Evaluating a novel, low-cost technique for cervical-spine immobilization for application in resource-limited LMICs: a non-inferiority trial.

STUDY DESIGN: Non-inferiority trial. OBJECTIVE: Limited cervical spinal (c-spine) immobilization in resource-limited settings of LMICs suggests alternatives are necessary for patients with traumatic injuries. We propose a novel method of c-spine immobilization using folded towels. SETTING: Washington University in St. Louis. METHODS: Using non-inferiority trial design, thirty healthy patients (median age = 22) were enrolled to test the efficacy of folded towels in comparison with rigid cervical collars, foam neck braces, and no immobilization. We measured cervical range of motion (CROM) in six cardinal directions in seated and supine positions. A weighted composite score (CS) was generated to compare immobilization methods. A preserved fraction of 75% was determined for non-inferiority, corresponding to the difference between the median values for CROM between control (no immobilization) and c-collar states. RESULTS: C-collars reduce median CROM in six cardinal directions in seated and supine positions by an average of -36.83° seated (-17.75° supine) vs. no immobilization. Folded towels and foam neck braces reduced CROM by -27° seated (-16.75° supine) and -14.25° seated (-9.5° supine), respectively. Compared to a 25% non-inferiority margin (permitting an average 9.21° of cervical movement across six cardinal directions), the CS determined folded towels are non-inferior (CSseated = 0.89, CSsupine = 0.47). Foam neck braces are inferior (CSseated = 2.35, CSsupine = 2.10). CS > 1 surpassed the non-inferiority margin and were deemed inferior. CONCLUSIONS: Folded towels are a non-inferior means of immobilizing c-spine in extension and rotation, but not flexion, vs. c-collars. We propose folded towels could be trialed in combination with backboards to deliver affordable and effective prehospital TSCI management in resource-limited settings.

Prehospital care for traumatic spinal cord injury by first responders in 8 sub-Saharan African countries and 6 other low- and middle-income countries: A scoping review.

INTRODUCTION: Traumatic spinal cord injury (TSCI) constitutes a considerable portion of the global injury burden, disproportionately affecting low- and middle-income countries (LMICs). Prehospital care can address TSCI morbidity and mortality, but emergency medical services are lacking in LMICs. The current standard of prehospital care for TSCI in sub-Saharan Africa and other LMICs is unknown. METHODS: This review sought to describe the state of training and resources for prehospital TSCI management in sub-Saharan Africa and other LMICs. Articles published between 1 January 1995 and 1 March 2020 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for TSCI. Two reviewers assessed full texts meeting inclusion criteria for quality using the Newcastle-Ottawa Scale and extracted relevant characteristics to assess trends in the state of prehospital TSCI care in sub-Saharan Africa and other LMICs. RESULTS: Of an initial 482 articles identified, 23 met inclusion criteria, of which ten were set in Africa, representing eight countries. C-spine immobilization precautions for suspected TSCI patients is the most prevalent prehospital TSCI intervention for and is in every LMIC first responder program reviewed, except one. Numerous first responder programs providing TSCI care operate without C-collar access (n = 13) and few teach full spinal immobilization (n = 5). Rapid transport is most frequently reported as the key mortality-reducing factor (n = 11). Despite more studies conducted in the Southeast Asia/Middle East (n = 13), prehospital TSCI studies in Africa are more geographically diverse, but responder courses are shorter, produce fewer professional responders, and have limited C-collar availability. DISCUSSION: Deficits in training and resources to manage TSCI highlights the need for large prospective trials evaluating alternative C-spine immobilization methods for TCSI that are more readily available across diverse LMIC environments and the importance of understanding resource variability to sustainably improve prehospital TSCI care.