Spine References
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Hauswald M. Ong G. Tandberg D. Omar Z. Out-of-hospital spinal
immobilization: its effect on neurologic injury [see comments in: Acad
Emerg Med 1998 Mar;5(3):203-4]
Academic Emergency Medicine. 5(3):214-9, 1998 March.
OBJECTIVE: To examine the effect of emergency immobilization on neurologic
outcome of patients who have blunt traumatic spinal injuries.
METHODS: A 5-year retrospective chart review was carried out at 2
university hospitals. All patients with acute blunt traumatic spinal or
spinal cord injuries transported directly from the injury site to the
hospital were entered. None of the 120 patients seen at the University of
Malaya had spinal immobilization during transport, whereas all 334
patients seen at the University of New Mexico did. The 2 hospitals were
comparable in physician training and clinical resources. Neurologic
injuries were assigned to 2 categories, disabling or not disabling, by 2
physicians acting independently and blinded to the hospital of origin.
Data were analyzed using multivariate logistic regression, with hospital
location, patient age, gender, anatomic level of injury, and injury
mechanism serving as explanatory variables.
RESULTS: There was less neurologic disability in the unimmobilized
Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds
to a <2% chance that immobilization has any beneficial effect. Results
were similar when the analysis was limited to patients with cervical
injuries (OR 1.52; 95% CI 0.64-3.62; p =0.34).
CONCLUSION: Out-of-hospital immobilization has little or no effect on
neurologic outcome in patients with blunt spinal injuries. 

Muhr MD, Seabrook DL, Wittwer LK.
Paramedic use of a spinal injury clearance algorithm reduces spinal
immobilization in the out-of-hospital setting.
Prehosp Emerg Care 1999 Jan-Mar;3(1):1-6.]
OBJECTIVE: To determine whether paramedics can safely use a spinal clearance
algorithm to reduce unnecessary spinal immobilization (SI) in the
out-of-hospital setting. METHODS: Paramedics were instructed in the use of a
spinal clearance algorithm that prompted assessment of the trauma patient's 1)
level of consciousness, 2) drug and/or alcohol use, 3) loss of consciousness
during the event, 4) presence of spinal pain/tenderness, 5) presence of
neurologic deficit, 6) concomitant serious injury, or 7) presence of pain with
range of motion. The algorithm indicated that if any of the above were
present, the patient should receive full SI, and if all of the above were
negative, then SI could be withheld. Paramedics completed a tracking form that
included the above and followed the patient to the emergency department (ED).
Data were then gathered to determine the presence of spinal fracture,
neurologic deficit, or a combination of the two. To compare the trends for SI,
a retrospective medical incident report (MIR) review was conducted from the
previous year. MIRs were selected based on the same criteria as those used for
study inclusion. RESULTS: Two hundred eighty-one patients were included in the
study, with 65% (n = 183) of them receiving SI. Two hundred ninety-three MIRs
were included in the retrospective sample, with SI being provided 95% (n =
288) of the time. Comparison of these samples shows a 33% reduction in
utilization of SI (95% confidence interval: 27.2%- 38.8%). CONCLUSION: An
out-of-hospital spinal clearance algorithm administered by paramedics can
reduce SI by one-third. Any application of a spinal clearance algorithm should
be accompanied by rigorous medical supervision.

Brown LH, Gough JE, Simonds WB. Can EMS providers adequately assess
trauma patients for cervical spinal injury? Prehosp Emerg Care 1998
Jan-Mar;2(1):33-6
OBJECTIVE: To determine whether EMS providers can accurately apply the
clinical criteria for clearing cervical spines in trauma patients. METHODS:
EMS providers completed a data form based on their initial assessments of all
adult trauma patients for whom the mechanism of injury indicated
immobilization. Data collected included the presence or absence of: neck
pain/tenderness; altered mental status; history of loss of consciousness;
drug/alcohol use; neurologic deficit; and other painful/distracting injury.
After transport to the ED, emergency physicians (EPs) completed an identical
data form based on their assessments. Immobilization was considered to be
indicated if any one of the six criteria was present. The EPs and EMS
providers were blinded to each other's assessments. Agreement between the EP
and EMS assessments was analyzed using the kappa statistic. RESULTS:
Five-hundred seventy-three patients were included in the study. The EP and EMS
assessments matched in 78.7% (n = 451) of the cases. There were 44 (7.7%)
patients for whom EP assessment indicated immobilization, but the EMS
assessment did not. The kappa for the individual components of the assessments
ranged from 0.35 to 0.81, with the kappa for the decision to immobilize being
0.48. The EMS providers' assessments were generally more conservative than the
EPs'. CONCLUSION: EMS and EP assessments to rule out cervical spinal injury
have moderate to substantial agreement. However, the authors recommend that
systems allowing EMS providers to decide whether to immobilize patients should
follow those patients closely to ensure appropriate care and to provide
immediate feedback to the EMS providers.

Chan D, Goldberg R, Tascone A, Harmon S and Chan L.
The Effect of Spinal Immobilization on Healthy Volunteers
Annals of Emergency Medicine, Vol. 23, No. 1 pp 48-51, January 1994.
Study Objective: To determine the effects of standard spinal immobilization on
a group of health volunteers with respect to induced pain and discomfort.
Interventions: 21 healthy volunteers were placed in a standard backboard
immobilization for a 30 minute period.  Number and severity of immediate and
delayed symptoms were determined. Measurements and Main Results: 100% of
subjects developed pain within the immediate observation period.  Occipital
headache and sacral, lumbar, and mandibular pain were the most frequent
symptoms.  55% of subjects graded their symptoms as moderate to severe.  29%
of subjects developed additional symptoms over the next 48 hours. Conclusion:
Standard spinal immobilization may be a cause of pain in an otherwise healthy
subject.

Chan D, Goldberg RM, Mason J, Chan L
Backboard versus mattress splint immobilization: a comparison of symptoms
generated
J Emerg Med 1996; 14 293-8
The study objective was to compare spinal immobilization techniques to a
vacuum mattress-splint (VMS) with respect to the incidence of symptoms
generated by the immobilization process. We used a prospective, cross-over
study in a university hospital setting. Participants consisted of 37 healthy
volunteers without history of back pain or spinal disease. Interventions
consisted of two phases. In Phase I, subjects were randomly assigned to be
immobilized on either a wooden backboard or a mattress-splint for 30 min. The
incidence and severity of any symptoms generated by the immobilization process
were recorded. In Phase II, the two groups were again tested after a 2-week
washout period, with the method of immobilization being reversed. Symptoms and
severity were again recorded. Pain symptoms were confined to four anatomic
sites: Occipital prominence, lumbosacral spine, scapulae, and cervical spine.
After adjusting for the effect of order of exposure, subjects were 3.08 times
more likely to have symptoms when immobilized on a backboard than when
immobilized on the VMS. They were 7.88 times more likely to complain of
occipital pain and 4.27 times more likely to complain of lumbosacral pain.
Severity of occipital and lumbosacral pain was also significantly greater
during backboard immobilization. We conclude that, when compared to a VMS,
standard backboard immobilization appears to be associated with an increased
incidence of symptoms in general and an increased incidence and severity of
occipital and lumbosacral pain in particular.

Prior information:
Goldberg R, Chan D, Mason J, and Chan L, "Standard Spinal Immobilization
Versus a Vacuum Mattress Splint: A Comparison of Symptoms Generated"  From
the Dept. of Emergency Medicine, Los Angeles County+USC Medical Center, Los
Angeles, CA. Unpublished.
Study Objective: To compare standard spinal immobilization techniques to a
vacuum mattress splint with respect to the incidence of symptoms generated
by the immobilization process.
Participants: 37 healthy volunteers without history of back pain or spinal
disease.  Interventions:  In Phase I, subjects were randomly assigned to be
immobilized on either a wooden backboard or a mattress-splint for 30
minutes.  The incidence and severity of any symptoms generated by the
immobilization process were recorded.  In Phase II, the two groups were
again tested after a two week washout period, with the method of
immobilization being reversed.  Symptoms and severity were again recorded.
Main Results: Pain symptoms were confined to four anatomic sites: occipital
prominence, lumbosacral spine, scapulae and cervical spine.  After
adjusting for the effect of order of exposure, subjects were 3.08 times
more likely to have symptoms when immobilized on a backboard than when
immobilized on the VMS (p < 0.0001).  They were similarly 7.88 times more
likely to complain of occipital pain (p < 0.0001) and 4.27 times more
likely to complain of lumbosacral pain (p < 0.0086).  Severity occipital
and lumbosacral pain was significantly higher during backboard
immobilization (p<0.0001, p<0.0088 respectively). Conclusion:  When
compared to VMS, standard backboard immobilization appears to be associated
with an increased incidence of symptoms in general and an increased
incidence and severity of occipital and lumbosacral pain in particular.

Lovell ME, Evans JH. A comparison of the spinal board and the vacuum
stretcher, spinal stability and interface pressure. Injury 1994;25(3):
179-180.
Abstract:  The interface pressures were measured between the sacrum,
mid-lumbar spine and various support surfaces.  Thirty health male
volunteers were recruited.  The spinal board, padded spinal board and
vacuum stretcher were the support surfaces evaluated.   We found high and
potentially ischaemic pressures between the sacrum and the spinal board
interface (mean 147.3 mmHg).  This was reduced in the padded board (115.5
mmHg) but dramatically reduced with the vacuum stretcher (36.7 mmHg).  It
was also noted that no support was given to the normal lumbar lordosis by
the spinal board (padded and unpadded), but support was given the the
vacuum stretghcer.  This raises the question of how stable is an unstable
spinal injury on a flat supporting surface.

Johnson DR, Hauswald M, Stockhoff C
Comparison of a vacuum splint device to a rigid backboard for spinal
immobilization
Am J Emerg Med 1996; 14 369-72
In this study, comparison of a vacuum splint device to a rigid backboard was
made with respect to comfort, speed of application, and degree of
immobilization. The study was a prospective, nonblinded comparative study
conducted at a statewide emergency medical services (EMS) training facility
and included a convenience sample of emergency medical technician (EMT) and
paramedic students. The vacuum splint was judged to be significantly more
comfortable on a 10-point scale than the rigid backboard after subjects had
been lying on each device for 30 minutes (P .001). It was also faster to
apply: 131.6 +/- 24.3 seconds versus 154.6 +/- 22.2 seconds (P .001). Various
measures of immobilization were similar for the two devices. The vacuum splint
provided better Immobilization of the torso and less slippage on a gradual
lateral tilt. The rigid backboard with head blocks was slightly better at
immobilizing the head. Vacuum splints offer a significant improvement in
comfort over a traditional backboard for the patient with possible spinal
injury. They can be applied in reasonable time frames and provide a similar
degree of immobilization when compared to a standard rigid backboard.
older information:.
Hauswald M, Johnson DR, and Stockhoff C.  "Superiority of a VAcuum Splint
Device Over a Traditional Spine Board for Immobilization."  From the Dept.
Of Emergency Medicine, University of New Mexico School of Medicine. 
Unpublished.
   Thirty EMT students were immobilized on both a wooden backboard and a
vacuum mattress splint for 30 minutes.  30 other students working in teams of
4 with one acting as a patient were timed as they immobilized the "patient" on
each device as quickly as possible.  The board was slowly lifted up to 90
degrees laterally, until the subject first felt any body part slip.  The angle
of tilt was recorded.
   Results: The vacuum splint was more comfortable than the wooden spine
board: 6.6 +/- 1.5 vs. 3.3+/-1.8 (p<0.001).  It was also slightly faster to
apply: 132 +/- 24 seconds vs. 155 +/- 22 seconds (p<0.001).  The angle at
which slippage was first noted was greater for the vacuum splint than the
spine board: 29.2 +/- 7.0 degrees vs. 19.8+/-4.3 degrees (p<0.05).
   Conclusion: Wooden spine boards have few advantages except that they are
cheaper and easier to clean than vacuum splints.  Vacuum splints are are much
more comfortable, quicker to apply and allow less slippage on lateral tilting.

Delbridge TR, Auble TE, Garrison HG and Menegazzi JJ, "Discomfort in Health
Volunteers Immobilized on Wooden Backboards and Vacuum Mattress Splints"
Prehospital and Disaster Medicine, Volume 8 Suppl 2 (Abstracts of
Scientific Papers 9th Annual Conference and Scientific Assembly of
NASEMSP). Jul-Sep 1993.
   Conclusion:  The results suggest that vacuum mattress splints cause less
discomfort than do wooden backboards;  the effect is more pronounced as the
duration of spinal immobilization increases.  Prospective studies are
necessary to evaluate the clinical significance of this effect and the
cost-effectiveness of similar alternative immobilization devices.