Pre-Hospital Care Management of a Potential Spinal Cord Injured Patient: A Systematic Review of the Literature and Evidence-Based Guidelines

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.

The definite risks and questionable benefits of liberal pre-hospital spinal immobilisation

“…[11]  Delayed transport, increasing time to definitive care. [19]  Confounding clinical examination and vital sign recordings. [20] Hauswald, [21] and the authors of three systematic reviews, [18,22,23] conclude that phSI may be contributing to patient morbidity and mortality.…”

“…[25,26] Conversely, Ahn and Singh found that 8% of vertebral column injuries were not immobilised and no clinical consequences resulted. [19] Gerrelts et al found that patients with a delayed diagnosis of cervical spine fracture did not develop permanent neurological deficits. [27] There were no case-control studies that directly compared the outcomes of patients who were immobilised against those that were not.…”

3D Transmissibility and Relative Transmissibility of Immobilized Supine Humans during Transportation

“…As an example, Perry et al [6] reported relative neck motions associated with horizontal vibration that were deemed clinically significant by a neuroscientist for a potential contribution to spinal cord injury. Ahn et al [7] conducted a comprehensive literature review on the management of pre-hospital care of potential spinal cord injury patients, including the ideal methods for spinal immobilization. The authors recommended the use of the spinal board, cervical collar, and head immobilization during the pre-hospital setting.…”

Journal Club: Long-term functional outcome in patients with acquired infections after acute spinal cord injury

“…Perhaps related to care, length of acute care stay has also been shown to affect functional outcomes after SCI, and could provide further insight. 9,10 Regarding inclusion/exclusion criteria, the authors provided valid reasoning for the inclusion of specific injury characteristics (limiting heterogeneity and ceiling effects in recovery), though no reason was given for the exclusion of individuals in prior care. Second, patients who were rehospitalized for unspecified infectious or parasitic diseases during follow-up were also excluded, and a justification was also not provided.…”