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

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. Historic data imply that cord injuries are less common and more likely to be incomplete than in the past, 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, 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. We cannot afford to be as conservative as the European sailors who continued to suffer and die of scurvy for 265 years after James Lancaster showed that lemon juice would prevent it. If we want to avoid placing our patients in a similar position, we will have to use different kinds of evidence to make our decisions. Fortunately, we do know some things. To treat patients with potential spinal injuries we know: