Spinal Immobilization: Where did the messaging go wrong?

Spinal Immobilization: Where did the messaging go wrong?
Kate Zimmerman, DO, FACEP
With much credit to Tim Pieh, MD

In 2015 the Medical Direction and Practices Board updated the Spine Management Protocol. This was done through face-to-face protocol roll-outs, conference calls, discussions at the Regional levels, MEMSEd protocol updates as well as supported by a comprehensive white paper which was and still is posted on the Maine EMS website. Despite the intended consistent messaging, I have personally seen significant liberties taken in the assessment and management of the potentially spine-injured patient that were not supported by the protocol. In this post, I will review and elaborate upon the information in the white paper – which I have openly transcribed into this blog. I give much credit to Dr. Pieh who was the original author of the white paper, “Spinal Immobilization Update” which can be found in its original form on the Maine EMS website (http://www.maine.gov/ems/ )under the publications tab.

THE BEGINNING…

I think that it is important to acknowledge that change is difficult. We have been using cervical collars and backboards as the primary method of protecting a suspected spinal injury since the inception of EMS in the 1960s. Since that time spinal immobilization has been largely unchanged. When I trained as an EMT in 1991, the backboard was still one of the most used tools on the truck. I also remember routinely using the K.E.D (Kendrick Extrication Device) during extrications from motor vehicles and wondering to myself if there were an easier way to get able-bodied patients out of the vehicles or other confined spaces who had suspected spinal injury. Our goal still is, and has always been, to do no further harm to our patients while getting them from the scene to the hospital. For the suspected spine-injured patient, c-collar placement and the mandated rigid back board. This also meant that the patient could not actively participate in the process as we were thought to do a better job at maintaining in-line stabilization than the patient was themselves. It was not until the past few years that we have begun to really comb though the evidence that led to the longboard dogma, only to realize that based on today’s standards, the evidence was weak. Our experience over the past half-century has also taught us that backboards can be harmful to patients and their use should carefully be considered. When you go back and look at the “evidence” behind the use of the longboard, you start at a report published in 1966 by Geisler et al.. This report attributed “delayed onset of paraplegia” in hospitalized patients with spinal fractures to “failure to recognize the injury and protect the patient from the consequences of his unstable spine.” This was translated to the care of patients in the prehospital setting. It does not answer the best way to protect these patients. However, like any other broken bone that is immobilized with a rigid splint, the rigid backboard was created. Since there is great morbidity and mortality associated with spinal injuries, the rigid backboard has not come into question. As I look back at the history, knowing what I know now, Geisler’s study should have asked the question, how can we best identify the potential spine-injured patient in the field so that we may safely transport them, rapidly identify the injury and closely monitor for cord edema which can lead to delayed paralysis? That question has been answered through a series of studies which have looked at spine assessment.

WHAT DID NOT CHANGE?

The way that we assess for spinal injuries is NOT changing. The data is strong and the process has been validated here in Maine. I think that it is important to review the story behind how we came to our spinal assessment protocol to reinforce its importance – and to reinforce how it is properly applied. Unfortunately, I have been witness to misapplication of this protocol leading to improper management of potentially spine-injured patients. It has left me with the sense that many providers feel that since the backboard is no longer mandated that the spine assessment is no longer important, this is not true. We have very strong evidence supporting our spine assessment protocol and we know how important it is for the outcomes of our patients.

In 2000, the NEXUS study validated a safe spinal clearance protocol. It was a multicenter, prospective, observational study of all ED patients with blunt trauma for whom cervical spine imaging was ordered. The study population consisted of 34,069 patients evaluated by imaging of the cervical spine after blunt trauma. Of these 34,069 patients, 818 (2.4 percent) had radiographically documented cervical-spine injury. There were eight patients whom the decision instrument identified as having a low probability of injury but who did have radiographically documented cervical-spine injury. The sensitivity of the protocol was 99.0 percent [95 percent confidence interval, 98.0 to 99.6 percent]). The negative predictive value was 99.8 percent (95 percent confidence interval, 99.6 to 100 percent). It was found that assessment of all five criteria in each patient was necessary for the decision instrument as a whole to achieve high sensitivity, since fulfillment of a single criterion was the only finding in some of the patients with injury, including some with clinically significant injury; this was the case for each of the five criteria.

Looking at the criteria, this is how they were defined in the study:

  1. Altered neurologic function is present if any of the following is present:
    • (a) Glasgow Coma Scale score of 14 or less;
      (b) disorientation to person, place, time, or events;
      (c) inability to remember 3 objects at 5 minutes;
      (d) delayed or inappropriate response to external stimuli; or
      (e) any focal deficit on motor or sensory examination.

     
    Patients with none of these individual findings should be classified as having normal neurologic function.

  2. . Patients should be considered intoxicated if they have either of the following:
    • (a) a recent history of intoxication or intoxicating ingestion; or
      (b) evidence of intoxication on physical examination.

     
    Patients may also be considered to be intoxicated if tests of bodily secretions are positive for drugs that affect level of alertness, including a blood alcohol level greater than .08 mg/dL.

  3. Midline posterior bony cervical spine tenderness is present if the patient complains of pain on palpation of the posterior midline neck from the nuchal ridge to the prominence of the first thoracic vertebra, or if the patient evinces pain with direct palpation of any cervical spinous process.
  4. Patients should be considered to have a distracting painful injury if they have any of the following:
    (a) a long bone fracture;
    (b) a visceral injury requiring surgical consultation;
    (c) a large laceration, de-gloving injury, or crush injury;
    (d) large burns; or
    (e) any other injury producing acute functional impairment.

Physicians may also classify any injury as distracting if it is thought to have the potential to impair the patient’s ability to appreciate other injuries.

Now, while the NEXUS study was designed to identify low risk patients who did not need radiography, the results were extrapolated to those that did not need radiography, did not have an injury and hence did not need cervical spine immobilization in the field. In 2002, this extrapolation was studied and the protocol was validated in the prehospital setting. This study was performed here in Maine by our formal Maine EMS Medical Director, Dr. John Burton. Thirty-two thousand Maine EMS trauma cases were reviewed in the year following the implementation of the Spine Assessment Protocol. Burton’s study showed Maine EMS providers only missed one clinically significant spinal fracture while caring for 32,000 patients and concluded that EMS providers can effectively and safely implement a protocol assessing patients with suspected spine injuries.

Please note that none of the 2015 protocol updates made any changes to how Maine EMS providers evaluate spine injuries. Thus, any patient who fails our well-established spinal assessment must be assumed to have potential unstable spine injury. It is still critical to protect these patients and keep them safe by immobilizing their spine and ensuring that they arrive to the hospital with minimal movement to their spine.

SO WHAT WAS THE CHANGE?

We updated HOW we immobilize the spine. A great deal of literature has been published since we last updated the Maine EMS selective spinal immobilization protocol. Backboards are excellent extrication tools, but are not the best tool for immobilization during patient transport.

The current literature on this topic can be organized into several important themes:

  1. Backboards can harm patients by causing the following:
    • (a) Pain, which may lead to (b)
      (b) Unnecessary imaging while in the emergency department
      (c) Respiratory compromise
      (d) Pressure sores
  2. Appropriate patients can safely self-extricate from motor vehicles
  3. Appropriate ambulatory patients who fail spinal evaluation can safely sit then lie down on an EMS cot (rather than performing standing take-downs)
  4. EMS cots are excellent spinal immobilization tools when used with a cervical collar (provided that the patient is supine and has the 5-point harness and other straps properly secured).

LITERATURE REVIEW

PAIN

The hard, stiff backboard concentrates pressure on points of skin that it contacts. This decreases tissue perfusion and causes pain. This can happen in as little as 20 minutes. Backboards also cause pain in the low back and cervical spine because of anatomically incorrect positioning due to placing a curved spine on a flat board. In one study, it found that low back and cervical pain persisted in healthy adults for 24 hours after spending only one hour on the board.

UNNECESSARY RADIOLOGICAL TESTING

The pain described above can make it difficult to distinguish pain due to underlying spine injury versus pain due to the backboard itself. Clinicians may be forced to perform imaging of these areas. Increased exposure to radiation from medical imaging has been associated with increased risk of cancer. Additionally, as stewards of the health care system, all providers should be critical of therapies that are contrary to the triple aim of outcome (including satisfaction), population health, and cost.

RESPIRATORY COMPROMISE

Studies have shown that straps tightened across the chest of patients lying flat on backboards have a restrictive effect which makes it harder to breathe with up to a 17% reduction in respiratory function and greatest effects at the extremes of age. For patients with underlying lung and chest injuries, these tight straps further disrupt the mechanics of breathing. Releasing these straps improves breathing but would *** the goal of immobilization.

PRESSURE SORES

Multiple studies have confirmed Linares’ et al. 1987 association of immobilization on backboards with the development of pressure sores. Significant tissue hypoxia in the sacral area occurs after just 30 minutes in healthy adults placed on a rigid, unpadded backboard. Can you imagine how quickly this would occur in the frail elderly patient? How about on any patient during a long transport or inter-facility transfer?

DON’T THROW THE BACKBOARD IN THE TRASH & REMEMBER THE SCOOP STRETCHER!

A backboard, scoop stretcher or other extrication device may be warranted for use during transport, based on the EMS provider’s judgment in the following circumstances:

  1. When extricating a patient who is inappropriate for self-extrication.
  2. Patients at risk for vomiting who are unable to manage their own airway (intoxicated/head-injured with altered mental status, etc.) and may need to be turned to their side during transport.
  3. Multisystem trauma or multiple long-bone fractures in which the backboard is an element of the splinting strategy.
  4. Unresponsive or agitated patients.
  5. When removal would delay transport of an unstable patient.

Remember the scoop stretcher! It needs to be dusted off, hinges oiled and personnel re-acquainted with its use. This is an excellent device to transfer a supine patient to the stretcher with minimal movement/rolling. I highly recommend doing in-house training re: moving a patient to your stretcher with a backboard vs. a scoop stretcher and then removing the device so that you can secure the patient directly to the cot.

IDENTIFYING PATIENTS FOR SELF-EXTRICATION

These are the same patients who are appropriate for sign off. They are calm, cooperative, sober and alert. They have no language or other barriers to communication. They can reliably hold their whole spine still while moving themselves carefully from a vehicle. They have no injuries (such as lower extremity injuries) that may inhibit their ability to self-extricate. They are patients already in a sitting position or standing. These are NOT patients that are sitting on the ground or lying on the ground. Those patients require a backboard or scoop stretcher to transfer them to the cot, all while having a c-collar in place and manual stabilization held until the patient is secured to the stretcher. Once on the stretcher in a supine position and all straps in place, it is not necessary to continue manual stabilization of the cervical spine as long as there is a collar in place. Please do not have a pillow under the head unless the patient is kyphotic. Remember, once at the hospital, spinal precautions must be maintained as you move the patient from your cot to the receiving hospital’s stretcher. This is not a time to ask the patient to “scoot over”.

SAFELY TRANSPORTING PATIENTS WITH KNOWN SPINAL INJURIES – just to reiterate…

Backboards have no role in inter-facility transport. The EMS cot is a safer, more comfortable and more appropriate spinal immobilization device. These patients should be secured to the EMS cot as if they were being secured to the backboard. The standard EMS cot provides a flat surface to which the patient can be secured. The pad conforms to the curves of the spine and distributes pressure evenly to protect from pressure sores. Securing the patient to the EMS cot with straps can reduce spinal flexion, rotation, and lateral motion. The surface of the cot mattress further reduces patient movement. Once on the cot, a backboard becomes redundant and should be removed unless otherwise needed (see above). Placing the patient on (and taking the patient off) the EMS cot must be done with strict spinal precautions. Slide boards are very useful in these situations.

Maine EMS and the MDPB have shared this and similar educational tools with hospitals, emergency departments, physicians, nurses and others. Despite this effort, there have been times in which controversy remained regarding the best mechanism in which to transport patients with known spine injuries. Please discuss management options with the transferring physicians; however, Maine EMS, the MDPB, and the Trauma Advisory Committee agree that backboards are not the standard of care for the inter-facility transport of patients, even when the patient has a known spine injury.

IMMOBILIZING AMBULATORY PATIENTS

These patients DO NOT need a standing take-down. EMS places the c-collar and holds spine still in traditional technique while the cot is placed behind the patient’s back. The patient may then sit on the cot and then lie flat with EMS guidance.

I hope that you have found this commentary and literature review helpful re: the white paper….more to come here (reviewing the literature and my prior lectures)

Maine EMS White Paper on Spine Management (PDF)


Geisler Paper Citation:

Med Serv J Can. 1966 Jul-Aug;22(7):512-23.
Early management of the patient with trauma to the spinal cord.
Geisler WO, Wynne-Jones M, Jousse AT.

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