Clinical Review

The Changing Standard of Care for Spinal Immobilization

Emergency Medicine. 2016 April;48(4):152-157

References

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20. American College of Emergency Physicians. Policy Statement- EMS Management of Patients with Potential Spinal Injury. 2015. Available at: http://www.acep.org/Physician-Resources/Policies/Policy-Statements/EMS-Management-of-Patients-with-Potential-Spinal-Injury. Accessed February 9, 2016.

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Many trauma patients arrive with complaints of pain at one or more sites. Some of these complaints, particularly back pain, may be secondary to the use of the backboard itself, especially in cases of prolonged transport.^21,22 In a study of healthy volunteers who were immobilized on a backboard for 30 minutes, all of them reported pain, along with headaches, most often involving the occipital and sacral regions.²³ A 1996 study compared spinal immobilization utilizing a backboard versus a vacuum mattress in 37 healthy volunteers with no history of back pain or spinal disease.²⁴ Compared to those immobilized with the vacuum mattress, patients immobilized with a backboard for 30 minutes were 3.1 times more likely to have symptoms, 7.9 times more likely to complain of occipital pain, and 4.3 times more likely to have lumbosacral pain.²⁴

Increased pain complaints in the setting of trauma can result in increased imaging, leading to increased costs and unnecessary radiation exposure.²⁵ Prolonged backboard times can also result in sacral pressure ulcers.²⁶ A recent study has shown that patients who undergo computed tomography (CT) scans with automatic tube current modulation (as most modern multidetector row CT systems utilize) while on a backboard may be exposed to a significant increase in radiation dose.²⁷

Spinal immobilization has also been linked to respiratory compromise, particularly with the use of straps across the chest, even when not applied tightly. One study found worse lung function test results in healthy immobilized volunteers.²⁸ Other studies have shown that older patients (even when healthy) and those with lung or chest injury have an even larger degree of restriction and respiratory compromise.^29,30

Risks from immobilization are not isolated to backboards. The use of cervical collars alone also carries potential risks. (See “What About Cervical Collars?”^8,31-39)

Risk of Secondary Neurological Deterioration Is Low

Many EMS systems have already adopted the new standards calling for less use of spinal immobilization. Though the evidence is compelling, not all EMS systems have adopted these standards due to strongly rooted beliefs and fears of long-term patient disability and subsequent litigation. However, these fears do not appear justified.

A recent review by Oto et al⁴⁰ found only 42 cases of early secondary neurological deterioration after blunt trauma in all of the indexed medical literature. They noted, “In twelve cases the authors did attribute deterioration to temporally associated precipitants, seven of which were possibly iatrogenic; these included removal of a cervical collar, placement of a halo device, patient agitation, performance of flexion/extension films, ‘unintentional manipulation,’ falling in or near the ED, and forced collar application in patients with ankylosing spondylitis.” Thirteen of these cases occurred during prehospital care, none of them sudden and movement-provoked, and all reported by a single study.” This review highlights the rarity of secondary deterioration.

When Should Immobilization Be Used?

So what’s the next step for spinal immobilization in the field? How do we appropriately protect trauma patients during transport? As always seems to be the case in medicine, more evidence is needed. Oteir et al⁴¹ recently published a review of new literature on the epidemiology and current practice of prehospital spine management. They reported that early (8-24 hours) transfer of patients with spinal injury to spinal care units, along with effective resuscitation, was the most important determinant of better neurological outcomes.⁴¹ This review reaffirms the need for more data evaluating the relationship between spinal immobilization and neurological outcomes.

Currently, recommendations call for selective spinal immobilization to decrease unnecessary application and potential harm. Use of backboards for spinal immobilization should be limited to the following types of patients:^1,20

Blunt trauma and altered level of consciousness;
Spinal pain or tenderness;
Neurological complaint (eg, numbness or motor weakness);
Anatomic deformity of the spine;
High-energy mechanism of injury and:
- Drug or alcohol intoxication;
- Inability to communicate; and/or
- Distracting injury.

Patients for whom immobilization on a backboard is not necessary include those with all of the following:

Normal level of consciousness (GCS 15);
No spine tenderness or anatomic abnormality;
No neurological findings or complaints;
No distracting injury;
No intoxication.

Cervical collars alone are still recommended for use in patients who do not meet validated clinical rules, such as the NEXUS or Canadian C spine rules.^1,20,42,43As these rules are well validated, they can be safely used to determine who should have a cervical collar placed, with or without a backboard. In a retrospective review, selective spinal immobilization was found to be 99% sensitive in identifying patients with cervical injuries.⁴⁴

Clearly, there is still work to be done. Due to the relative rarity of actual spinal cord injury with the consequences of neurological injury, prospective trials in this area are rare and very difficult to safely design. However, there is growing confidence that selective spinal protocols, together with the inclusion of validated clinical rules, can effectively limit exposure to unnecessary spinal immobilization. As the current evidence continues to mount for the potential harm in indiscriminate backboard and cervical collar use, it seems clear we should strive to decrease the overuse of prehospital and early spinal immobilization consistent with current position statements and validated clinical rules.