We read with interest Millin et al.'s literature review and analysis as well as the letter in response from Calland et al. We were particularly interested in their contention that multidisciplinary teams, including spine surgeons, should be assembled to address this important question. Directly addressing Calland et al.'s concerns about multidisciplinary teams, the Wilderness Medical Society has assembled clinical practice guidelines expert panels addressing spinal injuries since 2011. This analysis included at least one emergency physician, EMS physician, sports medicine physician, paramedic, PhD, EMT, wilderness physician, and military medical specialist as well as orthopaedic surgeon. The lead/senior author of the original 2013 and 2014 guidelines, and co-author on all subsequent versions, is an academic orthopaedic department chair who has decades of experience managing spine trauma and performing spine surgery. Additionally, he led the evidence-based medicine unit (and the associated clinical practice guidelines) of the American Academy of Orthopaedic Surgeons for five years. Inclusion of authors from those subspecialties (a much broader collection than suggested by Calland et al.) still did not change an analysis or recommendation similar to Millin et al.'s: that spinal immobilization was an inappropriate intervention which was demonstrably harmful and had no evidence-based demonstrable benefit. Calland et al. also cite "decades of accumulated clinical experience" as evidence that further study is needed, not "premature abandonment of established practice." What is the degree to which evidence becomes mature enough to change established practice? We have now passed the quarter century mark of accumulated evidence. As Millin et al. have demonstrated, that quarter century of "further study" has only further confirmed the same conclusion. Millin et al. ask how many more peer-reviewed manuscripts need to be published demonstrating harm before spinal immobilization is discarded. We would add, how many decades of data are needed before it is considered "mature"? Additionally, how many professional societies and multidisciplinary teams need to be assembled that come to this same conclusion before the harmful practice of spinal immobilization is discontinued? And finally, to frame this in its most appropriate and patient-centered context-how many patients need to be harmed?
Hawkins et al. (Tue,) studied this question.