However,there were no clinical consequences of not immobilizing, andnone of these column injuries had associated neurologicaldeficits (Armstrong et al., 2007; Brown et al., 1998; Domeieret al., 2002, 2005; Stroh and Braude, 2001).
Armstrong and associates examined whether the incidenceof unnecessary cervical spine immobilization by ambulancepersonnel could be safely reduced through the implementationof an evidence-based algorithm. Following a training program,paramedics collected data on 103 patients with potential cer-vical spine injuries, of which 69 (67%) had their cervical spinescleared at the accident scene. Of these, 60 (87%) were dis-charged at the scene with no clinical adverse events reported,and 9 (13%) were taken to the local emergency department withminor injuries, and all were discharged home the same day.However, 34 (33%) patients could not have their cervical spinessafely cleared at the scene according to the algorithm. Of these,4 (12%) patients self-discharged themselves at the scene, and30 (88%) were conveyed to an emergency department per theirprocedure protocol (Armstrong et al., 2007).
Brown and co-workers examined whether emergencymedical services (EMS) providers can accurately apply clini-cal criteria for clearing the cervical spine in trauma patients.Both emergency physicians and EMS providers indicatedimmobilization in 60% of patients, and their assessmentsdiffered for 21.3% of patients. Overall agreement indicated akappa value of 0.48, which reflects moderate agreement. TheEMS providers were generally more conservative than theemergency physicians (Brown et al., 1998).
Domeier and colleagues first examined prospectivelywhether or not retrospectively identified criteria could beused to identify patients without significant spinal fracture
outside of the hospital. By utilizing their criteria, 100% of allcervical injuries were identified. They identified 90% of pa-tients with thoracic injuries, and 96% of patients with lumbarinjuries. There were three false-negatives, of which two hadstable thoracic compression injuries, and one had a lumbartransverse fracture. Only one of these false-negatives wasadmitted to hospital for pain control, and was dischargedwithin 2 days, and the remaining false-negative injuries weredischarged from the emergency department. No significantspinal fractures were missed (Domeier et al., 1997).
In another study, Domeier and associates examined thereliability of a pre-hospital clinical evaluation tool in pa-tients with different severities and mechanisms of injury. Inall, 1059 patients were assessed in the high-risk group, ofwhich 9.4% had injuries, and 5423 low-risk group patientswere assessed, of which 2% had injuries. The criteria identi-fied 97% of injuries in the high-risk group, and 94% in thelow-risk group. The mechanism of injury did not affect theability of the clinical criteria to predict spinal injury (Domeieret al., 1999).
In 2005, Domeier and colleagues assessed whether theprotocols developed allowed EMS providers to appropriatelyimmobilize patients with spinal injuries. The sensitivity of theEMS protocol was 92% (95% CI 89.4, 94.6), and 8% of patientswith spinal injuries did not have immobilization; however,none of the non-immobilized patients sustained cord injuries.EMS providers also immobilized 12% of patients not requiredby the protocol. The use of the selective immobilization pro-tocol resulted in spine immobilization for most patients withspinal injury, without causing harm in cases in whom im-mobilization was withheld (Domeier et al., 2005).
Muhr and associates also examined training paramedics touse a clearance algorithm. If patients met all the criteria,paramedics could transport them without spine immobiliza-tion. They found that there was a 33% reduction in the utili-zation of spinal immobilization compared to pre-study data(Muhr et al., 1999).
Further research is needed to determine a universal triagesystem that can be implemented to train emergency medicaltechnicians in the pre-hospital setting. However, the resultsof the systematic review for this question must be balancedwith the realities of geographic variations in law and healthpolicy, and the varying risk tolerance of EMS systems in dif-ferent regions.
Recommendations
All recommendations were derived from the systematicreviews, statements from the authors, and the Delphi process.The latter was reported using the level of agreement and thecomments and suggestions of experts.
Question 1. What is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?
� Immobilization of patients with SCI during the pre-hospital setting should include a cervical collar, headimmobilization, and a spinal board.
� Patients should be transferred off the hardboard onadmission to a facility as soon as is feasible to minimizetime on the hardboard. If patients are awaiting transferto another institution, they should be taken off the hard-board while awaiting transfer.
PRE-HOSPITAL CARE MANAGEMENT OF SCI PATIENT 1359
� Padded boards or inflatable bean bag boards should beutilized to reduce pressure on the occiput and sacrum.
� These recommendations are intended for adults andchildren over the age of 12 years.
Question 2. During airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobi-lization?
� Airway management of acute SCI patients requiringintubation in the pre-hospital setting should include theuse of manual in-line cervical spine traction.
� Intubation of patients with acute SCI in the pre-hospitalsetting should not rely solely on cervical collar neckimmobilization.
� Indirect methods of intubation may cause less cervicalmovement than with direct laryngoscopy with a Millerblade.
Question 3. What is the impact of pre-hospital transporttime to definitive care on the outcomes of patients with acuteSCI?
� Transport of patients with acute traumatic SCI to thedefinitive hospital center for care should occur within24 h of injury.
Question 4. What is the role for pre-hospital care pro-viders in cervical spine clearance and immobilization?
� Emergency medical personnel in the pre-hospital settingcan be trained to apply criteria to clear patients of cer-vical spinal injuries and immobilize patients suspectedof having a cervical spinal injury.
� The implementation of this recommendation will likelybe impacted by regional variations in law and healthpolicy.
There is insufficient evidence to make recommendationsfor children, and the authors have concerns regarding theapplicability of adult recommendations to pediatric patients.
Summary
Pre-hospital care of patients with potential spinal cordinjury requires great care to minimize secondary SCI andpotential morbidity related to spinal immobilization. Thissystematic review provides an evidentiary table and a sum-mary of the review, in addition to recommended guidelinesbased on use of the Delphi method by a group of experts.
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Address correspondence to:Albert Yee, M.D., M.Sc., F.R.C.S.C.
Department of SurgeryUniversity of Toronto
2075 Bayview AvenueRoom MG-371
Toronto, Ontario M4N3M5, Canada
E-mail: [email protected]
PRE-HOSPITAL CARE MANAGEMENT OF SCI PATIENT 1361
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