Review Article

Trauma
2019, Vol. 21(3) 176–183

Is our current method of cervical spine ! The Author(s) 2018

Article reuse guidelines:
sagepub.com/journals-permissions
control doing more harm than good? DOI: 10.1177/1460408618777773
journals.sagepub.com/home/tra

Ary Phaily1 and Mansoor Khan2

Abstract
Introduction: Early cervical spine immobilisation has long been considered the standard of care in the management of
trauma patients with suspected spinal cord injury. There has been conflicting evidence regarding its benefits and risks.
This article reviews the current literature and whether the continued use of routine cervical spine immobilisation is still
appropriate in modern trauma care.
Method: A literature search was conducted using the Medline PubMed, Google Scholar and Cochrane Library online
databases. The searches were limited to full text, English language studies conducted on adults in the last 20 years (July
1997 to July 2017).
Results: The entrenchment of cervical spine immobilisation in trauma management is multifactorial. In the pre-hospital
setting, immobilisation is recommended whilst awaiting full assessment. Fear of missed diagnoses of spinal injuries
encourages defensive medicine and over-immobilisation. Effective cervical spine immobilisation is appropriate in certain
cases and reduces the risk of further spinal cord injury. However, research has shown that we are over-immobilising, and
in penetrating trauma, cervical spine immobilisation increases the risk of mortality.
Conclusions: The practice of routine cervical spine immobilisation for trauma patients is outdated, ineffective and
results in iatrogenic injury. Routine cervical spine immobilisation is not backed up by robust evidence. It has been clearly
shown that in cases of penetrating spinal injuries, cervical spine immobilisation is not only ineffective but is also linked to
an increased risk of mortality. Special considerations must also be taken in patients who have pre-existing spinal con-
ditions, impending airway compromise, or at risk of aspiration and those with head injuries or suspected traumatic brain
injuries. A selective approach to cervical spine immobilisation is recommended and should be reserved for cases deemed
high risk rather than a standard rule for all trauma patients.

Keywords
Cervical, collar, immobilisation, management, spine, trauma

prevent further motion of the cervical vertebrae and

Introduction
Early control of the cervical spine has long been con-
sidered the standard of care in the management of
trauma patients with suspected cervical or spinal cord
injury, which has remained unchanged over the last
three decades. With the worldwide dissemination of
the Advanced Trauma Life Support (ATLS) guidelines,
cervical spine control, in conjunction with airway man-
agement, is now entrenched as one of the primary
measures in trauma management.1–3
The aim of cervical spine immobilisation (CSI) is to
protect the cervical spine until a full assessment of the
patient can be made and any such injury can be ruled
out by qualified personnel.4 The intended benefits are to
thereby prevent secondary spinal cord injuries due to
bony instability. In addition, CSI is used to facilitate
safe extrication and transport of the patient to defini-
tive care.4–6 This is achieved in the ‘three-point immo-
bilisation’ paradigm, which includes using a cervical
spine collar with lateral head supports and straps into
a scoop stretcher or vacuum mattress.2,7
1
Bedford Hospital NHS Trust, Bedford, UK
2
St Mary’s Hospital, Paddington, London, UK
Corresponding author:
Mansoor Khan, St Mary’s Hospital, Paddington, London, UK.
Email: mansoorkhan@nhs.net
Phaily and Khan
In addition to the ATLS algorithm, the National
Institute for Health and Care Excellence (NICE) guide-
lines recommend full inline spinal immobilisation if
there is any suspicion of spinal injury (both bone and
cord). The recommendation to immobilise is based on
the presence of any one of several factors from the ini-
tial assessment, including where no assessment can be
made, if the patient is confused or intoxicated, or has
existing spinal problems. For the cervical spine, the
NICE guidelines recommend assessing patients as
high, low or no risk according to the Canadian
C-Spine rule.8,9
The long-established practice of CSI has recently
been called into question due to conflicting evidence
regarding its benefits.10 Studies have shown that CSI
is associated with an increased risk of aspiration,
respiratory compromise,5,11,12 raised intracranial pres-
sure,13 neck pain14,15 and pressure ulcers.16 There is
also strong evidence against CSI for penetrating
trauma, as it has been linked to delays in assessment
and transport to definitive care.16–19
In 2001, a Cochrane review concluded that there was
a lack of evidence on CSI. It stated that the effects of
immobilisation on neurological injury and spinal stabil-
ity were uncertain, and as CSI can contribute to airway
compromise, there is a possibility that immobilisation
may increase mortality and morbidity.1 There is little
possibility of conducting a randomised control trial
(RCT) to assess the effectiveness of CSI in the trauma
setting as the sample size required to achieve statistical
power would be impractical.7 As such, this review aims
to assess whether our current policy of cervical spine
control is appropriate, considering advances in the
management of trauma and current evidence. This
study was designed to answer two research questions:
1. In adult trauma patients attended by emergency ser-
vices in the pre-hospital setting, what are the benefits
and harm of CSI on the patients’ outcome?
2. Is routine CSI still the most appropriate standard
of care?
Methods
A literature search was conducted using the Medline
PubMed,20 Google Scholar21 and the Cochrane
Library22 online databases. The searches were limited
to full text, English language studies conducted on
adults in the last 20 years (July 1997 to July 2017).
The search criteria included using a combination of
Medical Subject Headings and text words of ‘trauma’,
‘spine’ and ‘immobilisation’ OR ‘immobilization’.
Google scholar initially returned over 17,900 articles;
177
this was filtered by searching only for the keywords in
the title. In total, 494 relevant articles were found, of
which 10 were duplicated.
The remaining abstracts were screened and 428 art-
icles unrelated to the research questions were excluded.
Out of the remaining 56 relevant publications, six were
found to be appropriate for inclusion into this review.
These include five retrospective cohort studies and one
case series and range in publication date from 1999 to
2016. The Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) flow diagram
(Figure 1) summarises this and the inclusion and exclu-
sion criteria (Table 1).23
Data quality and analysis
Each of the studies was assessed in terms of strength of
the body of evidence according to the Oxford Centre
for Evidence-based Medicine – Levels of Evidence
matrix. As there are no RCTs in this area, the studies
scored a maximum of 3b.24,25 Due to the different inter-
ventions and outcome measures assessed in each of the
included studies, a further statistical analysis was not
conducted, and the studies are assessed below in narra-
tive form.
Results
Table 2 summarises the results of the study selection. In
1999, Hauswald et al. published a retrospective five-
year cohort study assessing blunt spinal or spinal cord
trauma from two sites: the University of New Mexico
Hospital, which had an extensive emergency services
network and received all its patients with CSI, and
the University of Malaya Hospital, which had no pre-
hospital emergency service and received patients with-
out CSI. The hospitals were comparable in resources
and training, and the neurological injuries were
assessed as disabling or non-disabling by doctors who
were blinded to the origin of the data. The patients
presenting at both hospitals were found to be similar
in terms of age (34 vs. 35 years old, respectively) and
level of injury (cervical injury: 34% vs. 33%, respect-
ively). The results showed that patients from the New
Mexico group who were immobilised had a significant
neurological disability rate of 70% compared to 13%
for those from the Malaya group who were not immo-
bilised, giving an odds ratio of 2.03 (95% confidence
interval, 1.03–3.99, p ¼ 0.04).25
Vanderlan et al. retrospectively assessed the charts of
188 patients with penetrating cervical trauma present-
ing to Charity Hospital, Louisiana, USA between 1994
and 2003. They found that 35 of these patients died
giving a relative mortality of 23% (35/153); 94% of
178 Trauma 21(3)

Figure 1. PRISMA flow diagram.23

the deaths were due to gunshot wounds and the remain-

Table 1. Inclusion and exclusion criteria. der due to stab wounds and 77% of the patients who
Inclusion criteria Exclusion criteria died were immobilised. The study noted that CSI was
associated with an unadjusted increased risk of death
# Primary studies # Abstract only (odds ratio 2.77, p ¼ 0.016, 95% CI, 1.18–6.49) and
questioned whether this was due to a delay in transport
# Full text # Duplicates due to CSI, although they acknowledge transport times
# English # Population exclusive to paediatrics were unavailable in the study.26
Haut et al. reported 45,284 patients with penetrating
# Human # Non-traumatic
trauma between 2001 and 2004 gathered from the
# Adults (>18) # Not relevant to CSI American College of Surgeons’ National Trauma
# 1997 to 2017 # Letter/comment/review article Data Bank. The study had an overall mortality rate
of 8%. Unadjusted bivariate analysis of their data
# Trauma # Protocol comparison/validation showed that patients presenting with CSI were twice
# Simulated/healthy participants as likely to die as patients who were not immobilised
(14.7% vs. 7.2% respectively, p  0.001). On control-
# Not specific to research question
ling for confounders such as age, gender, race, Injury
# Cadaveric study Severity Score (ISS), insurance and pre-hospital pro-
# No acute immobilisation cedures given, patients who had CSI were still twice
as likely to die than those without (odds ratio of
CSI: cervical spine immobilisation. death 2.06, 95% CI, 1.35–3.13).18
Phaily and Khan 179

Table 2. Publications reviewed.

Level of Patient Mechanism

Year Study title Author Study type evidence Study period number of injury

2016 Cervical spine immobilisation in Turnock et al. Retrospective 3b Nine years 231 Penetrating
penetrating cervical trauma is cohort and five years
associated with an increased
risk of indirect central
neurological injury.
2010 Spine immobilisation in Haut et al. Retrospective 3b Three years 45,284 Penetrating
penetrating trauma: more cohort
harm than good?
2009 Increased risk of death with Vanderlan et al. Retrospective 3b Nine years 188 Penetrating
cervical spine immobilisation cohort
in penetrating cervical trauma.
2009 Prehospital spinal immobilisation Brown et al. Case series 4 Five years 75,851 Penetrating
does not appear to be
beneficial and may complicate
care following gunshot injury
to the torso.
2007 Factors predicting cervical Ackland et al. Retrospective 3b Eight months 366 All
collar-related decubitus cohort
ulceration in major trauma
patients
1999 Out-of-hospital spinal Hauswald et al. Retrospective 3b Five years 454 Blunt
immobilisation: Its effect cohort
on neurologic injury

A two centre, retrospective study by Turnock et al.
went further by demonstrating that CSI was associated
with an increased risk of iatrogenic, indirect neuro-
logical injury. The study consisted of 231 patients, of
which 35 died, giving a relative mortality of 18% (35/
196). No statistically significant difference was found in
the demographics for age, gender, race, or mechanism
and type of injury at either centre. A total of four of the
patients who survived to discharge suffered indirect
neurological injury: two secondary to disrupted carotid
arterial flow, one from cervical spinal cord injury sec-
ondary to shock with central cord ischaemia picked up
on imaging and one with indirect central cord syn-
drome. Three of these patients (both carotid injuries
and the central cord syndrome) had been given CSI,
and the authors stated that CSI was associated with
an increased risk of neurological injury (relative risk
1.635, p < 0.001; 95% CI, 1.23–1.95).27
Brown et al. examined two datasets of patients with
gunshot wounds to the torso – 357 patients from the
trauma registry of the Strong Memorial Hospital, New
York State, USA between 2003 and 2007 and 75,210
patients from the American National Trauma
Databank from 2001 to 2005. It concluded that pre--
hospital spinal immobilisation was not effective for
patients with gunshot wounds to the torso due to the
relative rarity of an unstable spinal fracture without
spinal cord injury, and the fact that spinal cord injuries
in trauma due to gunshot wounds are more likely due
to direct injury to the cord from the bullet rather than
fracture of the surrounding vertebrae.28
Lastly, a retrospective study by Ackland et al. com-
prising of 299 patients fitted with cervical collars over a
six-month period revealed that 9.7% developed cervical
collar-related decubitus ulceration, with the major risk
factor being admission to the intensive care unit (ICU).
Their data showed that 13% patients with a collar
admitted to ICU developed these ulcers compared to
3.9% of patients with a collar who did not go to ICU.29
Discussion
The entrenchment of CSI in trauma management is
multifactorial. In the pre-hospital setting, where time
and resources are limited, the NICE Spinal Injury
guidelines algorithm recommends applying spinal
immobilisation, whilst awaiting full assessment in the
presence of several factors which include the patient
being uncooperative, confused, or under the influence
of alcohol. Understandably, the algorithm errs on the
180
side of caution; however, many pre-hospital emergency
services do adopt a selective immobilisation practice.8,9
Fear of missed or delayed diagnoses of spinal cord
also plays a part. The burden to both the individual and
the health service is significant, and litigation cases
often award the claimant significant sums for dam-
ages.30 This encourages healthcare professionals to
practice defensive medicine and over-immobilise.
However, research has shown that we may be over-
immobilising patients, and in the case of penetrating
trauma, CSI increases the risk of mortality. As such,
we must rethink our current routine CSI and adopt a
more selective approach.1,25,26,31
Effectiveness
The primary concern behind early CSI is the potential
to cause secondary, iatrogenic spinal cord injury by
inadvertently displacing unstable vertebrae. Early
research into CSI reported that 3–25% of all spinal
cord injuries occurred after the initial trauma and
were secondary to early medical management efforts
or transport of the patient.6,7,32 The introduction of
CSI by emergency services over the last three decades
has been reported as being behind the improvement in
the neurological status of patients with spinal cord
trauma.33–35
However, later research suggests that the figures
published on secondary injury due to lack of immobil-
isation may have been exaggerated.25,36 On the other
hand, it would be impossible to know how many
patients have been protected from secondary spinal
cord injury with the application of CSI. It is worth
noting that an estimated 5% of patients with spinal
cord injuries develop a deterioration in neurological
function despite appropriate immobilisation, thought
to be secondary to inflammation, ischaemic effects,
oedema or haematoma formation.37–39
In addition, Hauswald et al. showed that patients
arriving without immobilisation suffered significantly
less neurological disability than those with CSI. The
same paper argues that a significant amount of force
is necessary to fracture the spine during the initial
trauma, and further movements of the spine are unli-
kely to cause further damage.1,36 A study by March
et al. in 2009 in healthy volunteers demonstrated that
CSI causes false-positive examination findings for mid-
line cervical tenderness.40
Adverse effects
Penetrating injuries
There are clear reports that routine CSI is associated
with increased morbidity and in some cases, increased
Trauma 21(3)
mortality and in patients with CSI and penetrating inju-
ries, this increased mortality is thought to be due to the
time taken to apply the collar causing a delay in reach-
ing definitive care. A significant proportion of penetrat-
ing injuries cause vascular damage and studies have
shown that these patients are at low risk for secondary
spinal injury; as such, the effectiveness of CSI in pene-
trating injuries is limited. In addition, Haut et al.
reported that patients with penetrating injuries to the
spine rarely have concomitant spinal instability.15,18,39
Airway control
Cervical spine control also has detrimental effects on
the ability to secure an airway. In one study, CSI sig-
nificantly reduced mouth opening and resulted in
increasing difficulty in laryngoscopy.41 When CSI was
substituted for manual in-line stability during laryngos-
copy, 56% of cases had view improved by one grade,
and in 10% by two grades.42 Patients with CSI are at an
increased risk of aspiration from vomiting, and the
collar itself is thought to cause respiratory restriction,
especially when attached to a spinal board.5,43,44
Head injury/TBI
It is estimated that a quarter of patients with spinal
cord injury also have some form of concomitant trau-
matic brain injury.3,5 Over a third of trauma patients
suffer from head injuries and 27% of all trauma deaths
are due to head injuries.45–47 The management of trau-
matic brain injury involves mitigating raised intracra-
nial pressure (ICP) and several studies have shown that
CSI causes a raised ICP, potentially due to causing
venous outflow obstruction and the added pain
involved with CSI.13,48,49
Ankylosing spondylitis
In one Norwegian study, 5% of patient with cervical
spine fractures were found to have concomitant anky-
losing spondylitis.50 Because of these conditions, these
patients normally have their spine flexed with cervi-
cothoracic kyphosis; however, during immobilisation
or when preparing them for imaging, they are at risk
of having their cervical spine overextended. A 10-year
retrospective study of this patient group showed
that 80% (n ¼ 12) of patients with cervical spine frac-
tures and ankylosing spondylitis deteriorated
subsequently.45,51
Ulceration
Auckland et al. showed that ulceration secondary to
CSI is also a significant problem – with approximately
Phaily and Khan
10% of patient with CSI going on to develop cervical
collar-related decubitus ulceration; this effect is even
more pronounced in the elderly and patients admitted
ICU. Although ulceration is linked to the length of time
CSI is applied, ulcers have been shown to develop as
early as 48 h after application.29,44,47
Costs
The policy of CSI for trauma patients is not without its
cost. An increased awareness of selective CSI would not
only be cost effective but would also improve the effi-
ciency of emergency services and avoid delays to defini-
tive care; it would also reduce the burden due to CSI-
associated morbidity.52,53 As well as avoiding the
potentially unnecessary radiation exposure given to
patients to exclude injuries, a selective CSI approach
would also save on the costs involved in organising,
waiting for and reporting such imaging.36,40,54,55
Psychological impact
The application of spinal immobilisation to healthy vol-
unteers has been shown to cause discomfort and mod-
erate to severe pain.53 In trauma patients, CSI not only
causes added pain but also exacerbates the stress
response due to the psychological impact of immobil-
isation and the increased anxiety it brings.52 Up to a
third of patients report developing new psychiatric dis-
orders in the year following trauma. It is important to
consider the negative psychological effects of CSI and
the potential to aggravate the long-term psychiatric
sequelae following discharge.56
Recommendations
A selective approach to cervical spine control is recom-
mended with CSI reserved for those who have neuro-
logical deficits on pre-hospital assessment rather than
as a standard rule for all trauma patients. Furthermore,
guidelines such as ATLS and NICE regarding cervical
spine control should be updated considering recent
research. In ATLS, cervical spine control should be
de-emphasised or at the very least, not prioritised at
the expense of airway control, specifically in patients
at high risk of developing airway compromise.3 The
current NICE guidelines on spinal injury assessment
need to be made more specific, as real-life application
of its recommendation would result in the clear major-
ity of trauma patients being immobilised.8
To achieve a shift towards more selective CSI appli-
cation, a cultural change needs to take place in both
hospital and emergency services to move away from the
defensive medicine view of spinal immobilisation.
181
Training and new guidelines based on the growing
body of evidence showing the complications associated
with CSI will result in improved pre-hospital assess-
ment of high-risk patients. As a result, there should
be a reduction in the number of patients over-immobi-
lised and a reduction in the number of patients exposed
to the increased risks associated with CSI. In the pre-
hospital setting, emphasis must be placed on avoiding
delay in definitive care in trauma patients who are crit-
ically injured. Furthermore, patients presenting with
CSI must be promptly assessed and have CSI removed
as early as possible.
Future
The 2001 Cochrane review found that routine pre-hos-
pital immobilisation was of uncertain value due to lack
of demonstrated benefits, the complications associated
with its use and the possibility that it may contribute to
airway compromise.1 Ethical and practical concerns
prevent a RCT in this area; however, it remains a
high priority research area. Delayed or missed spinal
injuries involve a significant cost burden to both
patients and health services. Conversely, the routine
application of spinal immobilisation has wide ranging
effects on the mortality, morbidity and efficiency of
trauma management by emergency services. In view
of the lack of evidence for, and the multiple risks asso-
ciated with, its use, CSI should be abandoned in favour
of better pre-hospital clearance protocols and selective
spinal immobilisation using a scoop stretcher or
vacuum mattress. In addition, guidelines and algo-
rithms need to be updated to reflect this and put greater
emphasis on avoiding delays to definitive care.
Conclusion
The practice of routine CSI for trauma patients appears
to be outdated, ineffective and in some cases, results in
iatrogenic harm. Decades of clinical experience and the
tendency to practice defensive medicine have firmly
established spinal immobilisation as the cornerstone
of trauma management. However, this trend is not sup-
ported by robust scientific evidence.
It has been clearly shown that in cases of penetrating
spinal injuries, CSI is not only ineffective but is also
linked to an increased risk of mortality. Special consid-
erations must also be taken in patients who have
pre-existing spinal conditions, impending airway com-
promise, or at risk of aspiration and those with head
injuries or suspected traumatic brain injuries.
Acknowledgements
None.
182
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Ethical approval
NA.
Informed consent
None.
Trial Registration
NA.
Guarantor
AP.
Contributorship
AP researched literature, developed the research protocol and
data analysis. MK conceived the idea, provided guidance on
methodology and article scope. Both authors reviewed and
edited the manuscript and approved the final version of this
article.
Provenance
Not commissioned, externally peer reviewed.
References
1. Kwan I, Bunn F and Roberts IG. Spinal immobilisation
for trauma patients. The Cochrane Library. 2001.
2. Ala’a OO, Smith K, Stoelwinder JU, et al. Should sus-
pected cervical spinal cord injury be immobilised?: a sys-
tematic review. Injury 2015; 46: 528–535.
3. American College of Surgeons Committee on Trauma.
Advanced Trauma Life Support (ATLS) Student Course
Manual, 9th ed. Chicago, IL: American College of
Surgeons, 2012.
4. Petherbridge S and Khan M. The case against extrication
in motorsport: reforming the deployment method. Trauma
2016; 18: 272–275.
5. Sundstrøm T, Asbjørnsen H, Habiba S, et al. Prehospital
use of cervical collars in trauma patients: a critical review.
J Neurotrauma 2014; 31: 531–540.
6. Burney RE, Waggoner R and Maynard FM. Stabilization
of spinal injury for early transfer. J Trauma Acute Care
Surg 1989; 29: 1497–1499.
7. Theodore N, Hadley MN, Aarabi B, et al. Prehospital
cervical spinal immobilization after trauma. Neurosurgery
2013; 72(suppl_3): 22–34.
8. National Clinical Guideline Centre (UK). Spinal injury:
assessment and Initial Management. London: National
Trauma 21(3)
Institute for Health and Care Excellence (UK); NICE
Guideline, No. 41. 5, Guideline summary, www.ncbi.
nlm.nih.gov/books/NBK367851/ (2016, accessed 21 July
2017).
9. Stiell IG, Wells GA, Vandemheen KL, et al. The
Canadian C-spine rule for radiography in alert and
stable trauma patients. JAMA 2001; 286: 1841–1848.
10. Bulger EM and Maier RV. Prehospital care of the
injured: what’s new. Surg Clin 2007; 87: 37–53.
11. Vickery D. The use of the spinal board after the pre-
hospital phase of trauma management. Emerg Med J
2001; 18: 51–54.
12. Hankins DG, Rivera-Rivera EJ, Ornato JP, et al.
Spinal immobilization in the field: clinical clearance cri-
teria and implementation. Prehosp Emerg Care 2001; 5:
88–93.
13. Davies G, Deakin C and Wilson A. The effect of a
rigidcollar on intracranial pressure. Injury 1996; 27:
647–649.
14. Stroh G and Braude D. Can an out-of-hospital cervical
spine clearance protocol identify all patients with injuries?
An argument for selective immobilization. Ann Emerg
Med 2001; 37: 609–615.
15. Kang DG and Lehman RA Jr. Spine immobilization:
prehospitalization to final destination. J Surg Orthop
Adv 2011; 20: 2.
16. Benger J and Blackham J. Why do we put cervical collars
on conscious trauma patients? Scand J Trauma Resuscit
Emerg Med 2009; 17: 44.
17. Barkana Y, Stein M, Scope A, et al. Prehospital stabil-
ization of the cervical spine for penetrating injuries of the
neck – is it necessary? Injury 2000; 31: 305–309.
18. Haut ER, Kalish BT, Efron DT, et al. Spine immobiliza-
tion in penetrating trauma: more harm than good?
J Trauma Acute Care Surg 2010; 68: 115–121.
19. Connell RA, Graham CA and Munro PT. Is
spinal immobilisation necessary for all patients sustaining
isolated penetrating trauma? Injury 2003; 34: 912–914.
20. PubMed – NCBI. National Center for Biotechnology
Information. U.S. National Library of Medicine, www.
ncbi.nlm.nih.gov/pubmed/ (accessed 21 July 2017).
21. Google Scholar – Google, https://scholar.google.co.uk/
(accessed 21 July 2017).
22. Cochrane Database of Systematic Reviews. The
Cochrane Database of Systematic Reviews, www.cochra-
nelibrary.com/cochrane-database-of-systematic-reviews/
(accessed 21 July 2017).
23. Moher D, Liberati A, Tetzlaff J, et al.; Prisma Group.
Preferred reporting items for systematic reviews and
meta-analyses: the PRISMA statement. PLoS Med
2009; 6: e1000097.
24. Howick J, Chalmers I, Glasziou P, et al. Explanation of
the 2011 Oxford Centre for Evidence-Based Medicine
(OCEBM) levels of evidence (background document).
Oxford Center for Evidence-Based Medicine, www.
cebm.net/index.aspx (accessed 2011, 16 Sep 2016).
25. Hauswald M, Tandberg D and Omar Z. Out-of-hospital
spinal immobilization: its effect on neurologic injury.
Acad Emerg Med 1998; 5: 214–219.
Phaily and Khan
26. Vanderlan WB, Tew BE and McSwain NE. Increased risk
of death with cervical spine immobilisation in penetrating
cervical trauma. Injury 2009; 40: 880–883.
27. Turnock AR, Carney MJ, Fleischer BP, et al. Cervical
spine immobilization in penetrating cervical trauma is
associated with an increased risk of indirect central
neurological injury. Trauma Emerg Care 2016; 1: 3–8.
28. Brown JB, Bankey PE, Sangosanya AT, et al. Prehospital
spinal immobilization does not appear to be beneficial
and may complicate care following gunshot injury to
the torso. J Trauma Acute Care Surg 2009; 67: 774–778.
29. Ackland HM, Cooper JD, Malham GM, et al. Factors
predicting cervical collar-related decubitus ulceration in
major trauma patients. Spine 2007; 32: 423–428.
30. Lekovic GP and Harrington TR. Litigation of missed
cervical spine injuries in patients presenting with blunt
traumatic injury. Neurosurgery 2007; 60: 516–523.
31. McHugh TP and Taylor JP. Unnecessary out-of-hospital
use of full spinal immobilization. Acad Emerg Med 1998;
5: 278–280.
32. Brunette DD and Rockswold GL. Neurologic recovery
following rapid spinal realignment for complete cervical
spinal cord injury. J Trauma Acute Care Surg 1987; 27:
445–447.
33. McGuire RA Jr. Protection of the unstable spine during
transport and early hospitalization. J Mississippi State
Med Assoc 1991; 32: 305–308.
34. Waters RL, Meyer PR, Adkins RH, et al. Emergency,
acute, and surgical management of spine trauma. Arch
Phys Med Rehabil 1999; 80: 1383–1390.
35. Green BA, Eismont FJ and O’Heir JT. Spinal cord injury
– a systems approach: prevention, emergency medical ser-
vices, and emergency room management. Crit Care Clin
1987; 3: 471–493.
36. Hauswald M, Hsu M and Stockoff C. Maximising com-
fort and minimising ischaemia: a comparison of four
methods of spinal immobilization. Prehosp Emerg Care
2000; 4: 250–252.
37. Marshall LF, Knowlton S, Garfin SR, et al.
Deterioration following spinal cord injury: a multicenter
study. J Neurosurg 1987; 66: 400–404.
38. Huang YH, Yang TM, Lin WC, et al. The prognosis of
acute blunt cervical spinal cord injury. J Trauma Acute
Care Surg 2009; 66: 1441–1445.
39. Tator CH and Fehlings MG. Review of the second-
ary injury theory of acute spinal cord trauma with
emphasis on vascular mechanisms. J Neurosurg 1991;
75: 15–26.
40. March JA, Ausband SC and Brown LH. Changes in
physical examination caused by the use of spinal immo-
bilization. Prehosp Emerg Care 2002; 6: 421–424.
183
41. Aoi Y, Inagawa G, Nakamura K, et al. Airway scope
versus Macintosh laryngoscope in patients with simulated
limitation of neck movements. J Trauma Acute Care Surg
2010; 69: 838–842.
42. Heath KJ. The effect on laryngoscopy of different cer-
vical spine immobilization techniques. Anaesthesia 1994;
49: 843–845.
43. Totten VY and Sugarman DB. Respiratory effects of
spinal immobilization. Prehosp Emerg Care 1999; 3:
347–352.
44. Bauer D and Kowalski R. Effect of spinal immobilization
devices on pulmonary function in the healthy, nonsmok-
ing man. Ann Emerg Med 1988; 17: 915–918.
45. Abram S and Bulstrode C. Routine spinal immobilization
in trauma patients: what are the advantages and disad-
vantages? Surgeon 2010; 8: 218–222.
46. Gennarelli TA, Champion HR, Copes WS, et al.
Comparison of mortality, morbidity, and severity of
59,713 head injured patients with 114,447 patients with
extracranial injuries. J Trauma Acute Care Surg 1994; 37:
962–968.
47. Hodgson NF, Stewart TC and Girotti MJ. Autopsies and
death certification in deaths due to blunt trauma: what
are we missing? Can J Surg 2000; 43: 130.
48. Mobbs RJ, Stoodley MA and Fuller J. Effect of cervical
hard collar on intracranial pressure after head injury.
ANZ J Surg 2002; 72: 389–391.
49. Craig GR and Nielsen MS. Rigid cervical collars and
intracranial pressure. Intens Care Med 1991; 17: 504–505.
50. Fredø HL, Rizvi SA, Lied B, et al. The epidemiology of
traumatic cervical spine fractures: a prospective popula-
tion study from Norway. Scand J Trauma Resuscit Emerg
Med 2012; 20: 85.
51. Thumbikat P, Hariharan RP, Ravichandran G, et al.
Spinal cord injury in patients with ankylosing spondylitis:
a 10-year review. Spine 2007; 32: 2989–2995.
52. Chan D, Goldberg RM, Mason J, et al. Backboard versus
mattress splint immobilization: a comparison of symp-
toms generated. J Emerg Med 1996; 14: 293–298.
53. Chan D, Goldberg R, Tascone A, et al. The effect of
spinal immobilization on healthy volunteers. Ann Emerg
Med 1994; 23: 48–51.
54. Brown LH, Gough JE and Simonds WB. Can EMS pro-
viders adequately assess trauma patients for cervical
spinal injury? Prehosp Emerg Care 1998; 2: 33–36.
55. Leonard JC, Mao J and Jaffe DM. Potential adverse
effects of spinal immobilization in children. Prehosp
Emerg Care 2012; 16: 513–518.
56. Bryant RA, O’Donnell ML, Creamer M, et al. The psy-
chiatric sequelae of traumatic injury. Am J Psychiatry
2010; 167: 312–320.