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An Out-Patient Cervical Spine Clearance Protocol
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Am Fam Physician. 2002 Jan 15;65(2):317.
Emergency medical services personnel can use a variety of techniques, when indicated, to inhibit spinal movement. These include application of a cervical collar, rotational support, a spine board, and securing straps. Out-of-hospital immobilization protocols can help identify patients who are at risk of neurologic damage because of cervical injuries. Although there is some uncertainty about the clinical usefulness of cervical immobilization following trauma, currently the standard of care is immobilization. Stroh and Braude report on a study of whether a selective spine immobilization clearance protocol would identify patients who require spine immobilization (see accompanying table).
The study group conducted a retrospective chart review of patients discharged from the hospital over a six-year period with the diagnosis of cervical spine fracture or dislocation, or spinal cord injury without radiologic abnormality. The study design was to determine the sensitivity and consequent safety of the protocol in identifying the need for immobilization in patients at risk for potentially significant cervical injuries. Charts of patients who had been brought to the hospital by the Fresno/Kings/Madera counties' emergency medical services were included. The charts of patients who had not arrived in immobilization were reviewed in detail for the presence or absence of the criteria for immobilization in the protocol. These were categorized to determine if the protocol was not applied appropriately or if the protocol actually missed the diagnosis.
Of the 504 patients transported by the Fresno/Kings/Madera counties' emergency medical services, 495 were properly identified and immobilized. Of the remaining nine, four patients refused immobilization or could not be physically immobilized. There were five missed injuries. In two of the latter, the protocol was violated because the criteria for immobilization were present, but immobilization was not considered. In three, the criteria for immobilization were absent, representing missed diagnoses. These results represent a sensitivity of 99 percent for immobilization of patients with confirmed cervical injury.
The authors conclude that adherence to the protocol would reduce unnecessary immobilizations. It is recognized that some judgment is required because strict protocols may result in some patients suffering negative effects from the procedure.
In an editorial in the same journal, Hoffman and Mower acknowledge the limitations in the test of this protocol and note that the data presented calculate to a positive predictive value for the protocol of just over 1 percent. They conclude that sensitivity is more important than specificity in a system that should play safe and that, even with the significant methodologic questions, the protocol seems reasonable.
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Stroh G, Braude D. Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann Emerg Med June 2001 37;6:609–15, and Hoffman JR, Mower WR. Out-of-hospital cervical spine immobilization: making policy in the absence of definitive information [Editorial]. Ann Emerg Med. June 2001;37:632–4.
Copyright © 2002 by the American Academy of Family Physicians.
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