Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable
Task Force Synthesis Citation
Laermans J, Djärv T, Singletary EM, Macneil F, Williamson F, Cimpoesu D, Flores G on behalf of the International Liaison Committee on Resuscitation First Aid Task Force.
Spinal motion restriction Task Force Synthesis of a Scoping Review [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force, 2024 October 28. Available from: http://ilcor.org
Methodological Preamble and Link to Published Scoping Review
A scoping review of cervical spinal motion restriction was conducted by the ILCOR First Aid Task Force Scoping Review team, taking into consideration the work previously done within the First Aid Task Force in 2015 (systematic review) and 2019 (two scoping reviews). Evidence from the literature published during the last 25 years (1999-2024) was sought and considered by the First Aid Task Force.
Scoping Review
Webmaster to insert the Scoping Review citation and link to Pubmed using this format when/if it is available.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Adults and children with possible traumatic cervical spinal injury.
Intervention: Cervical spinal motion restriction performed by a (trained) first aider.
Comparators: No cervical spinal motion restriction, or another type of cervical spinal motion restriction.
Outcomes: Any clinical outcome.
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) and case series were eligible for inclusion. Case reports and studies performing a single measurement of the outcome (e.g. feasibility study, proof-of-concept study) were excluded.
Grey literature and social media and non-peer reviewed studies, unpublished studies, conference abstracts and trial protocols were not eligible for inclusion as there was an abundant evidence base from published studies. All relevant publications in any language were included as long as there was an English abstract.
Timeframe: 1999-2024.
Literature search updated to July 31, 2024.
Search Strategies: FA 7311 Spinal motion restriction Appendix 1 search strategy
A search strategy was developed with assistance from Mark S. McKone, an information specialist at the Wake Forest School of Medicine Coy C. Carpenter Library in Winston-Salem, North Carolina, USA (see Appendix 1). Articles for review were obtained by searching the following databases, with final searches ran on July 31, 2024: Ovid MEDLINE(R) ALL <1946 to July 31, 2024>, Embase <1974 to 2024 July 30> and CINAHL Plus with Full text (1936 – Present) via EBSCOhost.
Records from the database searches were downloaded and imported into Covidence for removal of duplicates and screening. A total of 2291 records were retrieved, and after removing 977 duplicates, 1314 records remained for the title and abstract screening. After excluding 1226 records, a total of 87 full texts were screened (see Appendix 2 for PRISMA flow chart).
Additional studies were identified by screening reference lists of the included studies, and by screening the included studies of systematic reviews and scoping reviews retrieved via the database searches and reference list screening (listed in Appendix 3). Finally, the members of the ILCOR First Aid Task Force were asked to review the list and provide additional studies for review to ensure there were no obvious omissions. These other resources led to the full text screening of 131 additional records and finally led to the inclusion of 34 studies (see Appendix 2). FA 7311 Spinal motion restriction Appendix 2 flowchart; FA 7311 Spinal motion restriction Appendix 3 List of Sc R and SR
Inclusion and Exclusion Criteria: FA 7311 Spinal motion restriction inclusion exclusion criteria
Data tables:
See Appendix 4 (extracted data) and Appendix 5 (equity-relevant data using the PROGRESS-Plus framework).FA 7311 Spinal motion restriction Appendix 4 Extracted data; FA 7311 Spinal motion restriction Appendix 5 Equity
Task Force Insights:
1. Why this topic was reviewed.
This topic was prioritized by the First Aid Task Force after being identified as an ongoing concern by organizations that provide first aid training for the public and for those with a duty to respond (e.g., lifeguards, police, search and rescue, ski patrols). Members of the Scoping Review Team were aware of existing spinal motion restriction protocols in many countries that are used by Emergency Medical Service (EMS) professionals. Similar guidance for first aiders, including those with a duty to respond, continues to be debated. The First Aid Task Force considered the continuing controversy of the use of cervical collars and other devices by lay first aiders and the evidence of harm due to collars as well as the risk of secondary spinal cord injury after the initial trauma.
This topic has been reviewed on a number of occasions by the Task Force. The 2015 ILCOR Consensus on Science for this topic identified very low certainty evidence from 8 observational studies evaluating the critical outcomes of neurologic injury and complications {Singletary 2015 S269, Zideman 2015 e225}. That review was limited to mechanical cervical immobilization devices accessible to first aiders, including cervical collars and sandbags with tape, but did not include spine boards. No evidence was identified to address the important outcomes of overall mortality, pain, and the less important outcome of hospital length of stay. Based on the evidence, the 2015 European Resuscitation Council First Aid Guidelines {Zideman 2015 278} for cervical spinal motion restriction stated that “The routine application of a cervical collar by a first aid provider is not recommended. In suspected cervical spine injury, manually support the head in position limiting angular movement until experienced healthcare provision is available”.
In 2019, the ILCOR First Aid Task Force performed a scoping review to search for additional publications on cervical spinal motion restriction that would support past recommendations or lead to a new systematic review on this topic {Woodin 2019a }. In this review, use of spine boards was considered as well. Given the limited amount of additional evidence, and discussions around the ability of first aiders to properly apply a cervical collar and the non-routine use of cervical collars amongst others, the Task Force did not feel there was sufficient information to prompt new systematic reviews or the reconsideration of current resuscitation guidelines and treatment recommendations.
Also in 2019, the Task Force conducted a scoping review using a newly developed PICOST question on cervical spinal stabilization, focusing on the effectiveness of manual stabilization techniques such as the trap-squeeze and head-squeeze techniques {Woodin 2019b }. In this review, two studies were identified that only indirectly addressed the research question. The Task Force agreed that there was insufficient information to pursue a systematic review.
For the current 2024 review, the ILCOR First Aid Task Force conducted a scoping review, using a wide approach that encompassed the previous work done in 2015 and 2019. The aim was to identify the literature published since 1999 on cervical spinal motion restriction performed by (trained) first aiders, to get a broad overview of the effectiveness and the changes in practice pertaining to spinal motion restriction.
For this review, spinal motion restriction was defined as ‘attempting to maintain the spine in anatomic alignment and minimizing gross movement, with or without adjuncts or devices’. Studies were included if they: (a) concerned motion restriction at the level of the cervical spine with or without restriction at the level of the lower (i.e. thoracic, lumbar and sacral) spine, and (b) used devices for motion restriction that are commonly and readily available to (trained) first aiders, and (c) concerned techniques used for motion restriction do not require extensive amounts of specialized training. Extrication studies were included if they compared uninstructed self-extrication with no cervical collar versus uninstructed self-extrication with a cervical collar, or uninstructed self-extrication (with or without a cervical collar) with instructed self-extrication (with or without a cervical collar). Studies assessing the impact of implementing a more restrictive spinal motion restriction protocol were also included and analyzed separately. More information on the criteria applied to in- or exclude studies from this review, with the corresponding rationales, can be found in the ‘Inclusion and Exclusion criteria’ section above. The Task Force was aware that there exist multiple levels of first aid and took this into account in including some techniques used by regularly trained first aiders in the included studies.
2. Narrative summary of evidence identified: FA 772 a Spinal motion restriction New Appendix 7 Narrative Evidence Summary
3. Narrative Reporting of the task force discussions
Looking at the extensive evidence base that was identified and mapped in this scoping review, the Task Force noted that:
No studies directly or specifically addressed the PICOST intervention as applied by trained or untrained first aiders.
- The preponderance of the evidence identified comes from experimental studies in healthy young adult human volunteers or in human cadaver models, and as such, results may not be generalizable to the population of adults and children with possible traumatic cervical spine injury. In addition, 40% of all the included studies were conducted in the USA, which may further hinder the global generalizability of the findings.
- Multiple studies evaluated the use of a cervical collar with or without adjunct devices.
Only two studies looked at improvised devices for spinal motion restriction, which may be useful for first aiders in low-resource settings. One study used a folded fleece jacket collar, whereas the other used a folded towel wrapped around the neck and crossed around the chest.
In contrast, a vast number of experimental studies included head-to-head comparisons of multiple commercially available cervical collars. Partly because of this, there was marked heterogeneity between studies based solely on the different brands of cervical collars, their design (1-piece or 2-piece) and structure (rigid, semi-rigid, soft, improvised). This heterogeneity might hinder future systematic review teams from performing relevant evidence synthesis, such as meta-analysis.
In addition, as nearly all studies using a Philadelphia® collar failed to clearly report on the features of the collar (e.g. specific type, design, structure, manufacturer), categorizing them correctly will require systematic review teams to contact the authors of the individual studies. This categorization is also necessary to have a more trustworthy overview of the evidence on the comparative effectiveness of one-piece vs two-piece collars. This comparison is of particular interest to first aid, as in an emergency or out-of-hospital setting, a one-piece collar is considered by many to be easier, more efficient and rapid for application. - Although we included manufacturer names of devices and cervical collars, because this is a scoping review, we did not assess the risk of bias for the individual studies and we did not determine the certainty of the body of evidence. The findings of our scoping review should therefore be interpreted with this in mind.
- While experimental studies largely report decreased ranges of cervical motion with use of cervical collars and other devices to restrict spinal motion, few studies report on clinical neurological outcomes in patients. A number of studies report evidence of harm (i.e., increased intracranial pressure, development of pressure ulcers) associated with use of cervical collars in actual patients. However, the majority of the evidence base on these and other adverse effects (i.e., respiratory restriction, changes in swallowing function) comes from healthy volunteer studies.
- Although this scoping review did not initially intend to look at the effectiveness of implementing selective spinal motion restriction protocols, and therefore its search strategy was not sufficiently tailored to identify this type of studies, the clinical outcomes of the identified studies are encouraging. Future systematic review teams should consider searching for these studies, and map the available evidence to identify potential research gaps. Similarly, it may be worth looking further into the evidence on the effectiveness of different methods or devices for extrication from vehicles, given the high burden of road traffic injuries.
Further Task Force discussions noted:
● That strategies for spinal immobilization in patients with actual or potential spinal injuries have been used for decades due to concerns that movements associated with extrication and transportation could lead to worsened or additional harm. However, these practices (rigid cervical collar and long spine board application) have been driven more by legal considerations and unproven theories than concrete scientific or clinical evidence.
● That cervical collar application must be balanced against the risk of secondary spinal cord injury (either an exacerbation of existing neurological deficit or a de novo deficit).
● That lay first aiders have neither the training or equipment to diagnose spinal fractures, their stability or more subtle neurological deficits. Hence, they should be cautious in dealing with persons who may be at risk of spinal cord injury.
● That other more life-threatening injuries, such as an obstructed airway or control of major hemorrhage, should take precedence for treatment over the possibility of spinal (cord) injury which is a rarer occurrence in most trauma.
● The existence of multiple levels of first aid. The Task Force took this into account in including some techniques and devices that may be used by regularly trained first aiders.
● That determining the effectiveness of spinal motion restriction in real-life trauma patients is challenging because of several reasons. First of all, the rates of spinal (cord) injuries are low, and therefore, it is hard to draw conclusions on the basis of often just a handful of patients per study. Secondly, the data on the effectiveness of different methods or devices are confounded by the use of different protocols for selective spinal motion restriction, which vary considerably across different countries.
● That multiple caregivers are often sequentially involved in the pre-hospital cascade (i.e.. (un)trained first aider handing over to EMS), and recording who actually applied the spinal motion restriction device/technique is often not documented in hospital records. Therefore, determining the effectiveness of spinal motion restriction specifically by (un)trained first aiders presents an additional challenge.
This scoping review provides a comprehensive overview of the available evidence and may serve as a basis for future systematic reviews on one or more narrowly defined PICOST questions. The Task Force felt that formal data synthesis and determination of the certainty of the very vast evidence base is required to confidently formulate any treatment recommendations or Good Practice Statements.
On the basis of these discussions and consideration of the available evidence, the Task Force reaffirms the 2015 treatment recommendation:
“We suggest against the use of cervical collars by first aid providers (weak recommendation, very low-certainty evidence)”.
Knowledge Gaps
The First Aid Task Force noted the following knowledge gaps requiring further research:
- There were no studies that evaluated the benefits and harms of spinal motion restriction in conscious persons, performed by untrained or trained first aiders.
- There were no studies that evaluated the effectiveness of spinal motion restriction by first aiders in unconscious persons.
- There were only two studies that looked at methods for spinal motion restriction that could be applied specifically in low-resource settings (e.g. a folded fleece jacket as an improvised collar, a folded towel wrapped around the neck and crossed around the chest).
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