Research paper| Volume 22, ISSUE 2, P69-75, June 2019

A prospective evaluation of cervical spine immobilisation in low-risk trauma patients at a tertiary Emergency Department

Published:April 30, 2019DOI:



      In the Emergency Department cervical spine immobilisation precautions are frequently used. There is controversy in regard to the balance of risks and benefits of routine immobilisation in conscious patients.


      A prospective multi-methods evaluation in a tertiary trauma referral centre. The objectives were to investigate current practices and rate of concordance with established international guidelines. A provider survey focused on current knowledge, skills and attitudes and was disseminated to nurses, doctors and paramedics treating trauma patients. Additionally, clinical data were collected on a cohort of immobilised trauma patients. Demographic data were analysed using SPSS and content analysis was completed by manifest coding.


      The response rate to the survey was 85.2%. Interdisciplinary providers included nurses (n=46), doctors (n=68) and paramedics (n=41).
      Content analysis revealed a range of themes for improving care. Themes identified included improved application of guidelines, tailored use of equipment in low-risk patients, improved access to radiology results, and staff education. The series of five case vignettes provided to participants revealed a high level of variance in intended approaches to immobilisation. In the cohort of trauma patients (n=54), the median age was 54 years and the most common mechanism of injury was falls (40.7%). Median time spent with immobilisation was 325min. Adherence to a recognised decision tool was 35/54 (64.8%). Precautions were initiated by paramedics in 42/54 (77.8%).


      Despite widespread dissemination of guidelines, observed approaches to patient immobilisation appear to be highly variable in this trauma centre. Reducing variation for low-risk patients is likely to improve the patient journey and minimise the risk of prolonged immobilisation. Further assessment of the causes of variation could define goals for targeted translational change.


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        • Kanwar R.
        • Delasobera B.E.
        • Hudson K.
        • Frohna W.
        Emergency department evaluation and treatment of cervical spine injuries.
        Emerg Med Clin North Am. 2015; 33: 241-282
        • ATLS Subcommittee
        • American College of Surgeons’ Committee on Trauma
        • International ATLS Working Group
        Advanced trauma life support (ATLS®): the ninth edition.
        J Trauma Acute Care Surg. 2013; 74: 1363-1366
        • Deasy C.
        • Cameron P.
        Routine application of cervical collars – what is the evidence?.
        Injury. 2011; 42: 841-842
        • Horodyski M.
        • DiPaola C.P.
        • Conrad B.P.
        • Rechtine G.R.
        Cervical collars are insufficient for immobilizing an unstable cervical spine injury.
        J Emerg Med. 2011; 41: 513-519
        • Benger J.
        • Blackham J.
        Why do we put cervical collars on conscious trauma patients?.
        Scand J Trauma Resusc Emerg Med. 2009; 17: 44
        • Plumb J.O.
        • Morris C.G.
        Cervical collars: probably useless; definitely cause harm.
        J Emerg Med. 2013; 44: e143
        • Australian and New Zealand Committee on Resuscitation
        ANZCOR guideline 9.1.6 – management of suspected spinal injury.
        2016: 1-6
        • Clarke A.
        • James S.
        • Ahuja S.
        Ankylosing spondylitis: inadvertent application of a rigid collar after cervical fracture, leading to neurological complications and death.
        Acta Orthop Belg. 2010; 76: 413-415
        • Fredø H.L.
        • Inger J.
        • Bakken I.J.
        • Lied B.
        • Rønning P.
        • Helseth E.
        Incidence of traumatic cervical spine fractures in the Norwegian population: a national registry study.
        Scand J Trauma Resusc Emerg Med. 2014; 22: 78
        • DiMaggio C.J.
        • Avraham J.B.
        • Lee D.C.
        • Frangos S.G.
        • Wall S.P.
        The epidemiology of Emergency Department trauma discharges in the United States.
        Acad Emerg Med. 2017; 24: 1244-1256
        • Thompson W.L.
        • Stiell I.G.
        • Clement C.M.
        • Brison R.J.
        Association of injury mechanism with the risk of cervical spine fractures.
        CJEM. 2009; 11: 14-22
        • Hoffman J.R.
        • Wolfson A.B.
        • Todd K.
        • Mower W.R.
        • et al.
        Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS).
        Ann Emerg Med. 1998; 32: 461-469
        • Stiell I.G.
        • Wells G.A.
        • Vandemheen K.L.
        • Clement C.M.
        • et al.
        The Canadian C-spine rule for radiography in alert and stable trauma patients.
        JAMA. 2001; 286: 1841-1848
        • Michaleff Z.A.
        • Maher G.A.
        • Verhagen A.P.
        • Rebbeck T.
        • Lin C.W.
        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.
        CMAJ. 2012; 184: E867-E887
        • Mohan D.
        • Rosengart M.R.
        • Farris C.
        • Fischhoff B.
        • et al.
        Sources of non-compliance with clinical practice guidelines in trauma triage: a decision science study.
        Implement Sci. 2012; 7: 103
        • Cooney D.R.
        • Wallus H.
        • Asaly M.
        • Wojcik S.
        Backboard time for patients receiving spinal immobilization by emergency medical services.
        Int J Emerg Med. 2013; 6: 17
        • Nkusi A.E.
        • Muneza S.
        • Hakizimana D.
        • Nshuti S.
        • Munyemana P.
        Missed or delayed cervical spine or spinal cord injuries treated at a tertiary referral hospital in Rwanda.
        World Neurosurg. 2016 Mar; 87: 269-276
        • Platzer P.
        • Hauswirth N.
        • Jaindl M.
        • Chatwani S.
        • et al.
        Delayed or missed diagnosis of cervical spine injuries.
        J Trauma. 2006; 61: 150-155
        • Morrison J.
        • Jeanmonod R.
        Imaging in the NEXUS-negative patient: when we break the rule.
        Am J Emerg Med. 2014; 32: 67-70
        • Cone D.C.
        • Wydro G.C.
        • Mininger C.M.
        Current practice in clinical cervical spinal clearance: implication for EMS.
        Prehosp Emerg Care. 1999; 3: 42-46
        • Curtis K.
        • Fry M.
        • Shaban R.Z.
        • Considine J.
        Translating research findings to clinical nursing practice.
        J Clin Nurs. 2017; 26: 862-872
        • Atkins L.
        • Francis J.
        • Islam R.
        • O’Connor D.
        • et al.
        A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems.
        Implement Sci. 2017; 12: 77
        • Fontaine G.
        • Forgione M.
        • Lusignan F.
        • Lanoue M.A.
        • Drouin S.
        Cervical spine collar removal by emergency room nurses: a quality improvement project.
        J Emerg Nurs. 2018; 44: 228-235
        • Miller C.P.
        • Bible J.E.
        • Jegede K.A.
        • Whang P.G.
        • Grauer J.N.
        Soft and rigid collars provide similar restriction in cervical range of motion during fifteen activities of daily living.
        Spine. 2010; 35: 1271-1278
        • Stiell I.G.
        • Clement C.M.
        • Grimshaw J.
        • Brison R.J.
        • et al.
        Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial.
        BMJ. 2009; 339: b4146
        • Kourouche S.
        • Buckley T.
        • Munroe B.
        • Curtis K.
        Development of a blunt chest injury care bundle: an integrative review.
        Injury. 2018; 49: 1008-1023
        • Papadopoulos M.C.
        • Chakraborty A.
        • Waldron G.
        • Bell B.A.
        Lesson of the week: exacerbating cervical spine injury by applying a hard collar.
        BMJ. 1999; 319: 171
        • Heath K.J.
        The effect of laryngoscopy of different cervical spine immobilisation techniques.
        Anaesthesia. 1994; 49: 843-845
        • Rose M.K.
        • Rosal L.M.
        • Gonzalez R.P.
        • Rostas J.W.
        • et al.
        Clinical clearance of the cervical spine in patients with distracting injuries: it is time to dispel the myth.
        J Trauma Acute Care Surg. 2012; 73: 498-502
        • Kwan I.
        • Bunn F.
        • Roberts I.G.
        Spinal immobilisation for trauma patients.
        Cochrane Database Syst Rev. 2001; ([updated 2009])
      1. Queensland Ambulance – Cervical Spine Assessment and Management. [accessed 03.01.18].

        • The Sydney Children's Hospital Network
        Guideline 2012–8014: cervical spine (suspected) injury: patient management.
        2012 ([accessed 25.10.18])
        • Kornhall D.
        • Jørgensen J.
        • Brommeland T.
        • Hyldmo P.K.
        • et al.
        The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury.
        Scand J Trauma Resusc Emerg Med. 2017; 25: 2
        • Smith N.
        • Curtis K.
        Can emergency nurses safely and accurately remove cervical spine collars in low risk adult trauma patients: an integrative review.
        Australas Emerg Nurs J. 2016; 19: 63-74
        • Bandiera G.
        • Stiell I.G.
        • Wells G.A.
        • Clement C.
        • et al.
        The Canadian C-spine rule performs better than unstructured physician judgment.
        Ann Emerg Med. 2003; 42: 395-402
        • Meek R.
        • McGannon D.
        • Edwards L.
        The safety of nurse clearance of the cervical spine using the National Emergency X-radiography Utilization Study low-risk criteria.
        Emerg Med Australas. 2007; 19: 372-376
        • Vaillancourt C.
        • Charette M.
        • Kasaboski A.
        • Maloney J.
        • Wells G.A.
        • Stiell I.G.
        Evaluation of the safety of C-spine clearance by paramedics: design and methodology.
        BMC Emerg Med. 2011; 11 (1-227X-11-1)
        • Domeier R.M.
        • Frederiksen S.M.
        • Welch K.
        Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria.
        Ann Emerg Med. 2005; 46: 123-131
        • Morgan P.J.
        • Cleave-Hogg
        Comparison between medical students’ experience, confidence and competence.
        Med Educ. 2002; 36: 534-539
        • Bouland A.J.
        • Jenkins J.L.
        • Levy M.J.
        Assessing Attitudes toward Spinal Immobilization.
        J Emerg Med. 2013; 45: e117-e125
        • Tran J.
        • Jeanmonod D.
        • Agresti D.
        • Hamden K.
        • Jeanmonod R.K.
        Prospective validation of modified NEXUS cervical spine injury criteria in low-risk elderly fall patients.
        West J Emerg Med. 2016; 17: 252-257
        • Roche S.J.
        • Sloane P.A.
        • McCabe J.
        Epidemiology of spine trauma in an Irish regional trauma unit: a 4-year study.
        Injury. 2008; 39: 436-442
        • Middleton P.
        • Davies S.
        • Anand S.
        • Reinten-Reynolds T.
        • et al.
        The pre-hospital epidemiology and management of spinal cord injuries in New South Wales: 2004–2008.
        Injury. 2012; 43: 480-485