Columns, Patient Care, Training, Trauma

Weighing the Pros & Cons of Current Spine Immobilization Techniques

Issue 11 and Volume 38.

Previously considered the standard of care, there's no evidence to support routine use of backboards.

Previously considered the standard of care, there’s no evidence to support routine use of backboards. Photo Vu Banh

National Association of EMS Physicians and American College of Surgeons Committee on Trauma. EMS spinal precautions and the use of the long backboard. Prehosp Emerg Care. 2013;17(3):392–393.

This paper is the formal joint position of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma—the two premier professional organizations with specific interest in the pre-hospital care of trauma victims. After meeting in individual and joint meetings, they agreed to collaborate on a position statement to provide guidance on the appropriate use of the long backboard for spinal immobilization. Their conclusions are based on the relevant science regarding the pros and cons of the backboard and the growing use of selective spinal immobilization protocols.

It’s about time we finally have a formal position on this extremely controversial subject. To fully appreciate this paper, you must read it closely, but here’s my take on the topic supported by the position.

Throughout the past several years, since the NEXUS and Canadian C-spine rules were published, EMS has slowly but steadily adopted selective spinal immobilization protocols. This alone has significantly reduced the number of patients needlessly strapped to backboards and placed in C-collars. But the question now before us is: Once it’s determined a patient may require spinal immobilization, what’s the most appropriate method?

The C-collar is very similar in design to the devices used to provide long and short-term immobilization for patients who have suffered significant injury to their neck. Therefore, despite there being no documented evidence to support their use in the emergency situation, their use after diagnosis supports their emergency use as a standard of care.

On the other hand, there’s no evidence that the long backboard provides clinically appropriate support and immobilization of the injured spine. In fact, there’s a large and growing body of evidence that the backboard causes pain, promotes skin ulcers and harms patients by restricting their ability to breath.

Unlike the C-collar, physicians treating the injured spine in the hospital don’t use the backboard in any form. In fact, the original use of the backboard was as an extrication device only. Over time, the decision was made to simply keep the patient on the board and this was incorporated into the Department of Transportation curriculum without any scientific evidence to support it.

Many medical directors, myself included, supported an earlier draft of this position statement that clearly stated backboards should only be used for extrication, and then the patient should be lifted onto the stretcher.

This position statement essentially states that the relative risks and benefits of using the backboard must be evaluated with every patient. If the risks outweigh the benefits, it’s completely appropriate to place the patient on the stretcher, securing and padding them to limit spinal movement.

It doesn’t require the use of the traditional backboard but instead states that for patients suspected of a spinal injury, appropriate methods to reduce potentially harmful movement of the spine should be used. There’s growing literature to support the use of the scoop stretcher or vacuum mattresses for spinal immobilization. Patients placed on a backboard should be removed from it as soon as practical in the emergency department.

Of particular note, the position statement clearly admonishes that ambulatory patients don’t need spinal immobilization. Oh my God! No more standing take-downs while trying to hold a patient’s head still!

The biggest question is whether medical directors and services have the courage to modify their current guidelines to permit EMS providers to use their best judgment of who requires spinal immobilization and the best method to accomplish that safely.

Well, I wish I could say that EMS providers were uniformly using spinal stabilization appropriately, such as seated extrication devices like the Kendrick Extrication Device and short spine boards. Across the nation there are providers who not only have no history using these devices, but also don’t remember what they’re for or how to apply them. With that in mind, the limited accounts of spinal trauma worsened by rigid C-collar and placement on the stretcher alone seems to support the position statement.

Selective spinal immobilization provides a clear tool for providers to determine the degree of stabilization needed for each patient. However, the movement of patients to the stretcher is not defined. A standing patient can be coached to sit on the stretcher. A three-person assist to the supine position with head stabilization is then an easy maneuver, but removal of patients either from a vehicle or other situation may not be as easy.

The long spine board provides a safe method of movement. Aggressive training on how to move the patient to the stretcher sans long board will have to be developed. Further, instruction and emphasis on the scoop stretcher for this purpose is needed. Along with this, methods for limiting spinal movement once on the stretcher need to be made part of the National Standard Curriculum for EMS providers.

Provider fear of legal repercussions when utilizing new techniques has always been a topic during training. I anticipate some hesitation to adopt selective spinal immobilization until the information has been widely distributed.

So Doc? You have my vote. Let’s “Do no harm.” Let’s make patients comfortable, and ensure that the mechanism of injury is the only source of pain.