From the Alameda County Medical Center, University of California, San Francisco-East Bay, Oakland, CA.
J Trauma Acute Care Surg. 2014 Feb;76(2):534-41. doi: 10.1097/TA.0b013e3182aafe50.
The American College of Surgeons' Committee on Trauma's recent prehospital trauma life support recommendations against prehospital spine immobilization (PHSI) after penetrating trauma are based on a low incidence of unstable spine injuries after penetrating injuries. However, given the chronic and costly nature of devastating spine injuries, the cost-utility of PHSI is unclear. Our hypothesis was that the cost-utility of PHSI in penetrating trauma precludes routine use of this prevention strategy.
A Markov model based cost-utility analysis was performed from a society perspective of a hypothetical cohort of 20-year-old males presenting with penetrating trauma and transported to a US hospital. The analysis compared PHSI with observation alone. The probabilities of spine injuries, costs (US 2010 dollars), and utility of the two groups were derived from published studies and public data. Incremental effectiveness was measured in quality-adjusted life-years. Subset analyses of isolated head and neck injuries as well as sensitivity analyses were performed to assess the strength of the recommendations.
Only 0.2% of penetrating trauma produced unstable spine injury, and only 7.4% of the patients with unstable spine injury who underwent spine stabilization had neurologic improvement. The total lifetime per-patient cost was $930,446 for the PHSI group versus $929,883 for the nonimmobilization group, with no difference in overall quality-adjusted life-years. Subset analysis demonstrated that PHSI for patients with isolated head or neck injuries provided equivocal benefit over nonimmobilization.
PHSI was not cost-effective for patients with torso or extremity penetrating trauma. Despite increased incidence of unstable spine injures produced by penetrating head or neck injuries, the cost-benefit of PHSI in these patients is equivocal, and further studies may be needed before omitting PHSI in patients with penetrating head and neck injuries.
Economic and value-based evaluation, level II.
美国外科医师学会创伤委员会最近提出的院前创伤生命支持建议反对在穿透性创伤后进行院前脊柱固定（PHSI），这是基于穿透性创伤后不稳定脊柱损伤发生率较低的事实。然而，鉴于破坏性脊柱损伤的慢性和昂贵性质，PHSI 的成本效益尚不清楚。我们的假设是，穿透性创伤中 PHSI 的成本效益排除了常规使用这种预防策略的可能性。
从假设的 20 岁男性穿透性创伤患者群体的角度，采用基于马尔可夫模型的成本效益分析，对美国医院进行了前瞻性研究。分析比较了 PHSI 与单纯观察的结果。两组的脊柱损伤概率、成本（2010 年美国美元）和效用均来自已发表的研究和公共数据。增量效果以质量调整生命年来衡量。进行了孤立性头颈部损伤的亚组分析和敏感性分析，以评估建议的强度。
只有 0.2%的穿透性创伤会导致不稳定的脊柱损伤，只有 7.4%接受脊柱稳定术的不稳定脊柱损伤患者的神经功能有所改善。PHSI 组每位患者的终生总费用为 930446 美元，而非固定组为 929883 美元，两组的总质量调整生命年没有差异。亚组分析表明，PHSI 对于孤立性头颈部损伤患者的效果与非固定相比，效果不确定。
PHSI 对于躯干或四肢穿透性创伤患者来说并不具有成本效益。尽管穿透性头颈部损伤导致不稳定脊柱损伤的发生率增加，但 PHSI 在这些患者中的成本效益不确定，可能需要进一步研究才能在穿透性头颈部损伤患者中省略 PHSI。
经济和基于价值的评估，二级。
