Article Text

Should suspected cervical spinal cord injuries be immobilised? A systematic review protocol
  1. Ala'a O Oteir1,
  2. Paul A Jennings2,3,
  3. Karen Smith1,3,4,
  4. Johannes Stoelwinder1
  1. 1Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  2. 2Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
  3. 3Ambulance Victoria, Melbourne, Victoria, Australia
  4. 4Department of Emergency Medicine, University of Western Australia, Perth, Western Australia
  1. Correspondence to Ala'a O Oteir, Epidemiology & Preventive Medicine, Monash University, Level 5, Alfred Centre, Melbourne, Victoria 3004, Australia


Background Cervical spinal cord injuries may result in life-threatening situations and long-term disability. Prehospital spinal immobilisation is the standard of care for patients with potential spinal cord injury (SCI). It aims to prepare patients for transport, achieve neutral spinal alignment, and reduce movement and secondary injuries in potentially unstable spines. However, there is a lack of evidence on its clinical benefits and its overall effect on patient outcomes.

Objectives To identify the reported outcomes following immobilisation of suspected cervical SCI, to compare the effects of spinal immobilisation versus no immobilisation on the reported outcomes, and to provide recommendations for prehospital cervical immobilisation.

Design/methods A search of the literature will be conducted using relevant online databases. This will include all types of human studies that were published in English from the earliest record available to the first week of October 2013. One author will conduct the search and two independent authors will screen the titles and the abstracts identified by the search and critically appraise the selected papers. A third author will be available to resolve any disagreement. The findings will be reported according to Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Critical appraisal as well as the level and the strength of evidence will follow the National Health and Medical Research Council (NHMRC) guidelines.

Discussion Evidence-based practices should be pursued to further improve the prehospital care for suspected cervical SCI. This systematic review will contribute to the body of knowledge regarding the spinal immobilisation effects on the SCI patient's outcomes.

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Spinal cord injury (SCI) is defined as an acute traumatic lesion of the neural elements of the spinal canal, including spinal cord and cauda equina, that results in temporary or permanent sensory deficit, motor deficit, or bowel or bladder dysfunction.1 ,2 Most SCIs are in the cervical region cervical SCI (CSCI).3 The relatively smaller and increased mobility of cervical vertebrae, combined with reduced strength of the stabilising structure predispose the cervical column to higher risks of injury.4 It has been reported that CSCI accounts for up to 75% of SCIs in Canada,5 57.7% in Australia2 and 50% in Ireland.6 In severe cases, they can place a burden on the patient's independence, quality of life and socioeconomic circumstances.5 ,7

Prehospital spinal immobilisation guidelines have been developed to protect the possibly unstable cervical spinal column in cases of suspected cervical spine or spinal cord injured patients, until excluded by radiology.8 It aims to prevent further movement of the injured spine, to reduce the risk of secondary complications, and to facilitate extrication as well as transport.9 Immobilisation is achieved by using appropriate transfer techniques, cervical spine collars (c-collars),10 ,11 lateral support11 and spine boards and straps.10 ,11 Other devices used include a vacuum mattress device in combination with a rigid cervical collar,12 and a Kendrick Extrication Device to assist with extrication following a motor vehicle collision (MVC) or other confined space rescue.12

While prehospital spinal immobilisation is a widely accepted practice for patients with suspected SCIs,13–15 there is conflicting evidence of its possible benefits and harm.14 Moreover, there is scarce evidence about the effects of prehospital spinal immobilisation on patient's neurological outcomes. It may increase the risk of respiratory complications,9 ,16 ,17 back and neck pain,11 ,16–19 and intracranial pressure with cervical collar application.20 It is also a time consuming and expensive procedure.16

The objectives of this systematic review are to identify the reported outcomes after the immobilisation of a suspected cervical SCI, to compare the effects of spinal immobilisation versus no immobilisation on the reported outcomes, to identify the role of prehospital care provided in cervical spine clearance and immobilisation, and to provide recommendations for prehospital cervical immobilisation in suspected cervical SCI patients.


Research questions

The research question for this systematic review will be based on the acronym PICO, which denotes Population, Intervention, Comparison group and Outcomes21; In adult patients attended by Emergency Medical Services (EMS) following suspected cervical spine injury (Population), does the application of c-collar (Intervention) improve patients’ outcomes (Outcome) compared to no collar at all (Comparison)?

This systematic review aims to answer the questions below. In adult patients attended by EMS following an injury:

  • What are the patient's reported outcomes following a mechanism of injury with a potential to cause a cervical spine trauma?

  • What effects do c-collars have on the patient's reported outcomes?

  • What are the benefits and harm of c-collars?

  • What are the consequences of withholding c-collars?

  • Is cervical spinal immobilisation needed in all traumatic suspected cervical SCI patients?

Search strategy

A review of the literature will be conducted using several electronic medical literature databases and search engines including the:

  • OvidSP (MEDLINE, PsycINFO and DARE)

  • Cochrane library



  • Pubmed

  • Scopus

  • Web of science

  • Google scholar

The search strategy will include different combinations of Medical Subject Headings (MeSH) terms and keywords that are relevant to immobilisation, traumatic SCI, outcomes and prehospital care (see online supplementary table S1).22 The search will include articles published in English and human studies from the earliest record available to the first week of October 2013. Titles of the studies and the abstracts will be screened for relevance to the systematic review's questions. The full text of the potentially relevant articles will be obtained and screened for inclusion. Furthermore, the reference lists of the included literature will be manually searched to identify relevant literature that might have been overlooked in the search.

Inclusion criteria

The following table includes the inclusion and exclusion criteria (table 1).

Table 1

Inclusion/exclusion criteria

Types of studies, population and outcomes

All types of studies will be considered due to the scarce evidence on the evaluation of spinal immobilisation's effects on patient's outcomes. Moreover, all prehospital settings and levels of qualification will be considered where they comply with the inclusion criteria.

Population is limited to adult patients (≥16 years old) who have sustained a traumatic injury that may have led to a cervical CSCI. Cervical spinal immobilisation or no immobilisation are considered valid for inclusion as long as the study evaluates or describes the prehospital care for suspected SCI and its effects on patient's outcomes.

Any type of outcome measure following the application or non-application of c-collars will be included. This may include pain, psychological effects, neurological outcome, functional outcome, health-related quality of life (HRQoL), or adverse effects.

Data extraction, critical appraisal and analysis

One author will undertake the literature search. Two authors will screen the titles and the abstracts identified by the literature search and critically appraise the selected papers independently. A third independent author will be available to resolve any disagreement.

Eligible articles will be critically appraised and assessed for quality based on the National Health and Medical Research Council (NHMRC) guidelines.23 The level of evidence (LOE) will be categorised according to the type of research question as defined by NHMRC Evidence Hierarchy (see online supplementary table S2).24 The strength of the body of evidence will be evaluated using the NHRMC matrix, which has five components including evidence base, consistency, clinical impact, generalisability and applicability, where each component is graded from A to D as excellent, good, satisfactory, or poor, respectively (see online supplementary table S3).24

Synthesis of included studies

The systemic review's findings will be summarised and reported according to Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines.25 ,26 The PRISMA flow diagramme is designed to illustrate the process of conducting the systematic review including the number of studies that were identified, screened, eligible for inclusion, included and excluded with the rationale for exclusion.25

The report will also include a number of summary tables that include search results from each database, strength of evidence, the LOE of the selected studies, as well as the MeSH terms, keywords and the search strategies that have been used in the search strategy.


Cervical SCIs are devastating injuries that occur worldwide. Its consequences affect the patient's physical and psychological wellbeing. It also puts a burden on the patient's family, community, as well as the healthcare system.

The systematic review will contribute to the current debate on the benefits and harms of spinal immobilisation. It will also add to the body of evidence regarding the effects of spinal immobilisation on the outcomes of suspected cervical SCI patients. Acknowledgment of these effects will provide the basis for recommendations that may improve prehospital care for cervical SCI and reduce inappropriate practices. This may improve the patient's quality of life, independence, physical and psychological conditions.



  • Contributors AOO developed the protocol and wrote the manuscript. JS, KS and PAJ critically reviewed and edited the manuscript. All authors contributed to the final review and approval of the manuscript.

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.