Splinting / Fractures / Immobilization / Spinal Injuries

#### SPLINTING / IMMOBILIZATION / SPINAL INJURIES

BMC Emerg Med. 2018 Dec 20;18(1):57

# Emergency and acute care management of traumatic spinal cord injury: a survey of current practice among senior clinicians across Australia.

Sharwood L, Dhaliwal S, Ball J, Burns B, Flower O, Joseph A, Stanford R, Middleton J

BACKGROUND: To describe pre-hospital, emergency department and acute care assessment and management practices of senior clinicians for patients with acute traumatic spinal cord injury (TSCI) across Australia; and to describe clinical practice variation.

METHODS: We used a descriptive, cross-sectional study design to survey senior clinicians (greater than 10 years practice in this field) caring for patients with acute TSCI. The assessment, management and referral practices of prehospital, emergency department/trauma and surgical expert clinicians, across prehospital, early hospital care, diagnostic imaging and haemodynamic management were surveyed.

RESULTS: We invited 95 eligible senior clinicians; the response rate was 75%. Survey findings demonstrated overall lack of awareness or consistent use of evidence based published guidelines; many clinicians following 'locally written' or 'no particular' guideline. Practitioners were conflicted across multiple areas including patient assessment and diagnosis, treatment and transport decisions. Reported spinal immobilisation practices differed substantially, as did target setting for blood pressure; the majority of clinicians actively monitored risk of respiratory deterioration. Specialist care consult and specialist service bed availability was reported as problematic by more than one third of clinicians.

CONCLUSIONS: Unwarranted clinical practice variation is known to contribute to different health outcomes for patients with similar etiologies. Clinical practice guidelines offer evidence based, best practice standards, however are only effective if adopted throughout the healthcare system. Wide variability in acute care practices, pathways and timing to specialist centres for TSCI was evidenced by this survey despite seniority among clinicians. This devastating injury requires prompt, consistent, evidence based care from the moment of first responder. Improved outcomes for patients with TSCI would be more likely with standardised care across pre-hospital, emergency and acute care phases of care.

Eur Spine J. 2018 Dec;27(12):2999-3006

# Prehospital care of spinal injuries: a historical quest for reasoning and evidence.

Ten Brinke J, Groen S Dehnad M, Saltzherr T, Hogervorst M, Goslings J

PURPOSE: The practice of prehospital immobilization is coming under increasing scrutiny. Unravelling the historical sequence of prehospital immobilization might shed more light on this matter and help resolve the situation. Main purpose of this review is to provide an overview of the development and reasoning behind the implementation of prehospital spine immobilization.

METHODS: An extensive search throughout historical literature and recent evidence based studies was conducted.

RESULTS: The history of treating spinal injuries dates back to prehistoric times. Descriptions of prehospital spinal immobilization are more recent and span two distinct periods. First documentation of its use comes from the early 19th century, when prehospital trauma care was introduced on the battlefields of the Napoleonic wars. The advent of radiology gradually helped to clarify the underlying pathology. In recent decades, adoption of advanced trauma life support has elevated in-hospital trauma-care to an high standard. Practice of in-hospital spine immobilization in case of suspected injury has also been implemented as standard-care in prehospital setting. Evidence for and against prehospital immobilization is equally divided in recent evidence-based studies. In addition, recent studies have shown negative side-effects of immobilisation in penetrating injuries.

CONCLUSION: Although widely implementation of spinal immobilization to prevent spinal cord injury in both penetrating and blunt injury, it cannot be explained historically. Furthermore, there is no high-level scientific evidence to support or reject immobilisation in blunt injury. Since evidence in favour and against prehospital immobilization is equally divided, the present situation appears to have reached something of a deadlock. These slides can be retrieved under Electronic Supplementary Material.

J Spine Surg. 2019 Mar;5(1):97-109

The 100 most influential spine fracture publications.

Donnally C, Rivera S, Rush A, Bondar K, Boden A, Wang M

Background: Management of spine fractures has advanced considerably even over the past decade. A review of the current and historical literature can lead to a better appreciation of current management protocols. This is the first comprehensive review of the most influential articles related to spine fracture management. The purpose of this study is to identify and analyze the 100 most cited publications in spine fracture management.

Methods: Using the Clarivate Analytics Web of Science, search phrases were used to identify publications pertaining to spine fractures (110,809 publications). The 100 most cited articles were isolated. The frequency of citations, year of publication, country of origin, journal of publication, level-of-evidence (LOE), article type, and contributing authors/institutions were recorded. We also highlighted the ten most cited articles (per year) from the past decade.

Results: The publications included ranged from 1953-2010, with the majority published between 2000-2009 (n=41). Total citations ranged from 154 to 1,076. A LOE of IV had the plurality at 36%. The most cited article was "The 3 Column Spine and Its Significance in The Classification of Acute Thoracolumbar Spinal-Injuries" (Spine 1983) by F Denis. The majority of papers originated in the United States (n=65), and the highest number were published in Spine (n=27). Osteoporotic fractures were the specific topic in 34 publications. In the past decade, the article with the most citations/year was "A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures" by DF Kalmes in 2009.

Conclusions: Despite less time for citation than other decades, the 2000s contain the plurality of the influential publications. This may indicate that some of the most important changes to spine fracture management pertain to improved imaging modalities and surgical technologies. This review provides a guide for a comprehensive understanding of the historical and current literature pertaining to spine fracture management.

J Athl Train. 2018 Aug;53(8):752-755

# Removal of the Long Spine Board From Clinical Practice: A Historical Perspective.

Feld F

Since the early 1970s, initial management of patients with suspected spinal injuries has involved the use of a cervical collar and long spine board for full immobilization, which was thought to prevent additional injury to the cervical spine. Despite a growing body of literature demonstrating the detrimental effects and questionable efficacy of spinal immobilization, the practice continued until 2013, when the National Association of EMS Physicians issued a position statement calling for a reduction in the use of spinal immobilization and a shift to spinal-motion restriction. This article examines the literature that prompted the change in spinal-injury management and the virtual elimination of the long spine board as a tool for transport.

Eur J Trauma Emerg Surg. 2019 Apr 27. doi: 10.1007/s00068-019-01143-z. [Epub ahead of print]

# Analysis of cervical spine immobilization during patient transport in emergency medical services.

Nolte P, Uzun D, Häske D, Weerts J, Münzberg M, Rittmann A, Grützner P, Kreinest M

PURPOSE: It remains controversial how to immobilize the cervical spine (CS) in trauma patients. Therefore, we analyzed different CS immobilization techniques during prehospital patient transport.

METHODS: In this explorative, biomechanical analysis of immobilization techniques conducted in a standardized setting, we recorded CS motion during patient transport using a wireless human motion tracker on a volunteer. To interpret spinal movement a benchmark called motionscore (MS) was developed based on biomechanics of the injured spine.

RESULTS: We found the best spinal motion restriction using a spine board, head blocks and immobilization straps with and without a cervical collar (CC) (MS 45 vs. 27). Spinal motion restriction on a vacuum mattress with CC and head blocks was superior to no CC or head blocks (MS 103 vs. 152). An inclined vacuum mattress was more effective with head blocks than without (MS 124 vs. 187). Minimal immobilization with an ambulance cot, CC, pillow and tape was slightly superior to a vacuum mattress with CC and head blocks (MS 92 vs. 103). Minimal immobilization without CC showed the lowest spinal motion restriction (MS 517).

CONCLUSIONS: We suggest an immobilization procedure customized to the individual situation. A spine board should be used whenever spinal motion restriction is indicated and the utilization is possible. In some cases, CS immobilization by a vacuum mattress with CC and head blocks could be more beneficial. In an unstable status of the patient, minimal immobilization may be performed using an ambulance cot, pillow, CC and tape to minimize time on scene caused by immobilization.

Neurocrit Care. 2019 Apr;30(2):261-271

# Current Topics in the Management of Acute Traumatic Spinal Cord Injury.

Shank C, Walters B, Hadley M

Acute traumatic spinal cord injury (SCI) affects more than 250,000 people in the USA, with approximately 17,000 new cases each year. It continues to be one of the most significant causes of trauma-related morbidity and mortality. Despite the introduction of primary injury prevention education and vehicle safety devices, such as airbags and passive restraint systems, traumatic SCI continues to have a substantial impact on the healthcare system. Over the last three decades, there have been considerable advancements in the management of patients with traumatic SCI. The advent of spinal instrumentation has improved the surgical treatment of spinal fractures and the ability to manage SCI patients with spinal mechanical instability. There has been a concomitant improvement in the nonsurgical care of these patients with particular focus on care delivered in the pre-hospital, emergency room, and intensive care unit (ICU) settings. This article represents an overview of the critical aspects of contemporary traumatic SCI care and notes areas where further research inquiries are needed. We review the pre-hospital management of a patient with an acute SCI, including triage, immobilization, and transportation. Upon arrival to the definitive treatment facility, we review initial evaluation and management steps, including initial neurological assessment, radiographic assessment, cervical collar clearance protocols, and closed reduction of cervical fracture/dislocation injuries. Finally, we review ICU issues including airway, hemodynamic, and pharmacological management, as well as future directions of care.

Int J Oral Maxillofac Surg. 2019;Epub ahead of print

# Frequency of cervical spine injuries in patients with midface fractures.

Färkkilä E, Peacock Z, Tannyhill R, Petrovick L, Gervasini A, Velmahos G, Kaban L

The aim of this retrospective cohort study was to determine the frequency and risk factors for cervical spine injury (CSI) in patients with midface fractures. Patients ≥18 years of age entered in the Massachusetts General Hospital Trauma Registry from 2007 to 2017 were identified. Those with a midface fracture, computed tomography and/or magnetic resonance imaging of the cervical spine, and complete medical records were included. There were 23,394 patients in the registry; 3950 (16.9%) had craniomaxillofacial fractures and 1822 (7.8%) had a CSI. Craniomaxillofacial fractures included fractures of the midface (n=2803, 71.0%), mandible (n=873, 22.1%), and midface plus mandible (n=274, 6.9%). The overall frequency of CSI in patients with midface fractures was 11.4% (350/3077). Patients with midface fractures had a higher risk for CSI compared to patients without a midface fracture (odds ratio 2.4, 95% confidence interval 2.1-2.4, P<0.001). In a multivariate model, nasal and orbital fractures, chest injuries, age, injury severity score, and motor vehicle crash or fall as the etiology were independent risk factors for CSI. Mortality was two times higher in subjects with CSI. Early and accurate diagnosis of CSI is a critical factor when planning the treatment of patients with these fractures.

Eur Spine J. 2019 Oct;28(10):2390-2407

# Management and prognosis of acute traumatic cervical central cord syndrome: systematic review and Spinal Cord Society-Spine Trauma Study Group position statement.

Yelamarthy P, Chhabra H, Vaccaro A, Vishwakarma G, Kluger P, Nanda A, Abel R, Tan W, Gardner B, Chandra P, Chatterjee S, Kahraman S, Naderi S, Basu S, Theron F

PURPOSE: Spinal Cord Society (SCS) and Spine Trauma Study Group (STSG) established a panel tasked with reviewing management and prognosis of acute traumatic cervical central cord syndrome (ATCCS) and recommend a consensus statement for its management.

METHODS: A systematic review was performed according to the PRISMA 2009 guidelines. Delphi method was used to identify key research questions and achieve consensus. PubMed, Scopus and Google Scholar were searched for corresponding keywords. The initial search retrieved 770 articles of which 37 articles dealing with management, timing of surgery, complications or prognosis of ATCCS were identified. The literature review and draft position statements were compiled and circulated to panel members. The draft was modified incorporating relevant suggestions to reach consensus.

RESULTS: Out of 37 studies, 15 were regarding management strategy, ten regarding timing of surgery and 12 regarding prognosis of ATCCS.

CONCLUSION: There is reasonable evidence that patients with ATCCS secondary to vertebral fracture, dislocation, traumatic disc herniation or instability have better outcomes with early surgery (< 24 h). In patients of ATCCS secondary to extension injury in stenotic cervical canal without fracture/fracture dislocation/traumatic disc herniation/instability, there is requirement of high-quality prospective randomized controlled trials to resolve controversy regarding early surgery versus conservative management and delayed surgery if recovery plateaus or if there is a neurological deterioration. Until such time decision on surgery and its timing should be left to the judgment of physician, deliberating on pros and cons relevant to the particular patient and involving the well-informed patient and relatives in decision making. These slides can be retrieved under Electronic Supplementary Material.

Global Spine J. 2019 Aug;9(5):545-558

# Epidemiology of War-Related Spinal Cord Injury Among Combatants: A Systematic Review.

Furlan J, Gulasingam S, Craven B

Study Design: Systematic review.

Objectives: War-related spinal cord injuries (SCIs) are commonly more severe and complex than traumatic SCIs among civilians. This systematic review, for the first time, synthesized and critically appraised the literature on the epidemiology of war-related SCIs. This review aimed to identify distinct features from the civilian SCIs that can have an impact on the management of military and civilian SCIs.

Methods: Medline, EMBASE, and PsycINFO databases were searched for articles on epidemiology of war-related SCI among combatants, published from 1946 to December 20, 2017. This review included only original publications on epidemiological aspects of SCIs that occur during an act of war. The STROBE statement was used to examine the quality of the publications.

Results: The literature search identified 1594 publications, of which 25 articles fulfilled the inclusion and exclusion criteria. The studies were classified into the following topics: 17 articles reported demographics, level and severity of SCI, mechanism of injury and/or associated bodily injuries; 5 articles reported the incidence of war-related SCI; and 6 articles reported the frequency of SCI among other war-related bodily injuries. Overall, military personnel with war-related SCI were typically young, white men, with predominantly thoracic or lumbar level, complete (American Spinal Injury Association [ASIA] Impairment Scale A) SCI due to gunshot or explosion and often associated with other bodily injuries. Marines appear to be at a greater risk of war-related SCI than the military personal in the Army, Navy, and Air Force.

Conclusions: The war-related SCIs among soldiers are distinct from the traumatic SCI in the general population. The majority of the current literature is based on the American experiences in most recent wars.

Scand J Trauma Resusc Emerg Med. 2019 Aug 19;27(1):77

# New clinical guidelines on the spinal stabilisation of adult trauma patients - consensus and evidence based.

Maschmann C, Jeppesen E, Rubin M, Barfod C

Traumatic spinal cord injury is a relatively rare injury in Denmark but may result in serious neurological consequences. For decades, prehospital spinal stabilisation with a rigid cervical collar and a hard backboard has been considered to be the most appropriate procedure to prevent secondary spinal cord injuries during patient transportation. However, the procedure has been questioned in recent years, due to the lack of high-quality studies supporting its efficacy. A national interdisciplinary task force was therefore established to provide updated clinical guidelines on prehospital procedures for spinal stabilisation of adult trauma patients in Denmark. The guidelines are based on a systematic review of the literature and grading of the evidence, in addition to a standardised consensus process.This process yielded five main recommendations: A strong recommendation against spinal stabilisation of patients with isolated penetrating trauma; a weak recommendation against the prehospital use of a rigid cervical collar and a hard backboard for ABCDE-stable patients; and a weak recommendation for the use of a vacuum mattress for patient transportation. Finally, our group recommends the use of our clinical algorithm to ensure good clinical practice.