The Impact of Prehospital Spinal Immobilization in Patients with Penetrating Spinal Injuries: A Systematic Review and Meta-Analysis
Round 1
Reviewer 1 Report
In this systematic review, the authors aimed to investigate the efficacy of prehospital PHSI in patients with penetrating trauma. They conclude that the use of PHSI should be discouraged because it increases mortality and other health complications
Strength: well-written and good presentation of the results
The weaknesses are related to the retrospective nature of the papers included in this meta-analysis making this study a level 3 of evidence
- as the authors state in the limitation section all of the 6 studies have several bias and in 2 of them there were no data that compare mortality, are the conclusion supported by the results of this meta-analysis?
- in all studies included there were no data about trasportation time ; could it be an important bias for comparing mortality PHSI/nonPHSI?
- two studies (Haul et al. and Brown et al.) analyzed patients from the same database in the same period, could these studies be considered as duplication? in addition, in the study of Brown et al. there were no data of use of PHSI in patients from the NTDB database (75000 patients)
- minor revisions : the use of abbreviations is not always necessary for example using CSI for cervical spine immobilization could be confounded with SCI ecc...
Author Response
Comment: as the authors state in the limitation section all of the 6 studies have several biases and in 2 of them there were no data that compare mortality, are the conclusion supported by the results of this meta-analysis?
Author response: Although all 6 studies have bias and two studies did not report mortality, the four remaining studies do seem to support our meta-analysis with e significant p value. Therefore, we are inclined to say that PHSI does seem to cause a higher mortality rate.
Comment: in all studies included there were no data about transportation time; could it be an important bias for comparing mortality PHSI/nonPHSI?
Author response: Yes, we agree that this could be a confounding factor and have now included this in the limitations. Please see lines 426-428.
Comment: two studies (Haut et al. and Brown et al.) analyzed patients from the same database in the same period, could these studies be considered as duplication? in addition, in the study of Brown et al. there were no data of use of PHSI in patients from the NTDB database (75000 patients)
Author response: Yes, we agree that this could be duplication and have brought this out in the limitation sections. Please see lines 426-430.
Comment: minor revisions: the use of abbreviations is not always necessary for example using CSI for cervical spine immobilization could be confounded with SCI etc...
Author response: We have removed the CSI abbreviation completely so as not to confound with SCI.
Reviewer 2 Report
The authors of this publication take up an important issue of pre-hospital management in patients with penetrating spinal injuries. Spine injuries, due to the possible consequences, are among the most dangerous for the health and life of the patient. Algorithms for dealing with such injuries require securing the respiratory tract and the spine. This work will change the rules for dealing with penetrating injuries.
The study analyzed publications from well-selected databases from a long period of time - January 2000 - January 2021. Out of 928 publications, only 6 were included. This proves high and appropriate criteria for including and excluding publications from the analysis.
It is clear from the analysis of the included publications that the approach to pre-hospital care for a patient with spine injury should be changed. Blunt injuries where there is a risk of spinal instability require immobilization, penetrating injuries where immobilization may cause additional negative effects require consideration of the use of immobilization.
It should be emphasized that the analysis was carried out by hand by two authors of the research methodology.
The strength of the publication is the quality assessment and statistical analysis.
The authors also note the delay in patient transport, which significantly affects patient survival.
The publication is an important literature analysis that changes the perception of pre-hospital care in patients with penetrating spinal injuries. It should also be the basis for further research and changes towards pre-hospital care.
Author Response
No comments that we could find which requires a response. Thank you for your time and kind words regarding our manuscript.
Round 2
Reviewer 1 Report
the authors have addressed all my concerns. this paper is now suitable for pubblication
