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Spinal Immobilization: Just a pain in the neck?




The principles behind spinal immobilization, including the utilization of backboards and cervical collars was derived from expert opinion in the 1960's [1-3], and has never been subjected to a randomized controlled trial or high quality observational study.

Significantly more patients are immobilized than will actually have a fracture [4], and whether or not immobilization actually improves outcomes for those who do have a fracture, is highly debatable. 




Backboards should not be used once the patient reaches the Emergency Department (ED)

  • Backboards have numerous well documented risks of harm:
    • Increased field time for paramedics
    • Pressure ulcers [5]
    • Decreased tidal volumes [6,7]
    • Increased pain
    • Increases unnecessary imaging
  • Professional organizations such as the American College of Emergency Physicians (ACEP) and the National Association of EMS Physicians (NAEMSP) support changing EMS practice to the selective use of backboards in the prehospital setting, and removal of patients from the backboard as soon as possible upon arrival to the emergency department. 
  • The mounting evidence [8,9] and expert opinions [10] lends credence to the idea that we should consider stopping the use of backboards in the ED, or to identify more appropriate alternatives. 

Cervical Collars do not need to routinely be applied by EMS:

  • Patients placed in full spinal immobilization after penetrating trauma have an increased risk of mortality, likely due to the increased time required at scene [11]. 
  • One small study has suggested that paramedics can safely apply the Canadian C-Spine Rules (CCR), demonstrating a performance sensitivity of 100% and a specificity of 37.7% [12]. A larger, soon to be published study will prospectively confirm this in a larger population.
  • Other selective immobilization strategies (ie: the NEXUS criteria) lack sufficient sensitivity to be recommended for the prehospital setting [13-15].
  • Unconscious trauma patients are not included in the CCR, and are representative of a unique, high risk group. 

Cervical Collars have never been shown to demonstrate any benefit: 

  • It appears likely that cervical collars may reduce neck movement, but all of the literature on this utilizes healthy volunteers or cadavers, neither of which is an appropriate representation of trauma patients [16]. 
  • One retrospective study (with many limitations) found that patients with proven spinal fractures who had full spinal immobilization in place during transport actually had worse outcomes than patients who had no spinal immobilization during prehospital transport. This suggests that out of hospital immobilization has little to no effect on neurologic outcome [17]. 
  • A longstanding dogma has suggested that immobilization is important to prevent secondary neurological worsening when a spinal fracture is present. However, there are very few cases of this reported in the literature, as this an extremely rare event, and possibly just a medical myth [18]. 

Cervical Collars are not as benign as you might think

  • Cervical collars have many potential harms:
    • Difficulty in airway management [19, 20] and increased potential for aspiration. 
    • Increased intracranial pressure [21]. 
    • Risk of harm in patients with ankylosing spondylitis and a fracture [22, 23]. 
    • Increased ICU complications [24]. 
  • We are unable to exclude the possibility that these harms may outweigh any benefits to spinal immobilization, because there are no randomized trials looking at this question [25]. 
"Some spinal injuries are undoubtedly truly biomechanically and neurologically unstable and will benefit from immobilization. Others are probably biomechanically stable but fragile - these will suffer more neurological injury from delaying resuscitation." - Mark Hauswald [17]

Bottom Line:

It appears that spinal immobilization is not the universally safe intervention we have been taught throughout the years. As first line healthcare providers, it is incumbent upon us to consider this mounting body of evidence and encourage more selective use of spinal immobilization. 

 



Dr. Brandon Ritcey is a 5th year Emergency Medicine resident at the University of Ottawa with a special interest in Ultrasound.





Edited by Dr. Shahbaz Syed, 4th year Emergency Medicine resident at the University of Ottawa.








Cited References


1. Kossuth LC. The removal of injured personnel from wrecked vehicles. J Trauma. 1965;5(6):703–8
2. Farrington JD. Extrication of victims--surgical principles. J Trauma. 1968;8(4):493–512.
3. Farrington JD. Death in a Ditch. Bull Am Coll Surg. 1967;98(6):44–53; discussion 43.
4. Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. JNeurotrauma. 2014;31(6):531–40.
5. Ham W, Schoonhoven L, Schuurmans MJ, Leenen LPH. Pressure ulcers from spinal immobilization in trauma patients: a systematic review. J Trauma Acute Care Surg. 2014;76(4):1131–41.
6. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 3(4):347–52.
7. Ay D, Aktaş C, Yeşilyurt S, Sarıkaya S, Cetin A, Ozdoğan ES. Effects of spinal immobilization devices on pulmonary function in healthy volunteer individuals. Ulus Travma Acil Cerrahi Derg. 2011;17(2):103–7.
8. Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS. Cervical spine motion during extrication. J Emerg Med. 2013;44(1):122–127.
9. Dixon M, O'Halloran J, Cummins NM. Biomechanical analysis of spinal immobilisation during prehospital extrication: a proof of concept study. Emerg Med J. 2014 Sep;31(9):745-9.
10. Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. 2013;30(9):720–3.
11. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010;68(1):115–20; discussion 120–1.
12. Vaillancourt C, Stiell IG, Beaudoin T, et al. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med. 2009;54(5):663–671.e1.
13. Stroh G, Braude D. Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann Emerg Med. 2001;37(6):609–15.
14. Domeier RM, Frederiksen SM, Welch K. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann Emerg Med. 2005;46(2):123–31.
15. Burton JH, Dunn MG, Harmon NR, Hermanson T a, Bradshaw JR. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma. 2006;61(1):161–167.
16. Singletary EM, Zideman DA, De Buck ED, et al. 2015 International Consensus on First Aid Science With Treatment Recommendations Part 9: First Aid. Circulation. 2015;132(supp 1):S269-S311.
17. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214–9.
18. Oto B, Corey DJ, Oswald J, Sifford D, Walsh B. Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature. Acad Emerg Med. 2015;22(10):1200-12.
19. Santoni BG, Hindman BJ, Puttlitz CM, et al. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009 Jan;110(1):24-31.
20. Thiboutot F, Nicole PC, Trépanier CA, et al. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth. 2009 Jun;56(6):412-8.
21. Stone MB, Tubridy CM, Curran R. The Effect of Rigid Cervical Collars on Internal Jugular Vein Dimensions. Acad Emerg Med. 2010;17(1):100–102.
22. Thumbikat P, Hariharan RP, Ravichandran G, et al. Spinal cord injury in patient with ankylosing spondylitis: a 10-year review. Spine (Phila Pa 1976). 2007 Dec 15;32(26):2989-95.
23. Papadopoulos MC, Chakraborty A, Waldron G. Lesson of the week: exacerbating cervical spine injury by applying a hard collar. BMJ. 1999 Jul 17;319(7203):171-2.
24. Kanji HD, Neitzel, A, Sekhon, M, et al. Sixty-four-slice computed tomographic scanner to clear traumatic cervical spine injury: Systematic review of the literature. J of Crit Care. 2014;29(2):314.e9-314.e13.
25. Kwan I, Bunn F, Roberts I. Spinal immobilisation for trauma patients. Cochrane Database Syst Rev. 2001;(2):CD002803.

Other Useful Sources:

Abram S, Bulstrode C. Routine spinal immobilization in trauma patients: What are the advantages and disadvantages? Surgeon. 2010;8(4):218–222.
Cooney DR, Wallus H, Asaly M, Wojcik S. Backboard time for patients receiving spinal immobilization by emergency medical services. Int J Emerg Med. 2013;6(1):17.
Hauswald M, Braude D. Diffusion of Medical Progress: Early Spinal Immobilization in the Emergency Department. Acad Emerg Med. 2007;14(11):1087–1089.
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94–9.
Horodyski MB, Dipaola CP, Conrad BP, Rechtine GR. Cervical collars are insufficient for immobilizing an unstable cervical spine injury. J Emerg Med. 2011;41(5):513–519.
Lerner EB, Moscati R. Duration of patient immobilization in the ED. Am J Emerg Med. 2000;18(1):28–30.
Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CC. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. Can Med Assoc J. 2012;184(16):867–876.
Muhr MD, Seabrook DL, Wittwer LK. Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Prehosp Emerg Care. 3(1):1–6.
Oteir AO, Smith K, Stoelwinder JU, Middleton J, Jennings PA. Should suspected cervical spinal cord injury be immobilised?: a systematic review. Injury. 2015;46(4):528–35.
Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510–8.
Theodore N, Hadley MN, Aarabi B, et al. Prehospital cervical spinal immobilization after trauma. Neurosurgery. 2013;72(SUPPL.2):22–34.
Vaillancourt C, Charette M, Kasaboski A, Maloney J, Wells GA, Stiell IG. Evaluation of the safety of C-spine clearance by paramedics: design and methodology. BMC Emerg Med. 2011;11:1.
Vanderlan WB, Tew BE, McSwain NE. Increased risk of death with cervical spine immobilisation in penetrating cervical trauma. Injury. 2009;40(8):880–3.

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