Subject	Title	Author	Year	Type	Size	Design	Results	Ranking	Reviewer
Spinal Immobilization	Maximizing comfort and minimizing ischemia: a comparison of four methods of spinal immobilization	Hauswald M, Hsu M, Stockoff C	2000	Prospective comparative trial, non-blinded, convenience sample	22	Compared patient comfort among healthy volunteers lying upon backboards with different padding materials.	More padding was more comfortable.	2	BO
Spinal Immobilization	Out-of-hospital spinal immobilization: its effect on neurologic injury	Hauswald M, Ong G, Tandberg D, Omar Z	1998	Retrospective cohort study	454	Chart review comparing neurological outcome in blunt spinal trauma patients between an American system with prehospital spinal immobilization and a Malaysian system without immobilization.	Non-immobilized Malaysian patients had slightly but significantly better neurological outcomes.	5	BO
Spinal Immobilization	Spinal immobilisation for trauma patients (Review)	Kwan I, Bunn F, Roberts I	2001	Systematic review	4453	Cochrane review of randomized controlled trials comparing outcomes among spinal trauma patients after various types of immobilization	No qualifying studies were identified.	5	BO
Spinal Immobilization	Prospective analysis of acute cervical spine injury: a methodology to predict injury	Jacobs LM, Schwartz R	1986	Prospective cohort study, single-site	233	Studied head/neck trauma patients and compared the ability of physicians, radiographs, and specific clinical criteria to predict the presence of cervical spine injury	Physicians were specific but not sensitive at predicting injury; radiographs were sensitive but not specific; neurological criteria and falls over 10 feet were the only predictive signs.	3	BO
Spinal Immobilization	Cervical Spine Motion During Extrication: A Pilot Study	Shafer JS, Naunheim RS	2009	Prospective comparative trial, non-blinded, convenience sample	1	Used motion capture to compare C-spine movement while extricating a healthy volunteer from a car using four methods: self-extrication; self-extrication with C-collar; rapid extrication with C-collar; KED extrication with C-collar	Self-extrication with C-collar produced the least spinal movement; KED extrication with C-collar produced the most movement.	2	BO
Spinal Immobilization	Cervical Spine Motion During Extrication	Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS	2013	Prospective comparative trial, non-blinded, convenience sample	10	Expansion of Shafer 2009 pilot. Used motion capture to compare C-spine movement while extricating healthy volunteers using four methods: self-extrication; self-extrication with C-collar; rapid extrication with C-collar; KED extrication with C-collar	Similar to pilot study.	5	BO
Spinal Immobilization	Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group (NEXUS)	Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI	2000	Prospective cohort study, multi-site	34069	Studied blunt trauma patients and compared the ability of a five-part clinical decision rule to predict the presence of cervical spine injury. Rules: no midline cervical tenderness, focal neurological deficits, altered mental status, intoxication, or distracting injury.	2.4% had C-spine injury. For detecting clinically-significant C-spine injury, the algorithm's sensitivity was 99.6% and specificity was 12.9%; the negative predictive value was 99.9% and the positive predictive value was 1.9%.	5	BO
Spinal Immobilization	The cause of neurologic deterioration after acute cervical spinal cord injury	Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ	2001	Retrospective analysis	186	Chart review of patients with complete spinal cord injury to determine how many suffered delayed neurological deterioration after the initial trauma, and to examine the causes	6% of patients had neurological worsening within 30 days. None with penetrating inury worsened. 3% worsened within the first 24 hours, of which: only one worsened within 1 hour; none worsened in the prehospital period; many had ankylosing spondylitis; most worsened during application of immobilization devices.	4	BO
Spinal Immobilization	Distribution and patterns of blunt traumatic cervical spine injury	Goldberg W, Mueller C, Panacek E, Tigges S, Hoffman JR, Mower WR; NEXUS Group	2001	Prospective, descriptive observational study, multi-site	34069	Sub-study using NEXUS data; determined prevalence of C-spine injuries among blunt trauma patients and categorized them by significance, type, and location.	2.4% of patients had radiographic lesions; 68% of these were fractures, the remainder subluxations or dislocations. C2 was most often fractured. 70.7% of injuries were "clinically significant."	2	BO
Spinal Immobilization	Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature	Bohlman HH.	1979	Retrospective analysis	300	Chart review of patients with C-spine injuries, describing their types of injury, complications, management, and outcomes	Secondary deterioration often occurred during attempts at surgical or other stabilizing intervention. GI bleeds and PE were common complications. Ankylosing spondylitis was associated with poor outcomes.	1	BO
Spinal Immobilization	A re-conceptualisation of acute spinal care	Hauswald M	2012	Review article	23	Examines the theories behind the current standard of care for immobilization of acute spinal injury, including the biomechanical models, pathophysiology of injury, and more rational treatment options	Secondary injuries will rarely occur within the normal range of motion; they require force to be applied within abnormal spinal positions. Long boards are not rational for transport; a comfortable, high-friction surface should be used. Cervical collars may have some benefit but can also increase injury. Standing takedowns are irrational.	4	BO
Spinal Immobilization	The relevance of the occult cervical spine controversy and mechanism of injury to prehospital protocols: a review of the issues and literature	Butman AM, Schelble DT, Vomacka RW	1996	Systematic review	100	Reviews the available studies at time of publication ("nearly 100") investigating spinal injury and the role of prehospital immobilization.	Supports the modern standard of care, including immobilization based on mechanism, a cautious role for field clearance, and the efficacy of current techniques.	2	BO
Spinal Immobilization	Early management of the patient with trauma to the spinal cord.	Geisler WO, Wynne-Jones M, Jousse AT	1966	Retrospective analysis of convenience sample	958	Reviews spinal injury patients treated by the authors over 25 years, examining the prevalence of neurological deterioration, and outcomes after surgery.	3% of patients experienced no initial symptoms but later deteriorated neurologically, most after hospital admission. Surgical intervention offered little to no benefit in most patients.	2	BO
Spinal Immobilization	Neurologic recovery following rapid spinal realignment for complete cervical spinal cord injury.	Brunette DD, Rockswold GL.	1987	Case report	1	Discusses the case of an injured 17-yo male with complete paralysis after a C-spine fracture.	Near-complete recovery was demonstrated after careful immobilization and traction.	1	BO
Spinal Immobilization	Emergency transportation in the event of acute spinal cord lesion.	Hachen HJ.	1974	Report on local methods	0	Describes the development of an air ambulance service for transport of local spine injury patients in Switzerland.	Outcomes were reportedly improved after a critical care-type helicopter service was introduced. Scoop stretchers and vacuum mattresses were favored for patient movement.	1	BO
Spinal Immobilization	Overdistraction: a hazard of skull traction in the management of acute injuries of the cervical spine.	Jeanneret B, Magerl F, Ward JC.	1991	Case series	5	Describes cases where spinal traction after acute spinal fracture (then standard of care) resulted in neurological deterioration.	Recommends cautious application of traction, with no more than 2kg of traction in most cases.	1	BO
Spinal Immobilization	The unstable occult cervical spine fracture: a review.	Mace SE.	1992	Review article	62	Discusses the existence of patients without pain, tenderness, neurological symptoms, or obstacles to assessment (even without traumatic history), yet with radiological evidence of C-spine fracture.	Numerous cases without such clinical findings are described in the literature, although none that worsened during the prehospital phase.	4	BO
Spinal Immobilization	Occult cervical spine fracture in an ambulatory patient.	Bresler MJ, Rich GH.	1982	Case report	1	Describes a case of a conscious, ambulatory patient with no neck pain after significant trauma six hours earlier who was found on x-ray with a significant C4 fracture	Typical report of delayed diagnosis of C-spine fracture. Pt presented for wrist pain only; no neurological deficits were noted except slight reflex abnormalities. She was managed invasively and did well.	1	BO
Spinal Immobilization	Occult cervical spine fractures--a misstated concept.	Holliman CJ, Wuerz RC.	1992	Correspondence	0	Response to Mace 1992	Describes various errors and flaws in the Mace review, and notes that almost none of the cited cases of "occult" injury meet reasonable NEXUS-type criteria	2	BO
Spinal Immobilization	Asymptomatic cervical injuries: a myth?	Gatrell CB.	1985	Correspondence	0	Response to various reports of occult spinal injury	Notes that in nearly all reported cases, NEXUS-type rule-outs are present (pain, confounders, etc). The authors from one such study respond.	2	BO
Spinal Immobilization	Asymptomatic occult cervical spine fracture: case report and review of the literature.	McKee TR, Tinkoff G, Rhodes M.	1990	Case report	1	Describes a case of an elderly man s/p MVA who had no complaints of neck pain, confounding factors, or neurological deficits, yet was found upon imaging with a C2 fracture.	He was managed conservatively and did well; he never noted any neurological deficits and the injury remained asymptomatic.	1	BO
Spinal Immobilization	Cervical Spine Injury: An Evidence-Based Evaluation Of The Patient With Blunt Cervical Trauma. (EBMedicine)	Grossheim LF, Polglaze K, Smith R	2009	Systematic review	250	Reviews all available literature pertaining to ED care of blunt cervical trauma, including clinical and radiographic clearance.	Recommends various roles for clinical clearance (expanded NEXUS-type criteria), plain radiographs, CT, and MRI.	5	BO
Spinal Immobilization	Characteristics of injuries to the cervical spine and spinal cord in polytrauma patient population: experience from a regional trauma unit.	Prasad VS, Schwartz A, Bhutani R, Sharkey PW, Schwartz ML.	1999	Retrospective analysis, single-site	468	Chart review of C-spine injuries at a Canadian trauma center. Correlates mechanism, age, gender, and type/severity of injury.	27% of C-spine injuries produced injury to the cord. Injury to the lower C-spine caused more neurological harm. Backseat MVA occupants suffered more neurological harm than front occupants.	3	BO
Spinal Immobilization	Neurologic deterioration secondary to unrecognized spinal instability following trauma -- a multicenter study.	Levi AD, Hurlbert RJ, Anderson P, Fehlings M, Rampersaud R, Massicotte EM, France JC, Le Huec JC, Hedlund R, Arnold P.	2006	Retrospective analysis of convenience sample	24	Senior spine surgeons were asked to remember examples of patients who received "spinal clearance" yet suffered later neurological deterioration; 24 cases were presented (.21% of all spine patients, .025% of all trauma).	3 died; 3 were paralyzed; others had partial loss or radiculopathy. MVA was most common mechanism. Ankylosing spondylitis was high-risk. Average delay to secondary presentation was 20 days. Many had distracting injuries. Insufficient imaging was most common cause of missed diagnosis.	4	BO
Spinal Immobilization	Prevention of neurological deterioration before admission to a spinal cord injury unit.	Toscano J	1988	Prospective, descriptive observational study, single-site.	123	Spinal cord injury patients at a regional spine center during a 2-yr period were enrolled. Author interviewed ambulance staff, witnesses, patient, hospital staff, examined charts, to determine whether their neurological status worsened between initial injury and specialty admission.	28% deteriorated during EMS care; spine injury was "not suspected" by EMS in most cases and adequate immobilization not provided. Author attributes all cases of deterioration to mishandling. No literature cited.	4	BO
Spinal Immobilization	Cervical spine injury: analysis and comparison of patients by mode of transportation.	Urdaneta AE, Stroh G, Teng J, Snowden B, Barrett TW, Hendey GW.	2013	Retrospective cohort study, multi-site	718	Chart review of C-spine injuries arriving at three hospitals. Compared those who arrived by EMS vs. those who self-presented and examined their injury patterns.	93% arrived by EMS and were usually MVAs. 7% self-presented and were usually falls or sport injuries. EMS patients were less often triaged to low-acuity areas. Both groups had the same rate of neurological compromise; EMS had more "unstable" injuries, but self-presenters still were 30% unstable.	2	BO
Spinal Immobilization	Exclusion of cervical spine injury: a prospective study.	Cohn SM, Lyle WG, Linden CH, Lancey RA.	1991	Retrospective and prospective analysis, single-site	135	Chart review (retrospective and then prospective) of consecutive blunt trauma patients in a single center, examining their rate of C-spine injury, how this was diagnosed, and effect on airway management.	11-12% had C-spine injury. Most underwent intubation or operation prior to clearance without apparent neurological harm. Mean time to spinal clearance was 6-15 hours (many over 24 hours).	3	BO
Spinal Immobilization	The etiology of missed cervical spine injuries.	Davis JW, Phreaner DL, Hoyt DB, Mackersie RC.	1993	Retrospective analysis, multi-site	740	Chart review of C-spine injuries in six trauma hospitals, examining the rate at which diagnosis of their C-spine injury was missed or delayed, the cause of delay, and resulting sequelae	2.3% of trauma patients had C-spine injury. 4.6% of these had a delayed/missed diagnosis (<1 day to 30 days). 29% of these suffered complications (including paralysis and death). Inadequate imaging was the common cause.	2	BO
Spinal Immobilization	The Canadian C-spine rule for radiography in alert and stable trauma patients.	Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J.	2001	Prospective cohort study, multi-site	12782	10 Canadian hospitals enrolled consecutive stable, alert adult patients with blunt head or neck trauma. A standard clinical exam was performed and the findings correlated with eventual diagnosis of "important" C-spine injury.	1.7% of patients had significant C-spine injury. Predictive value of numerous clinical and mechanism factors were evaluated; a three-part decision rule was derived with 100% sensitivity and 42.5% specificity for important C-spine injury.	5	BO
Spinal Immobilization	The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.	Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G, Reardon M, Holroyd B, Lesiuk H, Wells GA.	2003	Prospective cohort study, multi-site	8283	Nine Canadian tertiary hospitals conducted a validation study identical to the Stiell 2001 derivation, except they included both the derived Canadian C-spine criteria and the NEXUS criteria, and compared their relative predictive values for significant C-spine fracture.	2% of patients had significant C-spine injury. The Canadian criteria were 99.4% sensitive and 45.1% specific for significant C-spine injury. The NEXUS criteria were 90.7% sensitive and 36.8% specific. Some physicians did not apply the head-rotation criteria from the Canadian rule.	3	BO
Spinal Immobilization	Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial.	Stiell IG, Clement CM, Grimshaw J, Brison RJ, Rowe BH, Schull MJ, Lee JS, Brehaut J, McKnight RD, Eisenhauer MA, Dreyer J, Letovsky E, Rutledge T, MacPhail I, Ross S, Shah A, Perry JJ, Holroyd BR, Ip U, Lesiuk H, Wells GA.	2009	Prospective comparative trial, non-blinded, multi-site.	11824	Twelve Canadian hospitals were matched into six similar pairs, each with an intervention and control center. Intervention centers were trained to use the Canadian C-spine rule to reduce radiography. Data was recorded for 12 months before and after adoption of the rule.	The Canadian rule had sensitivity of 100% Radiography was reduced by 12.8% in the intervention sites and increased by 12.5% at the control sites. These trends continued after the termination of the intervention period.	2	BO
Spinal Immobilization	The out-of-hospital validation of the Canadian C-Spine Rule by paramedics.	Vaillancourt C, Stiell IG, Beaudoin T, Maloney J, Anton AR, Bradford P, Cain E, Travers A, Stempien M, Lees M, Munkley D, Battram E, Banek J, Wells GA.	2009	Prospective cohort study, multi-site	1949	Three Canadian EMS systems were trained (2-hour web session) to use a modified version of the Canadian C-spine rule (no "delayed pain" criterion) on eligible patients with potential blunt neck injury. Their predictive accuracy was evaluated against the eventual diagnosis.	.6% of patients had significant C-spine injury. Paramedics using the rule were 100% sensitive and 37.7% specific for detecting it. They conservatively misinterpreted it in 16.4% of cases. 37.7% (731 patients) of immobilizations could have been prevented using the rule. Interobserver kappa was .93.	5	BO
Spinal Immobilization	Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department.	Stiell IG, Clement CM, O'Connor A, Davies B, Leclair C, Sheehan P, Clavet T, Beland C, MacKenzie T, Wells GA.	2010	Prospective cohort study, multi-site	3633	Six Canadian hospitals trained 191 ED triage nurses (2 hours each) to implement the Canadian C-spine rule. They applied it to eligible patients in triage with potential blunt neck injury, and their predictive accuracy was evaluated against the eventual diagnosis.	1.2% of patients had significant C-spine injury. Triage nurses using the rule were 90.2% sensitive and 43.9% specific for detecting it. Four injuries were missed with no resulting harm, and after retraining there were no further misses. Interobserver kappa was .78.	3	BO
Spinal Immobilization	Prospective Performance Assessment of an Out-of-Hospital Protocol for Selective Spine Immobilization Using Clinical Spine Clearance Criteria.	Domeier RM, Frederiksen SM, Welch K.	2005	Prospective cohort study, multi-site	13357	First responders in two counties were trained to use a modified NEXUS criteria for spinal immobilization. Data was collected over four years and their predictive success for significant C-spine injury was evaluated.	3% of patients had spine injury; .37% had cord injury. First responders were 92% sensitive and 40% specific for detecting significant C-spine injury. 33 injuries were missed, none with compromise to the cord. 39% fewer patients were immobilized under the protocol.	4	BO
Spinal Immobilization	Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments.	Dickinson G, Stiell IG, Schull M, Brison R, Clement CM, Vandemheen KL, Cass D, McKnight D, Greenberg G, Worthington JR, Reardon M, Morrison L, Eisenhauer MA, Dreyer J, Wells GA.	2004	Secondary retrospective analysis of prospective data set	8924	Data from the original Canadian C-spine derivation study (Stiell 2001) was reanalyzed retrospectively to determine the predictive value of the NEXUS criteria (all captured in the initial dataset) in that patient population.	The NEXUS criteria predicted significant C-spine injury with sensitivity 92.7% and specificity 37.8%. There were 11 misses, none with resulting negative outcomes. Applying the criteria clinically could have reduced radiography by 68.9% to 62.8%.	2	BO
Spinal Immobilization	Pain and tissue-interface pressures during spine-board immobilization.	Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR.	1995	Prospective crossover trial, non-blinded, convenience sample	12	Healthy volunteers alternated lying upon wooden backboards and wooden backboards with EHOB commercial foam overlay for 80 minutes each, with a break between. They rated relative and absolute pain, and pressure was measured at their occiput, sacrum, and heels.	Lying upon the mattress was less painful at all times, and produced less pressure at all areas, than lying upon the bare backboards.	2	BO
Spinal Immobilization	Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review.	Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW.	2012	Meta-analysis	15	Reviewed all available literature involving the NEXUS and Canadian C-spine criteria, graded their quality, and extracted data on their demonstrated sensitivity and specificity.	The Canadian C-spine rule had sensitivity from 90% to 100% (median LR+ 1.69) and specificity from 1% to 77% (median LR- .18). The NEXUS rule had sensitivity from 83% to 100% (median LR+ 1.44) and specificity from 2% to 46% (median LR- .30). In the only direct comparison, the Canadian rule was superior.	4	BO
Spinal Immobilization	Unintentional strangulation by a cervical collar after attempted suicide by hanging.	Lemyze M, Palud A, Favory R, Mathieu D.	2011	Case report	1	Describes a patient who survived attempted hanging, was immobilized by C-collar, but continued to deteriorate neurologically after admission.	Most short-fall hangings cause death by impeding cerebral venous return. CT showed cerebral edema and no C-spine injury; after removal of the C-collar the patient improved rapidly.	2	BO
Spinal Immobilization	Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization.	Stroh G, Braude D.	2001	Case-control study	504	Chart review of patients with diagnosis of C-spine injury from five hospitals over a six-year period. Those who arrived by EMS were reviewed to determine whether they were immobilized prehospitally, and if the EMS service's modified NEXUS criteria successfully predicted their injury.	1.8% (9) patients were not immobilized. .8% (4) could not be immobilized due to refusal, agitation, or kyphosis. .4% (2) were inappropriately not immobilized. .6% (3) were missed by the criteria (all young or old). 2 patients had long-term neurological deficits. The criteria was 99% sensitive for detecting injury.	3	BO
Spinal Immobilization	Does applying the Canadian Cervical Spine rule reduce cervical spine radiography rates in alert patients with blunt trauma to the neck? A retrospective analysis.	Rethnam U, Yesupalan R, Gandham G.	2008	Retrospective cohort study	114	Chart review of patients from two UK hospitals. Adult patients with C-spine radiography for suspected injury were examined to determine whether the Canadian C-spine rule would have eliminated the need for imaging.	Only 10% (12) patients had all aspects of the rule applied, including 45-degree rotation. Not including this, 75% (86) patients ruled-in as low-risk and might have foregone radiography. 1.7% (2) patients had significant injury and would have been detected by the rule.	1	BO
Spinal Immobilization	Vertebral artery injury after acute cervical spine trauma: rate of occurrence as detected by MR angiography and assessment of clinical consequences.	Friedman D, Flanders A, Thomas C, Millar W.	1995	Prospective cohort study, single-site.	37	C-spine injured patients at a spinal cord center who underwent MRI were evaluated using MR angiograms to determine the prevalence of vertebral artery injury. Normal control subjects were also evaluated.	24% (9) patients had arterial occlusion or narrowing. 2.7% (1) patient had a stroke from vertebral artery occlusion and died. The rest had no neurological deficit.	2	BO
Spinal Immobilization	Pre-hospital Management of Spinal Cord Injuries.	Green BA, Eismont FJ, O'Heir JT.	1987	Review article	10	Reviews the historical practice of prehospital care for spinal injury in the US and makes recommendations for current standard-of-care.	Recommends the use of scoop stretchers to move patients to backboards; gentle manual traction; and other typical measures. Asserts that the incidence of partial (versus total) spinal cord injury has increased from the 1970s into the 1980s due to training of first responders.	1	BO
Spinal Immobilization	Neurologic complications following immobilization of cervical spine fracture in a patient with ankylosing spondylitis.	Podolsky SM, Hoffman JR, Pietrafesa CA.	1983	Case report	1	Describes an 80-year-old female with ankylosing spondylitis who fell and complained of neck pain without neurological deficit, yet suffered neurological deterioration upon all attempts to stabilize her spine or apply traction in a neutral position.	The patient had a C5-C6 fracture and eventually died.	2	BO
Spinal Immobilization	Traumatic Paraplegia and Tetraplegia in Ankylosing Spondylitis.	Guttmann L	1966	Case series	7	Presents seven patients with ankylosing spondylitis who suffered traumatic spinal injuries.	Many of the injuries were at lower vertebral levels (thoracic, lumbar). Many suffered catastrophic outcomes from relatively minor mechanisms of injury.	2	BO
Spinal Immobilization	Fractures and dislocations of the spine complicating ankylosing spondylitis: A report of six cases.	Grisolia A, Bell RL, Peltier LF	1967	Case series	6	Describes the cases of six patients with ankylosing spondylitis and traumatic spinal fractures.	Of the six ankylosing spondylitis patients admitted for spinal injury, 83% (5) had neurological deficit and 50% (3) had complete transection and severe instability.	2	BO
Spinal Immobilization	Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficiency and communication.	Vandemark RM.	1990	Review article	0	Discusses clinical challenges and the practical application of existing evidence surrounding spinal immobilization and clearance in the ED.	Recommends risk-stratification of potential C-spine trauma patients with a scaled approach to imaging. Suggests that plain films are not 100% sensitive. Recommends clear communication between providers, particularly radiologists and ED physicians, when referring to spinal "clearance."	1	BO
Spinal Immobilization	Cervical radiographic evaluation of alert patients following blunt trauma.	Fischer RP.	1984	Prospective cohort study, single-site.	333	Consecutive, alert blunt head trauma patients who could respond to questions and commands were enrolled; their eventual diagnosis was later evaluated.	1.5% had cervical fracture, and all had cervical pain/tenderness. None had neuro findings, but .9% of non-injured patients did have neuro findings. 79% had LOC. 32% were drinking. 19% had other major injury. 13% had skull fracture. 2.4% had intracranial injury (depressed skull fx, subdural or epidural hematoma).	3	BO
Spinal Immobilization	Post-traumatic neck pain: a prospective and follow-up study.	McNamara RM, O'Brien MC, Davidheiser S.	1988	Prospective cohort study, multi-site	351	Alert patients with neck pain after trauma who could provide a reliable history completed a questionnaire in the ED and were followed through and after discharge to determine their outcome.	2% had C-spine fracture or ligamentous injury. Immediate onset of pain, midline cervical tenderness, and limited range-of-motion were all 100% sensitive for injury. 43% had persistent pain/neuro symptoms. Many sought further care after discharge. 66% were pursuing litigation.	4	BO
Spinal Immobilization	Delayed diagnosis of cervical spine injuries.	Gerrelts BD, Petersen EU, Mabry J, Petersen SR.	1991	Retrospective cohort study, single-site	1331	All patients with "severe blunt injury" and spinal imaging were reviewed to identify those whose diagnosis of C-spine injury was delayed, and determine the clinical consequences.	5.6% of patients had C-spine injury. 18% of them died. 30% of the remainder had neuro deficits, 16% with complete transection. 8.2% had diagnosis delay 2+ days; none of them had long-term deficit.	3	BO
Spinal Immobilization	Etiology and clinical course of missed spine fractures.	Reid DC, Henderson R, Saboe L, Miller JD.	1987	Prospective cohort study, single-site	253	Assessed consecutive "spinal trauma" patients at a tertiary center and followed to identify those who were later diagnosed with spinal injury after discharge.	15% of patients had a delay in diagnosis of fx, many with intoxication, multiple fractures, other major trauma, head injury or LOC. Delayed diagnoses had the same overall incidence of neurological deficit as early diagnosis, but had 9.1% greater chance of worsening in the interim.	3	BO
Spinal Immobilization	Delayed sequelae of vertebral artery dissection and occult cervical fractures.	Tulyapronchote R, Selhorst JB, Malkoff MD, Gomez CR.	1994	Case series	3	Describes three patients who suffered delayed neurological sequelae after C-spine trauma.	All cases demonstrated occlusion or injury to vertebral arteries, even when spinal injury was not initially diagnosed.	1	BO
Spinal Immobilization	Multicenter prospective validation of prehospital clinical spinal clearance criteria.	Domeier RM, Swor RA, Evans RW, Hancock JB, Fales W, Krohmer J, Frederiksen SM, Rivera-Rivera EJ, Schork MA.	2002	Prospective cohort study, multi-site	8975	EMS providers performed and documented a modified NEXUS exam in trauma patients who underwent prehospital spinal immobilization. The criteria were later evaluated for their predictive value for a diagnosis of spinal injury (by radiography or by follow-up after discharge).	3.3% of patients had spinal injury. .66% had cord injury. The criteria were 95% sensitive and 35% specific for injury, with 4.7% PPV and 99.5% NPV. Fifteen injuries were missed; none had neurological sequelae. Clinical application of the criteria could have reduced immobilization by 35%.	5	BO
Spinal Immobilization	Clinical prediction of cervical spine injuries in children. Radiographic abnormalities.	Rachesky I, Boyce WT, Duncan B, Bjelland J, Sibley B.	1987	Retrospective analysis, multi-site.	2133	Chart review of pediatric patients (<18) who underwent C-spine radiography for trauma at two tertiary centers. Clinical findings were evaluated to determine the most predictive criteria for a diagnosis of C-spine injury.	1.2% had C-spine injury. A criteria combining "history of neck pain" and/or "vehicular accident with head trauma" was 100% sensitive and 68% specific for injury, and would have reduced imaging by 32%.	3	BO
Spinal Immobilization	Risk factors for early occurring pressure ulcers following spinal cord injury.	Mawson AR, Biundo JJ Jr, Neville P, Linares HA, Winchester Y, Lopez A.	1988	Prospective cohort study, single-site	39	Consecutive patients with traumatic spinal cord injury and neuro deficit were interviewed and examined after admission to correlate the later development of pressure ulcers with their duration of spinal immobilization.	59% developed pressure ulcers within 30 days, most within the first four days. Those with ulcers within 8 days were immobilized significantly longer; those with ulcers within 30 days were immobilized insignificantly longer.	4	BO
Spinal Immobilization	Incidence of cervical spine injuries in association with blunt head trauma.	Bayless P, Ray VG.	1989	Retrospective analysis, single-site.	176	Chart review of all adult patients presenting to a trauma center with significant blunt head trauma, evaluating the prevalence of resulting cervical spine injury.	1.7% of patients had cervical spine injury. All had either neck pain or were uncooperative; none had neuro deficit.	3	BO
Spinal Immobilization	Cervical injury in head trauma.	Neifeld GL, Keene JG, Hevesy G, Leikin J, Proust A, Thisted RA.	1988	Prospective cohort study, multi-site.	856	Adult patients with blunt head/neck trauma warranting radiography at four trauma centers underwent a standard history and exam to determine incidence of C-spine injury.	3.16% of patients had C-spine injury. Those who were altered, had neuro deficits or distracting injury were 5.1% likely to have injury. The remainder were 1.5% likely, and all had midline neck tenderness; none had lateral or no neck pain.	4	BO
Spinal Immobilization	Injuries to the cervical spine causing vertebral artery trauma: case reports.	Schwarz N, Buchinger W, Gaudernak T, Russe F, Zechner W.	1991	Case series	4	Describes four cases of vertebral artery insufficiency caused by blunt C-spine trauma.	Most cases involved vertebral dislocations producing neurological signs which resolved after stabilization. One patient died from vertebral artery embolism during surgical intervention.	2	BO
Spinal Immobilization	Assessing multiple trauma: is the cervical spine enough?	Pal JM, Mulder DS, Brown RA, Fleiszer DM.	1988	Retrospective analysis, single-site	371	Review of trauma registry at single trauma center. Multiple injury or severe burn patients with spinal injury were identified and analyzed for case details.	17% of the cohort had spinal injury, of which 27% were cervical (24% of which had neuro deficit), 27% thoracic (15% with deficit), 38% lumbosacral (30% with deficit), and 8% multiple. Deficits from one cervical injury worsened in-hospital, and improved after one thoracic injury. Most cord injuries were complete. (Author Q&A included.)	4	BO
Spinal Immobilization	Cervical spine clearance: a review.	Richards PJ.	2005	Review article	221	Extensively reviews existing literature on acute spinal injury care, focusing on early hospital management and clearance by clinical means and imaging.	Presents various recommendations, particularly for high suspicion and high reliance on CT, with deemphasis on the role of flexion/extension films.	2	BO
Spinal Immobilization	Cervical collars are insufficient for immobilizing an unstable cervical spine injury.	Horodyski M, DiPaola CP, Conrad BP, Rechtine GR 2nd.	2011	Prospective comparative trial	5	Lightly embalmed cadavers were manipulated using cranial tongs and monitored using motion capture. Motion and resistance were measured: with and without two types of collars; before and after instability was produced below C5.	Neither collar significantly limited spinal movement in either intact or unstable cadavers.	3	BO
Spinal Immobilization	Caring for the patients with cervical spine injuries: what have we learned?	Ghafoor AU, Martin TW, Gopalakrishnan S, Viswamitra S.	2005	Systematic review	70	Reviews literature and makes recommendations for early management of patients with suspected C-spine injury, focusing on airway interventions.	Recommends high suspicion and the use of Macintosh or Bullard laryngoscopes.	2	BO
Spinal Immobilization	Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria (NEXUS) for C-spine radiography in young trauma patients.	Ehrlich PF, Wee C, Drongowski R, Rana AR.	2009	Retrospective cohort study, single-site	275	Chart review of all patients <10 years at a pediatric trauma center to determine the predictive value of NEXUS vs. Canadian C-spine criteria for C-spine injury.	2.5% had significant C-spine injury. In patients who underwent radiography, NEXUS would have been 43% sensitive and 96% specific; CCR would have been 86% sensitive and 94% specific. (Each could have been applied in only ~86% of cases.) In non-imaged patients, there were no injuries, but NEXUS identified 8 and CCR identified 13.	4	BO
Spinal Immobilization	Backboard versus mattress splint immobilization: a comparison of symptoms generated.	Chan D, Goldberg RM, Mason J, Chan L.	1996	Prospective crossover trial, non-blinded, convenience sample	37	Healthy volunteers age 17-49 were either immobilized in the usual manner on longboards or upon vacuum splints for 30 minutes, then described their pain. Two weeks later the groups were reversed.	Patients were ~3 times as likely to complain of pain after longboard immobilization, especially at the occiput or lumbosacrum.	2	BO
Spinal Immobilization	The effect of spinal immobilization on healthy volunteers.	Chan D, Goldberg R, Tascone A, Harmon S, Chan L.	1994	Prospective comparative trial, non-blinded, convenience sample	21	Healthy volunteers age 10-43 were fully immobilized by medics and laid on boards for 30 minutes, then asked to describe pain or other simptoms, immediately and after 48 hours.	100% of patients developed immediate symptoms, 55% moderate to severe; 29% had symptoms at 48 hours.	3	BO
Spinal Immobilization	Are scoop stretchers suitable for use on spine-injured patients?	Del Rossi G, Rechtine GR, Conrad BP, Horodyski M.	2010	Prospective comparative trial, non-blinded	5	Global instability was surgically induced below C5 in five lightly-embalmed cadavers. Sensors on C5 and C6 monitored intervertebral movement while log-rolling onto a spineboard, lifting onto a spineboard, or use of a scoop stretcher.	The scoop stretcher produced insignificantly less spinal movement than the two spineboard methods.	3	BO
Spinal Immobilization	Airway management in adults after cervical spine trauma.	Crosby ET.	2006	Review article	143	Extensively and comprehensively examines the literature surrounding various aspects of early management after spinal injury, with a focus on the effects of airway management on C-spine immobilization.	Reviews numerous options for management, but suggests that evidence in most cases is lacking.	4	BO
Spinal Immobilization	Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study.	Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M.	1992	Prospective cohort study, single-site	974	Blunt trauma patients undergoing radiography at a trauma center had data forms completed by the treating staff describing various clinical features. Their predictive value was correlated against final diagnosis of spinal fracture.	2.7% had C-spine injury. No single factor was highly predictive, but a NEXUS-type combination was effective. The presence of "whiplash"-type injury had excellent NPV; neck pain (not tenderness) had poor PPV. Pretest clinical judgment had excellent NPV.	4	BO
Spinal Immobilization	Deterioration following spinal cord injury. A multicenter study.	Marshall LF, Knowlton S, Garfin SR, Klauber MR, Eisenberg HM, Kopaniky D, Miner ME, Tabbador K, Clifton GL.	1987	Retrospective analysis of prospective dataset	283	Data from a spinal registry was analyzed to extract consecutive spinal cord-injured patients admitted to five trauma centers, and analyzed to isolate cases of neurological deterioration after admission.	4.9% deteriorated, almost all during an intervention (traction, halo vest application, etc).	2	BO
Spinal Immobilization	Ascending cord lesion in the early stages following spinal injury.	Frankel HL.	1969	Case series	7	Describes patients who suffered spinal injury with neurological deficit, and over the course of days experienced gradually ascending paralysis.	Initial injuries were all thoracic, and some ascended as high as C7. Worsening was from 2 to 18 days post-injury. Many had fever. Edema, hematoma, and other causes were suspected. (Discussion included.)	1	BO
Spinal Immobilization	Neurologic deterioration after cervical spinal cord injury.	Farmer J, Vaccaro A, Albert TJ, Malone S, Balderston RA, Cotler JM.	1998	Retrospective analysis, single-site	19	Chart review of C-spine cord injuries to investigate the traits of those that suffered delayed neurological deterioration.	1.8% of all C-spine cord injuries deteriorated. Average delay until deterioration was ~4 days. Most injuries were at C5-C6. Ankylosing spondylitis, vertebral artery injury, and sepsis were high-risk.	3	BO
Spinal Immobilization	Missed and mismanaged injuries of the spinal cord.	Poonnoose PM, Ravichandran G, McClelland MR.	2002	Retrospective analysis, single-site	569	Chart review of spinal cord injury patients to isolate those whose care was affected by a delay in recognition and diagnosis of their injury.	9.1% of patients had a delay in diagnosis, and 58% of those had resulting inappropriate/negligent care. Authors attribute further deterioration to mismanagement in 50% of cases. Inadequate imaging, altered mental status, and ankylosing spondylitis were often involved.	2	BO
Spinal Immobilization	Guidelines for the management of acute cervical spine and spinal cord injuries.	Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC, Mielke DH. (Am. Assoc. Neuro Surgeons, Congress of Neuro Surgeons)	2002	Systematic review	832	Comprehensive review of existing literature (over 800 studies) involving all aspects of acute care for spinal injury	Finds no high-quality evidence for most questions of care, but recommends general adherence to current standard of care, including prehospital immobilization with collar and board, which should be removed as soon as possible.	5	BO
Spinal Immobilization	EMS Spinal Precautions and the Use of the Long Backboard.	National Association of EMS Physicians (NAEMSP) and American College of Surgeons Committee on Trauma (ACS-COT)	2013	Position statement	0	Position statement on the topic of spinal immobilization by the NAEMSP and ACS-COT. No evidence or justifications included.	Notes dearth of evidence for prehospital immobilization, but recommends its use in NEXUS-positive patients. Suggests low-risk patients can wear a C-collar and sit upon a stretcher, and that all patients should be removed from backboards ASAP.	4	BO
Spinal Immobilization	New focus on spinal cord injury.	Gunby I.	1981	News piece	0	News piece interviewing Paul R. Meyer, Jr of the Midwest Regional Spinal Cord Injury Care System, describing recent developments in acute spinal care and their effects on patient outcomes.	Quotes Dr. Meyer stating that in 1979, 55% of cord injuries at their center were complete, which declined to 39% in 1981. Other sources corroborate, and attribute the decrease to prehospital interventions.	3	BO
Spinal Immobilization	Why do we put cervical collars on conscious trauma patients?	Benger J, Blackham J.	2009	Review article	22	Opinion piece on the currently widespread practice of prophylactically immobilizing conscious patients after potential spinal trauma.	Notes that no evidence has demonstrated a benefit from any spinal immobilization, secondary deterioration is usually an inevitable, gradual edematous/hemorrhagic process, and collars/boards cause some harm; suggests conscious patients can adequately limit their own movements.	2	BO
Spinal Immobilization	Care of the multiply injured patient with cervical spine injury.	1989	1989	Review article	58	Reviews literature and makes recommendations for early management of patients with C-spine injury and other significant trauma.	Offers typical standard-of-care recommendations, including early immobilization and imaging. Suggests EMS immobilization has lead to a decrease in complete cord injury since its adoption.	2	BO
Spinal Immobilization	Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck trauma.	Ramasamy A, Midwinter M, Mahoney P, Clasper J.	2009	Retrospective analysis, multi-site	90	Chart review of UK military casualties from Middle East theater who sustained penetrating neck trauma, investigating their incidence of C-spine injury.	22% had C-spine injury; none of the remainder had AMS or neuro deficit. Of those with C-spine injury, 90% died and 80% had cord injury; of those who survived to admission, all had AMS or neuro deficit, 66% eventually died, of which 75% had unstable spines, and survivors all had stable injuries.	4	BO
Spinal Immobilization	Spine immobilization in penetrating trauma: more harm than good?	Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC.	2010	Retrospective cohort study, multi-site	45284	Data mine from US trauma registry (NTDB), investigating patients with isolated penetrating trauma, and comparing outcomes among those with spinal immobilization vs. without. Patients matched by injury severity and other variables.	Immobilized patients were more seriously injured, but after adjusting for confounders, were still twice as likely to die (OR 2.06). This was consistent across all subgroups, although insignificant for stab wounds. .01% had incomplete, unstable spine injury. NNT for spine preservation was therefore 1,032; NNH for mortality was 66.	5	BO
Spinal Immobilization	Thoracolumbar immobilization for trauma patients with torso gunshot wounds: is it necessary?	Cornwell EE 3rd, Chang DC, Bonar JP, Campbell KA, Phillips J, Lipsett P, Scalea T, Bass R.	2001	Retrospective cohort study, multi-site	1000	Data mine from Maryland trauma registry investigating patients with penetrating torso gunshot injuries to determine their incidence of spinal trauma and mortality.	14.1% had spinal injury. Of those, 52% had complete neuro deficits (none with unstable spines), 41% had incomplete or no deficit, and only 1.4% (.2% of total) were operatively stabilized.	3	BO
Spinal Immobilization	Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma?	Connell RA, Graham CA, Munro PT.	2003	Retrospective analysis, multi-site.	1929	Data mine of Scotland trauma registry (STAG) investigating patients with isolated penetrating trauma to determine incidence and type of spinal injury.	.62% had significant spinal cord injury from penetrating trauma, most from sharp weapons. About half were complete. All were immobilized, and all were either in traumatic arrest or had clinically obvious neuro deficit.	4	BO
Spinal Immobilization	Prehospital stabilization of the cervical spine for penetrating injuries of the neck - is it necessary?	Barkana Y, Stein M, Scope A, Maor R, Abramovich Y, Friedman Z, Knoller N.	2000	Retrospective analysis, single-site.	44	Chart review of Israeli military casualties, all immobilized, who suffered penetrating neck trauma; investigated the incidence of unstable spinal injuries.	22% of survivors had neck hematoma or subcutaneous emphysema hidden by the C-collar. None needed surgical stabilization and only one needed traction. All patients either died or suffered immediate total transection; none were thought to benefit from prehospital immobilization. Most injuries were from projectiles.	2	BO
Spinal Immobilization	Stability of cervical spine fractures after gunshot wounds to the head and neck.	Medzon R, Rothenhaus T, Bono CM, Grindlinger G, Rathlev NK.	2005	Retrospective analysis, single-site.	81	Chart review of consecutive patients at an inner city trauma center with gunshot wounds to the head or neck and resulting cervical spine fracture.	Of 81 potential C-spine involvements, 23% actually had C-spine fracture. 14% of assessable patients had neuro deficit, of which 27% were unstable fractures (3.7% of total). 75% were awake without deficit; none had fracture. 6% were altered and all had stable fractures. Most needed airway management.	3	BO
Spinal Immobilization	Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee.	Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE.	2011	Position statement with systematic review	20	Systematically reviews available evidence on spinal immobilization for penetrating trauma and offers recommendations from the PHTLS committee for prehospital care.	There is no evidence and little physiological rationale for immobilizing penetrating trauma; resulting spinal injury is rarely unstable, and this practice increases mortality. It is not recommended.	5	BO
Spinal Immobilization	Increased risk of death with cervical spine immobilisation in penetrating cervical trauma.	Vanderlan WB, Tew BE, McSwain NE Jr.	2009	Retrospective cohort study, single-site	188	Chart review of patients with penetrating cervical trauma at a trauma center; investigated the effects of C-spine immobilization on mortality.	C-spine immobilization increased chance of death by odds ratio of 2.77 (CI 1.18-6.49). When analyzing only isolated penetrating cervical injuries, the odds ratio was 8.82 (CI 1.09-194.19). The OR for death in prehospital or ED setting was 3.36 (CI 1.12-10.74).	2	BO
Spinal Immobilization	Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault.	Rhee P, Kuncir EJ, Johnson L, Brown C, Velmahos G, Martin M, Wang D, Salim A, Doucet J, Kennedy S, Demetriades D.	2006	Retrospective analysis, multi-site	24246	Chart review of patients at two trauma centers with either blunt or penetrating trauma after assault; investigating their incidence of C-spine injury and their outcomes.	.4% of blunt assault patients had C-spine fx (27.8% of those had cord injury, and 1 patient had cord injury without fx), 33% of those needed surgical fixation, and 83% of those presented with neuro deficits. 1.3% of gunshot assaults had C-spine fx (69% with cord injury, and 3 had cord injury without fx), 15% of those needed surgical fixation, and 85% of those presented with neuro deficit. 12% of stabbing assaults had C-spine fx (66% had cord injury, and 2 had cord injury without fx), 33% of those needed surgical fixation, and 100% of those presented with neuro deficits.	4	BO
Spinal Immobilization	National survey of the incidence of cervical spine injury and approach to cervical spine clearance in U.S. trauma centers.	Grossman MD, Reilly PM, Gillett T, Gillett D.	1999	Retrospective analysis, multi-site	111219	Poll of 165 trauma centers compiling data on the annual incidence of C-spine and cervical spinal cord injuries among their total admissions.	4.3% of all admissions had C-spine injury. 3.0% had C-spine injury without cord injury (1.3% had C-spine injury with cord injury), and .70% had cord injury without spine injury. .01% of all C-spine injuries had delayed/missed diagnosis.	3	BO
Spinal Immobilization	Glass intact assures safe cervical spine protocol.	Sochor M, Althoff S, Bose D, Maio R, Deflorio P.	2013	Retrospective cohort study, multi-site	14191	The NASS CDS national database of automobile collisions (crashes towed from the scene only) was polled to determine frequency of significant C-spine injury among patients meeting criteria: age 16-60; seated in front wearing lap and shoulder belts; windows (rolled up) and windshield had no damage; and front airbags present but not deployed.	The criteria were 95.20% sensitive (CI 91.45%-98.95%) and 54.27% specific for significant C-spine injury, with NPV 99.92%. Six cases were missed, most with no cord involvement.	4	BO
Spinal Immobilization	Stabilization of spinal injury for early transfer.	Burney RE, Waggoner R, Maynard FM.	1989	Retrospective cohort study, single-site	61	Chart review of patients transferred into a spinal trauma center to establish whether the method and timing of transfer contributed to neurological deterioration.	No patients deteriorated neurologically during or after transport, and 43% showed later improvement. Those transferred within 24 hours were more likely to improve (49%) than others (10%). Most were immobilized by longboard and collar or similar methods. Use of ground, helicopter, or fixed-wing transport was immaterial.	2	BO
Spinal Immobilization	The Canadian C-spine rule performs better than unstructured physician judgment.	Bandiera G, Stiell IG, Wells GA, Clement C, De Maio V, Vandemheen KL, Greenberg GH, Lesiuk H, Brison R, Cass D, Dreyer J, Eisenhauer MA, Macphail I, McKnight RD, Morrison L, Reardon M, Schull M, Worthington J; Canadian C-Spine and CT Head Study Group.	2003	Retrospective analysis of prospective dataset	6265	Secondary analysis of data from Stiell 2001 to compare the predictive value (for significant C-spine injury) of the Canadian C-spine rule against unstructured clinical judgment of the treating physicians.	Physician judgment was 92% sensitive for predicting the possibility of injury (>0% estimated pretest probability) before radiographs; the Canadian rule was 100% sensitive. Their specificity was 53.9%, versus 44.0% for the Canadian rule. 5 cases would have been missed by physician judgment.	1	BO
Spinal Immobilization	Avoiding a pitfall in resuscitation: the painless cervical fracture.	Maull KI, Sachatello CR.	1977	Correspondence	0	Remarks on early acute care for patients with potential spinal injury.	Notes that, in the authors' experience, clinically occult spinal injury is possible, and asserts without evidence that such patients should be radiographically cleared before manipulating their neck.	1	BO
Spinal Immobilization	Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation.	Kaups KL, Davis JW.	1998	Retrospective cohort study, single-site	215	Chart review of patients at a trauma center with gunshot wounds to the head, investigating their incidence of unstable cervical spine injury.	Although most patients had spinal immobilization in the field, none likely benefitted, as only 1.3% had bullet paths involving the spine, all of whom either died or had no neurological deficit. Airway management was probably negatively affected by immobilization.	3	BO
Spinal Immobilization	Initial evaluation and management of gunshot wounds to the face.	Demetriades D, Chahwan S, Gomez H, Falabella A, Velmahos G, Yamashita D.	1998	Retrospective analysis, single-site	247	Chart review of patients admitted to a trauma center with gunshot wounds to the face, investigating clinical details and the incidence of various complications	8.1% of patients had cervical spine injury resulting from a gunshot wound to the face.	2	BO
Spinal Immobilization	Efficacy of cervical spine immobilization methods.	Podolsky S, Baraff LJ, Simon RR, Hoffman JR, Larmon B, Ablon W.	1983	Prospective comparative trial, non-blinded, convenience sample	25	Healthy volunteers were immobilized using various methods (several types of hard cervical collar, soft collar, sandbags, and combinations), asked to articulate their neck, and movement at the neck was measured by manual goniometer.	Sandbags, tape, and a Philadelphia collar together were the most effective method. A soft collar had little effect.	3	BO
Spinal Immobilization	Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma (EAST) practice management guidelines committee.	Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, Holevar MR, Khwaja KA, Mayglothling JA, Shapiro MB, Winston ES.	2009	Position statement with systematic review	78	Updated recommendations for ED C-spine clearance from the EAST committee.	Recommends clinical clearance for NEXUS-positive patients with intact, pain-free range-of-motion. Recommends against immobilization for penetrating head trauma unless the missile trajectory involves the spine.	3	BO
Spinal Immobilization	The risk of neurologic damage with fractures of the vertebrae.	Riggins RS, Kraus JF.	1977	Retrospective analysis, multi-site	619	Secondary analysis of Kraus 1975 data, an 18-county review of hospital and coroner data in years 1970-1971. Correlated the incidence of vertebral fracture against incidence of spinal cord injury in the study population.	~14% of spinal fractures/dislocations suffered cord injury. Fracture of vertebral body and posterior elements, with displacement, had over 61% chance of cord injury. C-spine injury had neuro deficit in 39%; thoracic, 10%; and lumbar, 3%.	3	BO
Spinal Immobilization	Recent trends in mortality and causes of death among persons with spinal cord injury.	DeVivo MJ, Krause JS, Lammertse DP.	1999	Retrospective analysis, multi-site	28239	Data mine of NSCISC registry from Shriner's and Model SCI centers; analyzed traumatic spinal cord injury patients admitted since 1970 and investigated trends in outcome over time.	Mortality after injury decreased by two-thirds after 1973, but long-term mortality among 1-year survivors rebounded after 1993 above initial levels.	2	BO
Spinal Immobilization	Fractures and dislocations of the cervical spine; an end-result study.	Rogers WA.	1957	Case series	77	Review of C-spine injured patients treated by the author over the 1940s.	64% had neuro symptoms. ~10% of patients experienced early neurological deterioration after the initial injury; all were anterior dislocations.	2	BO
Spinal Immobilization	Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: much ado about nothing.	Velmahos GC, Theodorou D, Tatevossian R, Belzberg H, Cornwell EE 3rd, Berne TV, Asensio JA, Demetriades D.	1996	Prospective cohort study, single-site	549	Enrolled alert, cooperative, non-intoxicated blunt trauma patients arriving in spinal immobilization but without neck pain at a trauma center. Attempted spinal clearance by assessing neck tenderness and pain-free range-of-motion in rotation and flexion.	0% of patients who completed the clinical exam without pain had radiographically-apparent spinal injury, despite distracting injuries in 38.6% and craniofacial injury in 35%. Unnecessary radiographic clearance cost $200k+ and often delayed discharge by up to a day.	4	BO
Spinal Immobilization	Unnecessary out-of-hospital use of full spinal immobilization.	McHugh TP, Taylor JP.	1998	Prospective cohort study, single-site	129	Enrolled patients at a trauma center who arrived with C-spine immobilization and were free from NEXUS criteria as well as pregnancy, recent seizure, or high trauma score. Investigated their incidence and timing of neck/back pain.	51.9% had no neck/back pain on scene, but 31.3% of them developed pain after immobilization. 33.3% had neck pain at the scene, which increased to 44.2% at the ED. 31% had back pain at the scene, which increased to 49.6% at the ED. No patient had pain decrease, and many were not asked about pain before immobilization.	3	BO
Spinal Immobilization	Clinical examination and its reliability in identifying cervical spine fractures.	Duane TM, Dechert T, Wolfe LG, Aboutanos MB, Malhotra AK, Ivatury RR.	2007	Prospective cohort study, single-site	534	Blunt trauma patients at a trauma center were examined for neck pain/tenderness, deformity, or neuro deficits. The results were compared against the diagnosis of C-spine fx by neck CT.	9.7% had C-spine fx on CT. The clinical exam was 76.9% sensitive and 54.7% specific for fx, with 15.5% PPV and 95.7% NPV. For those with GCS 15, no intoxication or distracting injury, sensitivity was 58.8% and specificity 62.7%; 57% of missed injuries in that cohort needed stabilization.	3	BO
Patient Assessment	Accuracy of the ATLS guidelines for predicting systolic BP using palpated pulses.	Deakin CD, Low JL.	2000	Prospective observational study	20	Patients with hypovolemic shock had their pulses checked by a blinded observer and compared to the reading from their arterial blood pressure monitor.	Although loss of pulses followed the order classically described by ATLS, the numbers commonly quoted would consistently and significantly over estimate the patient's blood pressure.	3	VD
Fluid Resuscitation	A randomised controlled trial of prehospital intravenous fluid replacement therapy in serious trauma.	Turner J, Nicholl J, Webber L, Cox H, Dixon S, Yates D.	2000	Prospective, randomised controlled trial.	1309	Trauma patients randomised prehospitally to receive either immediate fluid or delayed fluid resuscitation.	There was no evidence of any difference in mortality rates or composite outcomes between any subgroups, or between protocols within any subgroup.	5	JO
Fluid Resuscitation	Hypotensive Resuscitation during Active Hemorrhage: Impacton In-Hospital Mortality	Dutton RP, Mackenzie CF, Scalea TM.	2002	Prospective, randomised controlled trial.	110	Compared a target SBP > 100 mm Hg to a target SBP of 70 mm Hg. Fluid therapy was titrated to either endpoint until definitive hemostasis was achieved. In-hospital mortality, injury severity, and probability of survival were determined for each patient.	Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality in this study.	4	JO
Cardiac Arrest	Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest	Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, Nichol G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L, Campeau T, Dagnone E, Lyver M; Ontario Prehospital Advanced Life Support Study Group.	2004	Prospective, Non-randomised controlled trial.	5638	OPALS trial: 1391 OCHA patients enrolled before introduction of ACLS capable EMS, 4247 enrolled subsequent to ACLS up skilling. Mortality rates compared between groups.	The addition of advanced-life-support interventions did not improve the rate of survival after out-of-hospital cardiac arrest in a previously optimized EMS system of rapid defibrillation.	5	JO
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