***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND Extrication and spinal immobilization in the trauma patient with unknown injuries is a common practice of emergency medical services . High-speed crashes occurring in open-wheel racing seldom result in extrication or spinal immobilization . OBJECTIVES To evaluate the safety of self-extrication in IndyCar ® ( Indianapolis , IN ) by comparing drivers self extricated with full spinal immobilization and subsequent radiation exposure . METHODS A retrospective review of prospect ively collected de-identified IndyCar ® crash and drivers ' medical records was performed at treating Level I trauma centers . One hundred thirty-five crash incidents involving drivers evaluated by a medical team were included . Any driver with severe multiple trauma was excluded due to distracting injuries . Drivers underwent st and ard protocol for postcrash injury . Diagnostic and treatment outcomes including spinal and neurologic injury , need for surgery , and radiation exposure were collected for review . RESULTS  Self-extrication  occurred in 121 ( 90 % ) crashes , and overall cumulative radiation exposure ranged from 100 to 250 mSv , or 0.82 - 2.06 mSv per driver .  Extrication with full spinal immobilization occurred in 14 ( 10 % ) drivers , with overall cumulative radiation exposure ranging from 140 to 350 mSv , or 10 - 25 mSv per driver . A total of 29 injuries were identified , nine of which ( 31 % ) were spinal . In these , six were emergency medical services extricated and three self extricated . None were unstable spinal fractures result ing in surgical care , surgical disease , or neurologic deficit . CONCLUSION In our IndyCar ® racing experience , a protocol -led self-extrication system result ed in neither a mismanagement of an unstable spinal fracture nor neurological deficit , and reduced radiation exposure BACKGROUND Intoxication often prevents clinical clearance of the cervical spine ( Csp ) after trauma leading to prolonged immobilization even with a normal computed tomography ( CT ) scan . We evaluated the accuracy of CT at detecting clinical ly significant Csp injury , and surveyed participants on related opinions and practice . METHODS A prospect i ve multicenter study ( 2013–2015 ) at 17 centers . All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT , with follow-up thru discharge .  alcohol- and drug-intoxicated patients ( TOX+ ) were identified by serum and /or urine testing . Primary outcomes included the incidence and type of Csp injuries , the accuracy of CT scan , and the impact of TOX+ on the time to Csp clearance . A 36-item survey querying local protocol s , practice s , and opinions in the TOX+ population was administered . RESULTS Ten thous and one hundred ninety-one patients were prospect ively enrolled and underwent CT Csp during the initial trauma evaluation . The majority were men ( 67 % ) , had vehicular trauma or falls ( 83 % ) , with mean age of 48 years , and mean Injury Severity Score ( ISS ) of 11 . The overall incidence of Csp injury was 10.6 % . TOX+ comprised 30 % of the cohort ( 19 % EtOH only , 6 % drug only , and 5 % both ) . TOX+ were significantly younger ( 41 years vs. 51 years ; p < 0.01 ) but with similar mean Injury Severity Score ( 11 ) and Glasgow Coma Scale score ( 13 ) . The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated ( 8.4 % vs. 11.5 % ; p < 0.01 ) . In the TOX+ group , CT had a sensitivity of 94 % , specificity of 99.5 % , and negative predictive value ( NPV ) of 99.5 % for all Csp injuries . For clinical ly significant injuries , the NPV was 99.9 % , and there were no unstable Csp injuries missed by CT ( NPV , 100 % ) . When CT Csp was negative , TOX+ led to longer immobilization versus sober patients ( mean , 8 hours vs. 2 hours ; p < 0.01 ) , and prolonged immobilization ( > 12 hrs ) in 25 % . The survey showed marked variations in protocol s , definitions , and Csp clearance practice s among participating centers , although 100 % indicated willingness to change practice based on these data . CONCLUSION For intoxicated patients undergoing Csp imaging , CT scan was highly accurate and reliable for identifying clinical ly significant spine injuries , and had a 100 % NPV for identifying unstable injuries . CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization . There was wide disparity in practice s , definitions , and opinions among the participating centers . LEVEL OF EVIDENCE Diagnostic tests or criteria , level II OBJECTIVES To compare the incidences and severities of pain experienced by healthy volunteers undergoing spinal immobilization in the neutral position with and without occipital padding .  To compare the incidence of pain when immobilized in the neutral position with the incidence in a nonneutral position . METHODS Thirty-nine healthy volunteers over the age of 18 years who had no acute pain or illness , were not pregnant , and had no history of back problems or surgery voluntarily participated in a prospect i ve , r and omized , crossover study conducted in a clinical laboratory setting . Appropriately sized rigid cervical collars were applied to the subjects , who were then immobilized on wooden backboards with their cervical spines maintained in the neutral position using towels ( padded ) or plywood ( unpadded ) under their occiputs . The subjects were secured to the board with straps , soft head blocks , and tape for 15 minutes to simulate a typical ambulance transport time . The straps , head blocks , and tape were removed , and the subjects remained on the board for an additional 45 minutes to simulate a typical emergency department experience . The subjects were then asked to identify the location(s ) of any pain on anterior and posterior body outlines and to indicate the corresponding severity of pain on a 10-cm visual analog scale . The subjects were also asked questions about movement , respiratory symptoms , and strap discomfort in an attempt to distract them from the true focus of the study ( i.e. , pain ) . A similar survey was given to each participant to complete 24 hours later . The same subjects were immobilized with the alternate occipital material a minimum of two weeks later utilizing the same procedure . They again completed both surveys . RESULTS Pain was reported by 76.9 % of the subjects following removal from the backboard for the unpadded trial and 69.2 % of the subjects following the padded trial ( p < 0.45 ) . Twenty-three percent ( 23.1 % ) of the subjects reported neck pain after the unpadded trial , while 38.5 % reported neck pain after the padded trial ( p < 0.07 ) . Occipital pain was reported by 35.9 % in the unpadded trial and 25.6 % in the padded trial ( p < 0.29 ) . Twenty-four hours later , pain was reported by 17.9 % of the subjects following the unpadded trial and 23.1 % of the subjects following the padded trial ( p < 0.63 ) . Eight percent ( 7.7 % ) reported neck pain 24 hours after the and unpadded trial and 12.8 % after the padded trial ( p < 0.5 ) . Occipital pain was reported by 7.7 % of the subjects 24 hours after the unpadded trial and 2.6 % after the padded trial ( p < 0.63 ) . This study had a power of 0.90 to detect a difference of 30 % between the trials . The authors found a significantly lower incidence of pain ( p < 0.01 ) and occipital pain ( p < 0.01 ) in their unpadded trial compared with that reported by Chan et al. , who used neither padding nor neutral positioning to immobilize subjects . CONCLUSIONS Pain is frequently reported by healthy volunteers following spinal immobilization . Occipital padding does not appear to significantly decrease the incidence or severity of pain . Alignment of the cervical spine in the neutral position may reduce the incidence of pain , but further studies should be conducted to substantiate this observation INTRODUCTION Traditional EMS teaching identifies mechanism of injury as an important predictor of spinal injury . Clinical criteria to select patients for immobilization are being studied in Michigan and have been implemented in Maine . Maine requires automatic immobilization of patients with " a positive mechanism " clearly capable of producing spinal injury . OBJECTIVE To determine whether mechanism of injury affects the ability of clinical criteria to identify patients with spinal injury . METHODS In this multicenter prospect i ve cohort study , EMS personnel completed a check-off data sheet for prehospital spine-immobilized patients .  Data included mechanism of injury and yes/no determinations of the clinical criteria : altered mental status , neurologic deficit , evidence of intoxication , spinal pain or tenderness , and suspected extremity fracture . Hospital outcome data included confirmation of spinal injury and treatment required . Mechanisms of injury were tabulated and rates of spinal injury for each mechanism were calculated . The patients were divided into three different high-risk and low-risk groups . RESULTS Data were collected for 6,500 patients . There were 209 ( 3.2 % ) patients with spinal injuries identified . There were 1,058 patients with 100 ( 9.4 % ) injuries in the first high-risk mechanism group , and 5,423 patients with 109 ( 2 % ) injuries in the first low-risk group . Criteria identified 97 of 100 ( 97 % ) injuries in the high-risk group and 102 of 109 ( 94 % ) in the low-risk group . Two additional data divisions yielded identical results . CONCLUSION Mechanism of injury does not affect the ability of clinical criteria to predict spinal injury in this population BACKGROUND A distracting injury m and ates cervical spine ( c-spine ) imaging in the evaluable blunt trauma patient who demonstrates no pain or tenderness over the c-spine . The purpose of this study was to examine which distracting injuries can negatively affect the sensitivity of the st and ard clinical examination of the c-spine . METHODS This is a prospect i ve observational study conducted at a Level I Trauma Center from January 1 , 2008 , to December 31 , 2009 . After institutional review board approval , all evaluable ( Glasgow Coma Scale score ≥13 ) blunt trauma patients older than 16 years sustaining a c-spine injury were enrolled . A distracting injury was defined as any immediately evident bony or soft tissue injury or a complaint of non-c-spine pain whether or not an actual injury was subsequently diagnosed . Information regarding the initial clinical examination and the presence of a distracting injury was collected from the senior resident or attending trauma surgeon involved in the initial management . RESULTS During the study period , 101 evaluable patients sustained a c-spine injury .  Distracting injuries were present in 88 patients ( 87.1 % ) . The most common was rib fracture ( 21.6 % ) , followed by lower extremity fracture ( 20.5 % ) and upper extremity fracture ( 12.5 % ) . Only four ( 4.0 % ) patients had no pain or tenderness on the initial examination of the c-spine . All four patients had bruising and tenderness to the upper anterior chest . None of these four patients developed neurologic sequelae or required a surgical stabilization or immobilization . CONCLUSION C-spine imaging may not be required in the evaluable blunt trauma patient despite distracting injuries in any body regions that do not involve the upper chest . Further definition of distracting injuries is m and ated to avoid unnecessary utilization of re sources and to reduce the imaging burden associated with the evaluation of the c-spine OBJECTIVE For thirty years , emergency medical services agencies have emphasized limiting spinal motion during transport of the trauma patient to the emergency department . The long spine board ( LSB ) has been the mainstay of spinal motion restriction practice s , despite the paucity of data to support its use . The purpose of this study was to determine reduction in lateral motion afforded by the LSB in comparison to the stretcher mattress alone . METHODS This was a r and omized controlled crossover trial where healthy volunteer subjects were r and omly assigned to either LSB or stretcher mattress only . All subjects were fitted with a rigid cervical collar , secured to the assigned device ( including foam head blocks ) , and driven on a closed course with prescribed turns at a low speed ( < 20 mph ) . Upon completion , the subjects were then secured to the other device and the course was repeated . Each subject was fitted with 3 graduated-paper disks ( head , chest , hip ) . Lasers were affixed to a scaffold attached to the stretcher bridging over the patient and aim ed at the center of the concentric graduations on the disks . During transport , the degree of lateral movement was recorded during each turn . Significance was determined by t test . RESULTS In both groups , the head demonstrated the least motion with 0.46±0.4-cm mattress and 0.97±0.7-cm LSB ( P≤ .0001 ) . The chest and hip had lateral movement with chest 1.22±0.9-cm mattress and 2.22±1.4-cm LSB ( P≤ .0001 ) , and the hip 1.20±0.9-cm mattress and 1.88±1.2-cm LSB ( P≤ .0001 ) , respectively . In addition , lateral movement had a significant 
    Output:
    
This process yielded five main recommendations : A strong recommendation against spinal stabilisation of patients with isolated penetrating trauma ; a weak recommendation against the prehospital use of a rigid cervical collar and a hard backboard for ABCDE-stable patients ; and a weak recommendation for the use of a vacuum mattress for patient transportation .