Spinal immobilization is one of the most frequently performed procedures in the prehospital care of trauma patients in North America. While clinical and biomechanical evidence suggest that spinal immobilization limits pathologic motion of the injured spinal column, there is no rigorous evidence to support the need for spinal immobilization in all patients following trauma.3 In a 2003 Cochrane review, no randomized controlled trials that evaluated prehospital spinal immobilization in trauma patients were identified.4
In 2005, Kwan et al did a comprehensive review of randomized controlled trials of spinal immobilization on healthy participants. Seventeen randomized controlled crossover trials comparing the various types of spinal immobilization devices in 529 healthy volunteers 7 to 85 years of age were identified. Of note, substantial amounts of head and neck motion were reported regardless of whether rolled towels or foam wedges were used. A comparison of these 3 devices showed no significant difference in the efficacy of reducing head and neck movements.5
Despite its widespread use, the clinical benefits of prehospital spinal immobilization have been questioned. The current protocol for prehospital spinal immobilization has a strong historical rather than scientific precedent based less on objective evidence and more on the concern that a patient with a injured spine may deteriorate neurologically without immobilization.6 Spinal immobilization has never been proven to prevent secondary spinal injury. 7 It has also been argued that considerable force is= required to fracture the spine at initial impact and any subsequent movements by routine handling and transport are unlikely to cause further damage to the spinal cord. Estimates in the literature regarding the incidence of neurological injury due to inadequate immobilization may have been exaggerated.7,8 Approximately 5 million patients in the United States receive spinal immobilization every year, regardless of chief complaint, largely in response to the fear of doing harm due to unrecognized occult fractures.9 Still, there are examples of patients whose spinal cord injury occurred after immobilizatio devices were removed and the patient was allowed to move his or her neck. While this may occur infrequently, it can be catastrophic when it does occur.
Although cervical spine injuries involving patients wearing helmets are relatively uncommon, when they do occur, they present a unique and sometimes difficult diagnostic and therapeutic challenge. In addition, shoulder pads worn by football, hockey, and lacrosse players further complicate the treatment of these patients. The management of the helmeted patient with a potential neck injury begins at the scene with proper immobilization and positioning. Immobilization of the neck in the neutral position restricts movement of the unstable vertebral column in an effort to prevent damage to the spinal cord and nerve roots. In almost all cases, the helmet and shoulder pads should not be removed prior to arrival in the ED; the facemask can be carefully removed to allow better visualization and access to the patient's airway.
The National Collegiate Athletic Association (NCAA) published helmet removal guidelines as part of a consensus statement by the Inter-Association Task Force for Appropriate Care of the Spine-Injured Athlete.23 The NCAA has stated that, unless there are special circumstances such as respiratory distress coupled with an inability to access the airway, the helmet should never be removed during prehospital care of the student athlete with potential head/neck injuries unless:
If the helmet is removed prior to ED arrival, the shoulder pads should also be removed to prevent extension of the cervical spine.23 (See Table 1 for a description of the helmet removal process.)
Lisa Freeman Grossheim; Kevin Polglaze; Rory Smith
April 2, 2009