Did You Ever Have to Make Up Your Mind? Spine Care and Decision Making When There Is Not Adequate Data

Field: Medicine (Health Sciences)

The article by Oto et al.1 in this issue of Academic Emergency Medicine attempts to describe every case of neurologic injury that is purported to have been caused by postaccident emergency care in the medical literature. The underlying question is whether “immobilizing” the spine using standard methods (boards, straps, collars, etc.) is protective and beneficial. Spinal cord injuries are potentially devastating but because these standard methods cause harm—delay in transport, interference with care, respiratory compromise in certain cases, and decubiti in others—the question is critically important. The article unfortunately fails to resolve the question. The only cases that convincingly show deterioration caused by movement involved major force, such as falling and neurosurgical procedures that are known to risk cord damage, and do not reflect situations that are likely to be encountered in ambulances or the emergency department (ED). A surprising number of cases actually involved forcing patients with chronic deformities into “neutral” position with cervical collars and backboards. Thus these cases are not helpful. Most reports are of poor quality and at best show a temporal association between care and deterioration—an association that holds true regardless of what, if any, care is delivered. Other sources of information also fail to resolve the question.2 Historic data imply that cord injuries are less common and more likely to be incomplete than in the past,3 but much has changed in safety, neurosurgery, and rehabilitation over the past decades. Mandatory seatbelts and passive restraints are clearly more important than ambulance care in reducing spinal injuries. The only comparative study showed that standard prehospital care was associated with more neurologic injuries,4 but again this was only an association. No study provides enough information to make a reasonable risk/benefit calculation, much less an economic analysis such as quality-or disability-adjusted life-year versus cost. The problem is even more complicated because it is certainly true that the risk and potential benefit is different for different patients—delay is much more serious for the multitrauma patient than for one suffering an isolated injury, for example. This dilemma is not uncommon in medicine: what should the clinician do when there are not enough high-quality primary data to make the decision obvious? One solution is to just keep doing what one has always done. In this case, just keep tying every patient who might conceivably have an injured spine down to a board with tape, webbing, and collars. This solution has some merit, as it feeds into the understandably conservative nature of human behavior; changing what we believe and do is difficult and unpleasant. It has also been justified on the assumption that it minimizes risk to the provider, although this argument is ethically suspect and probably assumes that malpractice attorneys are not quite as bright as they actually are. After all, it would be difficult to argue that a decubitus ulcer was not caused by pressure from the board or that being immobilized in the supine position had nothing to do with an aspiration pneumonia. One popular variant is to wait for a definitive clinical trial, but in some cases this will result in doing the same thing forever. No conceivable care will change the outcome for the vast majority of trauma patients since they have no spinal injury, a complete and irrevocable one, or other fatal injuries. This means that a rigorous study would have to be enormous and even then would not be of very high quality; for example, it could never be double-blinded. Changing nothing is acceptable if a treatment is benign, but in this case it clearly is not and puts all trauma patients at risk to hopefully benefit the very small number who have acutely biomechanically unstable but modifiable neurologic injuries. None of these statements are really debatable, but none of them have the “Category 1” controlled clinical trial evidence so beloved by experts in evidence-based medicine. So what is reasonable? Oto et al. have demonstrated that the standard paradigm is not evidence-based. That does not mean it is wrong, but it does mean that there is no convincing evidence for or against the standard board/straps/collar method of acute spinal care. This essentially means we are at clinical equipoise. A reasonable approach would be to transport all patients on comfortably soft surfaces, preferably ones that are not slippery. Backboards, if used at all, should be limited to extrication and short transports. Formal “immobilization” of struggling or seizing patients should be avoided. These patients require reassurance, sedation, or antiseizure medication—not tighter straps and “brutane.” An ambulatory patient can be helped to sit on the ambulance cot and then the backrest can be slowly lowered until the patient is comfortable. Tying an ambulatory patient to a backboard while he or she is standing and then tilting it to the horizontal makes no sense. Restraining the sides of the patient with bolsters will reduce the potential for injury by dissipating energy. Cervical collars should perhaps be reserved for patients who have injuries that are known to be stable in distraction. Most importantly, care of a possible spinal injury cannot be viewed as an imperative to be done in isolation. Other aspects of care may take priority. For stable patients with isolated injuries, careful padding to absorb the energy generated by transport and a slow drive to definitive care is reasonable. For others airway management or rapid transport should be the top priority. These decisions are not based on “Category 1” evidence, but we know that even controlled clinical trials are subject to their own biases and flaws.10 The kind of logical decision making outlined above has been described as “science-based” in distinction to “evidence-based” medicine.11 It uses facts and analyses that actually have a much higher probability of reflecting the real world than controlled trial data alone does. In this world, there is never enough evidence to be certain; we must always make do with less than revealed truth.