Session IV - Spine

Fri., 10/8/04 Spine & Pelvis, Paper #25, 4:20 pm

Selective Spinal Immobilization: A Retrospective Study of Six Clinical Criteria for Prehospital Trauma Triage

Paul H.P. Fung Kon Jin (n); J. Carel Goslings, PhD (n);
Jan S.K. Luitse, MD (n); Kees Jan Ponsen, MD (n);
Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

Purpose: Full spinal immobilization of patients who have sustained blunt trauma is a widely accepted pre-hospital measure, applied in order to prevent (further) damage to the spinal cord. Daily, many trauma victims are immobilized after accidents. However, there is marginal evidence for the effectiveness of spinal immobilization and growing evidence of the negative effects of immobilization. A more selective protocol might be able to reduce possible morbidity and mortality as well as the present immobilization protocol.

Methods: In a retrospective study, the sensitivity of a selective immobilization protocol based on six specific clinical criteria was examined for patients admitted with a spinal fracture to a level-1 trauma center. The six clinical criteria that replaced mechanism of trauma were: reduced awareness, evidence of intoxication, neurologic deficit, pain of the spine on palpation, (significant) distracting injury, and age of 65 or older. If one or more criteria were positive, standard full immobilization would be indicated. The other patients would not have been immobilized.

Results: On the basis of the ICD-9 codes for spinal fractures with or without spinal damage, a total of 238 blunt-trauma victims were admitted to the trauma center from 1998 through 2002. The average age of the population was 42.6 years (median, 39; range, 5 to 98) with 32.8% female. A total of 236 had at least one positive criterion (sensitivity, 99.2%). The two missed patients were both male and were 40 and 41 years of age. Radiographs showed a small fissure in the arch of C2 and a transverse process fracture of L3, respectively. Both patients were discharged the next day without complications or medical interventions.

Conclusion: In this retrospective study, a selective protocol based on clinical criteria instead of trauma mechanism showed 99.2% sensitivity for spinal fractures with or without spinal cord damage. On the basis of this study and the current controversy surrounding spinal immobilization, a prospective study should be considered to evaluate the six clinical criteria in a pre-hospital setting. Such an evidence-based protocol would have major implications for pre-hospital trauma care.