Review of:Shafer JS, Naunheim RS: "Cervical spine motion during extrication:
A pilot study." Western Journal of Emergency Medicine. 10(2):74-78, 2009.
This study was undertaken to determine the amount of cervical spine flexion that occurs with various extrication techniques. It used multiple cameras to track the movement of markers affixed to subjects as they were extricated. The degree of flexion, extension, and rotation of the cervical spine was calculated. EMTs were used as subjects and were extricated in the following manner.
- The "driver" was allowed to exit the vehicle of their own volition without a cervical collar and lie on a backboard.
- The "driver" was allowed to exit the vehicle of their own volition with a cervical collar in place and lie on a backboard.
- The "driver" was extricated head first via standard technique by the remaining two paramedics with a cervical collar alone. (Standard technique involves turning the driver so that the legs are in the passenger's seat, allowing the driver to lie back and raising the right hip so a long board can be placed under the hip. A second paramedic who enters the front seat passenger s door helps slide the "driver" up on to the board.)
- The "driver" was extricated head first via standard technique by the remaining two paramedics with a cervical collar and KED.
Analysis of the images revealed the least amount of cervical motion occurred when the "driver" was allowed to exit the vehicle without assistance after having a cervical collar applied.
The authors, while not advocating a change in policy or protocol, suggest that additional research should be undertaken in light of these findings to better define the most appropriate, safe and effective means of patient extrication.
Doc Wesley:The authors present a compelling argument with their evidence. This coupled with the NEXUS data that indicates, according to two recent studies, that only 48 of 13,652 patients with spinal injuries were missed by application of selective spinal immobilization would suggest that this may be a safe option for the patient who does not quite fit the "no immobilization" finding but refuses full immobilization.
Previously, I discussed the decreasing use of the KED, which I believe might offer a more efficient means of extricating a patient. The standard technique of rotating the patient's legs into the passenger compartment and then sliding them onto a backboard appears to cause significantly greater cervical motion and is certainly more time consuming.
I'm hopeful that additional research will be forthcoming by these and other researchers so that we can start applying a more science-based approach to extrication and stop torturing our patients with plywood and killing our backs in the process.
Medic Marshall:I think this is a great study and agree with the authors that further research is needed to make a stronger case. However, I really believe changing the mind set of "thou shall C-collar and back board everyone with neck/back pain" regardless of concern for other factors is going to be difficult to change. In my humble opinion, EMTs and paramedics tend to be overly aggressive in deciding who needs to be placed on a long back board and c-collar. As Dr. Wesley points out above, 48 of 13,652 [or 0.35%] patients with spinal injuries were missed by application of selective spinal immobilization. For me, that's pretty compelling evidence for a selective spinal immobilization guideline.
Although I'm not sure how an actual study of cervical movement during extrication is feasible. In fact, I think it may be close to impossible. Think how often do we rapidly extricate our patients from vehicles or entrapments? Every time? Often? Never? I would venture a guess somewhere around 90% of the time patients are rapidly extricated. And when rapid extrication is underway, how often do we make sure proper technique is used?
At the end of the day, we all want to do what's best for our patients. It may be more beneficial for us as field providers to adopt selective spinal immobilization guidelines and stop back boarding everyone. Not to mention the number of bac