Prehospital Spine Immobilization/Spinal Motion Restriction in Penetrating Trauma: a Practice Management Guideline from the Eastern Association for the Surgery of Trauma (EAST)

ABSTRACTBackgroundSpine immobilization in trauma has remained an integral part of most emergency medical services (EMS) protocols despite a lack of evidence for efficacy and concern for associated complications, especially in penetrating trauma patients. We reviewed the published evidence on the topic of prehospital spine immobilization or spinal motion restriction in adult patients with penetrating trauma to structure a Practice Management Guideline.MethodsWe conducted a Cochrane style systematic review and meta-analysis, and applied GRADE methodology to construct recommendations. Qualitative and quantitative analyses were used to evaluate the literature on the critical outcomes of mortality, neurologic deficit, and potentially reversible neurologic deficit.ResultsA total of 24 studies met inclusion criteria, with qualitative review conducted for all studies. We used five studies for the quantitative review (meta-analysis). No study showed benefit to spine immobilization with regard to mortality and neurologic injury, even for patients with direct neck injury. Increased mortality was associated with spine immobilization, with RR 2.4 (CI 1.07, 5.41). The rate of neurologic injury or potentially reversible injury was very low, ranging from 0.002 to 0.076 and 0.00034 to 0.055, with no statistically significant difference for neurologic deficit or potentially reversible deficit, RR 4.16 (CI 0.56, 30.89), and RR 1.19 (CI 0.83, 1.70), although the point estimates favored no immobilization.ConclusionsSpine immobilization in penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurologic deficits, even potentially reversible neurologic deficits. We recommend that spine immobilization not be used routinely for adult patients with penetrating trauma.Level of EvidenceLevel IIStudy TypeSystematic Review with Meta-analysis Background Spine immobilization in trauma has remained an integral part of most emergency medical services (EMS) protocols despite a lack of evidence for efficacy and concern for associated complications, especially in penetrating trauma patients. We reviewed the published evidence on the topic of prehospital spine immobilization or spinal motion restriction in adult patients with penetrating trauma to structure a Practice Management Guideline. Methods We conducted a Cochrane style systematic review and meta-analysis, and applied GRADE methodology to construct recommendations. Qualitative and quantitative analyses were used to evaluate the literature on the critical outcomes of mortality, neurologic deficit, and potentially reversible neurologic deficit. Results A total of 24 studies met inclusion criteria, with qualitative review conducted for all studies. We used five studies for the quantitative review (meta-analysis). No study showed benefit to spine immobilization with regard to mortality and neurologic injury, even for patients with direct neck injury. Increased mortality was associated with spine immobilization, with RR 2.4 (CI 1.07, 5.41). The rate of neurologic injury or potentially reversible injury was very low, ranging from 0.002 to 0.076 and 0.00034 to 0.055, with no statistically significant difference for neurologic deficit or potentially reversible deficit, RR 4.16 (CI 0.56, 30.89), and RR 1.19 (CI 0.83, 1.70), although the point estimates favored no immobilization. Conclusions Spine immobilization in penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurologic deficits, even potentially reversible neurologic deficits. We recommend that spine immobilization not be used routinely for adult patients with penetrating trauma. Level of Evidence Level II Study Type Systematic Review with Meta-analysis Corresponding Author: Catherine Garrison Velopulos MD, MHS, FACS, University of Colorado School of Medicine, Trauma, Acute Care Surgery, and Critical Care. Email: Catherine.Velopulos@ucdenver.edu. Mailing Address: 12631 E. 17th Street, Room 6001, Aurora, Colorado 80045 Presented at: Eastern Association for the Surgery of Trauma 30th Annual Scientific Assembly, January 10-14, 2017, Hollywood, FL. Conflicts of Interest disclosure for all authors: Dr. Haut is supported by a research grant (1R01HS024547) from the Agency for Healthcare Research and Quality (AHRQ) titled “Individualized Performance Feedback on Venous Thromboembolism Prevention Practice.” Dr. Haut is supported by a contract (CE-12-11-4489) from the Patient-Centered Outcomes Research Institute (PCORI) titled “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology.” Dr. Haut receives royalties from Lippincott, Williams, & Wilkins for a book - "Avoiding Common ICU Errors". Dr. Haut is a paid consultant and speaker for the “Preventing Avoidable Venous Thromboembolism— Every Patient, Every Time” VHA IMPERATIV® Advantage Performance Improvement Collaborative and the Illinois Surgical Quality Improvement Collaborative "ISQIC." Dr. Haut was the paid author of a paper commissioned by the National Academies of Medicine titled “Military Trauma Care’s Learning Health System: The Importance of Data Driven Decision Making” which was used to support the report titled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.” None of these funding sources contributed to this work. © 2017 Lippincott Williams & Wilkins, Inc.

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