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Pressure ulcers from spinal immobilization in trauma patients: A systematic review

Ham, Wietske RN, CEN, MSc; Schoonhoven, Lisette PhD, RN; Schuurmans, Marieke J. PhD, RN; Leenen, Luke P.H. PhD, MD

Journal of Trauma and Acute Care Surgery: April 2014 - Volume 76 - Issue 4 - p 1131–1141
doi: 10.1097/TA.0000000000000153
Review Articles

BACKGROUND To protect the (possibly) injured spine, trauma patients are immobilized on backboard or vacuum mattress, with a cervical collar, lateral headblocks, and straps. Several studies identified pressure ulcer (PU) development from these devices. The aim of this literature study was to gain insight into the occurrence and development of PUs, the risk factors, and the possible interventions to prevent PUs related to spinal immobilization with devices in adult trauma patients.

METHODS We systematically searched PubMed (MEDLINE), EMBASE, Cochrane, and CINAHL for the period 1970 to September 2011. Studies were included if participants were healthy volunteers under spinal immobilization or trauma patients under spinal immobilization until spine injuries were diagnosed or excluded. Outcomes of primary interest included occurrence, severity, and risk for PU development as well as prevention of PU development related to spinal immobilization devices.

RESULTS The results of included studies show an incidence of collar-related PUs ranging from 6.8% to 38%. Described locations are the occiput, chin, shoulders, and back. The severity of these PUs varies between Stages 1 and 3, and one study describes PUs requiring surgical debridement, indicating a Stage 4 PU. Described risk factors for PU development are high pressure and pain from immobilizing devices, the length of time in/on a device, intensive care unit admission, high Injury Severity Scores (ISSs), mechanical ventilation, and intracranial pressure monitoring. Preventive interventions for collar-related PUs include early replacement of the extrication collar and regular skin assessment, collar refit, and position change.

CONCLUSION The results from this systematic review show that immobilization with devices increases the risk for PU development. This risk is demonstrated in nine experimental studies with healthy volunteers and in four clinical studies.

LEVEL OF EVIDENCE Systematic review, level III.

From the University Medical Center (W.H., M.J.S., L.P.H.L.), Utrecht; and Scientific Institute for Quality of Healthcare (IQ Healthcare) (L.S.), Radboud University Medical Center, Nijmegen, the Netherlands; and Faculty of Health Sciences (L.S.), University of Southampton, Southampton, United Kingdom.

Submitted: October 18, 2013, Revised: November 26, 2013, Accepted: December 2, 2013.

Address for reprints: Wietske Ham, RN, CEN, MSc, University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands; email:

© 2014 Lippincott Williams & Wilkins, Inc.