Administration and Leadership, Patient Care, Trauma

An Evidence Review of Prehospital Spinal Immobilization

Issue 11 and Volume 40.

Approximately 2% of all injuries that present to EDs are spinal cord injuries (SCIs).1 While overall incidence may seem low, traumatic SCIs are a serious matter. In fact, one reason for adhering to strict immobilization assessment and guidelines is the extreme cost of missing the diagnosis of a spinal injury. This may be why practices for immobilizing a patient’s spine prior to hospital transport have been largely unchallenged for the last 30 years.

SCIs are measured either by morbidity rates or by degree of resulting impairment: motor, sensory or autonomic.2 Prehospital care by EMS personnel is part of the larger spectrum of care that SCI patients receive, but statistics suggest that up to 25% of SCIs may be worsened during extrication after a motor vehicle crash (MVC) when using the status quo for spinal immobilization. A study that used healthy volunteers and video motion-capture methods found the motion of cervical spine (C-spine) was greater when volunteers were extricated onto a spine board than when they were able to exit the vehicle on their own, wearing a cervical collar (C-collar) for stabilization.3

Evidence continues to show that it’s time for a change in field practice and that traditional stabilization methods are overused. In order to further evaluate current evidence-based practice of spinal immobilization and its relationship to SCIs, a literature search was conducted and is presented in this article.

SUPPORT OF CURRENT STANDARDS

Effective, time-tested practices of spinal cord immobilization are in place for a reason and supported by current literature. In 2013, researchers emphasized how improvement in the neurological status of patients with SCIs arriving in EDs is due to services that EMS provides. According to the authors, “Spinal immobilization is now an integral part of prehospital management and is advocated for all patients with potential spinal injury after trauma by EMS programs nationwide and by the American College of Surgeons.”4

Evidence does support the use of spinal immobilization techniques, just not applied to all cases in a routine way as has been done in the past.

Immobilization is defined in this study as use of a C-collar for neck immobilization along with lateral supports and straps and a spinal head immobilizer. The authors emphasize immobilization as an integral part of trauma patient care that also includes oxygen support, blood pressure stabilization and measured volume replacement.

However, the authors note limitations such as adverse effects of traditional immobilization techniques, including discomfort and application time that delays transport, as well as the impracticality of applying studies on healthy volunteers to patients with SCIs. They offer the vacuum splint device as a more comfortable alternative to the traditional rigid backboard, noting that vacuum devices aren’t recommended for extrications.

The authors also advocate the need for accurate triage at the scene of Level 2 and Level 3 potential spinal injury patients. Of nonfatal SCI cases in the United States, almost half are caused by MVCs, followed by falls, violence (primarily gunshot wounds) and sporting accidents.5

CHANGING ATTITUDES

Literature reviews draw different conclusions as to why protocols haven’t changed. One notes fear of C-spine injuries because of the inherent risk of permanent SCI with potential life-threatening and -changing consequences.6

The influence of historically poor evidence is the primary reason for continuing the practice of C-collars, and researchers noted that current EMS protocols are based on historic practices rather than scientific evidence.7

When comparing the benefits of C-collars to the possible adverse effects of collar use, the latter includes an increase of intracranial pressure through jugular venous compression, compromised airway management, pressure ulcers and even the capacity to cause hesitancy in healthcare personnel to address necessary exams. Therefore, researchers recommend omitting routine collar application in all but specific extrication processes, suggesting instead the continued exploration of immobilization on spine boards with head immobilizers and straps while continuing to consider vacuum mattresses, as previously mentioned.7 This leads to other specific scenarios in which the benefit of spinal immobilization doesn’t outweigh risk.

Two articles identify a specific trauma population— gunshot wound victims—that doesn’t benefit from prehospital spinal immobilization.8,9 The difference in risk of death, which may be almost double, is attributed to the extra time it takes to stabilize the patient’s spine with a C-collar and strapping to a long board. In gunshot wounds, case time is the most critical aspect of care. A retrospective analysis of penetrating trauma patients in the National Trauma Data Bank lends further weight to the argument.10 Of the 45,284 patients studied, mortality rate was almost twice as high in the spine-immobilized patients, leading the authors to conclude that spinal immobilization may not be indicated for head, neck or torso injury in the absence of neurological deficit of complaint.

Clinical decision-making tools, like the Canadian C-spine rule (CCR), may provide an alternative to traditional mechanism of injury protocols such as the Prehospital Trauma Life Support (PHTLS) protocol. A trial comparing adherence and effectiveness of three traditional EMS protocols, including the PHTLS protocol, suggests traditional protocol adherence leads to unnecessary stabilization while non-adherence leads to injuries being missed and thus creating a potential lose-lose combination.11

Various ways of supporting standards for change have been proposed. A performed analysis of physics, biomechanics and physiology involved in spinal trauma recommended not using hard backboards for transport, especially in the case of ambulatory, uncooperative or seizing patients, and not using C-collars except in specific injury types.1

An added benefit of eliminating unnecessary use of spinal immobilization will, in turn, decrease the time to definitive treatment. Empowering EMTs and paramedics to determine the need for immobilization during transport has shown promising results in clinical trials. In an effort to establish a clinical decision (or prediction) rule, a Canadian clinical trial on CCR designed to empower EMS personnel to decide whether to immobilize during transport was evaluated and revealed a significant portion (40%) of patients could be safely transported without immobilization when EMS personnel used an established standardized algorithm for decision-making in the field.12

The Northern Territory and Queensland Ambulance Services in Australia are excellent examples of an EMS service outside the province of Canada using the CCR spinal algorithm with similar results.

DISCUSSION

While spinal immobilization of trauma patients remains an integral part of prehospital care, alternate ways of looking at and applying techniques exist. As with any action performed, just because it’s always been done this way doesn’t provide sufficient reason to continue current practices.

The fact most trauma patients don’t have spinal instability nor benefit from spinal immobilization should be impetus for continuing to evaluate your agency’s current evidence-based practice for spinal immobilization.13

Evidence does support the use of spinal immobilization techniques, just not applied to all cases in a routine way as has been done in the past. One researcher aptly writes, “Hopefully we can move away from the forest of hard boards in the ambulance bays of our community hospitals and at the same time develop a saner policy for our patients.”14

More prudent policies may include EMS personnel being trained in the use of protocols based on decision rules rather than mechanism of injury approaches.10 Prehospital professionals can be appropriately trained to apply ruleout criteria for patients suspected of having a spinal injury.15 EMS personnel already perform this function, but better ways to do so may exist. Alternatives to long boards such as vacuum mattress/splint devices should be examined. Any increase in cost may be compensated by a decrease in adverse events and morbidity.

Figure 1: Canadian C-spine rule (CCR)

 Canadian C-spine rule (CCR)

EMS providers are an important part of a larger health stakeholder picture. According to the National Association of EMS Physicians and American College of Surgeons Committee on Trauma position statement, “Protocols or plans to promote judicious use on long boards during prehospital care should engage as many stakeholders in the trauma/EMS system as possible.”16

This applies to any proposed change. Hospitals must also not be forgotten in regards to larger stakeholders, because they’re largely protocol driven and many EDs aren’t on the same page when it comes to how their EMS agencies conduct spinal immobilization in the field.

Alternatively, many EMS agencies also report that, although they and their medical director desire to modify their spinal immobilization protocols, their receiving hospitals continue to insist many patients be unnecessarily boarded in the field. Therefore, more joint education and sharing of literature is necessary to change attitudes and protocols.

It’s important to remember that there are perspectives and knowledge to be shared from every aspect of care and ED physicians currently have protocols in approaching SCI patients as evident in the literature.17-19

Advances in care are a great opportunity to ensure the best quality of life for SCI patients.20 This point is paramount for all emergency care stakeholders to keep in mind.

REFERENCES

1. Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. 2013;30(9):720–723.

2. Furlan J, Noonan V, Singh A, et al. Assessment of impairment in patients with acute traumatic spinal cord injury: A systematic review of the literature. J Neurotrauma. 2011;28(8):1445–1477.

3. Engsberg J, Standeven J, Shurtleff T, et al. Cervical spine motion during extrication. J Emerg Med. 2013;44(1):122–127.

4. Theodore N, Hadley M, Aarabi B, et al. Prehospital cervical spinal immobilization after trauma. Neurosurgery. 2013;72 (Suppl 2):22–34.

5. Dagal A, Dooney N. Anesthetic considerations in acute spinal cord trauma. Int J Crit Illn Inj Sci. 2011;1(1):36–43.

6. Sundstrøm T, Asbjørnsen H, Habiba S, et al. Prehospital use of cervical collars in trauma patients: A critical review. J Neurotrauma. 2014;31(6):531–540.

7. Stuke L, Pons P, Guy J, et al. Prehospital spine immobilization for penetrating trauma—Review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma. 2011;71(3):763–770.

8. Brown J, Bankey P, Sangosanya A, et al. Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso. J Trauma. 2009;67(4):774–778.

9. Seppa N. Gunshot victims have need for speed: Delay for spine stabilization doubles death risk, study finds. Science News. 2010;177(3):8.

10. Haut E, Kalish B, Efron D, et al. Spine immobilization in penetrating trauma: More harm than good? J Trauma. 2010;68(1):115–121.

11. Hong R, Meenan M, Price E, et al. Original research. Comparison of three prehospital cervical spine protocols for missed injuries. West J Emerg Med. 2014;15(4):471–479.

12. Vaillancourt C, Charette M, Kasaboski A, et al. Evaluation of the safety of C-spine clearance by paramedics: Design and methodology. BMC Emerg Med. 2011;11:1.

13. Kang DG, Lehman RA Jr. Spine immobilization: Prehospitalization to final destination. J Surg Orthop Adv. 2011;20(1):2–7.

14. Sporer K. Why we need to rethink C-spine immobilization. EMS World. 2012;41(11):74–76.

15. Ahn H, Singh J, Nathens A, et al. Pre-hospital care management of a potential spinal cord injured patient: A systematic review of the literature and evidence-based guidelines. J Neurotrauma. 2011;28(8):1341–1361.

16. National Association of EMS Physicians and the 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.

17. Chin LS, Mesfin FB, Dawodu ST. (July 7, 2015.) Spinal cord injuries treatment & management. MedScape. Retrieved Sept. 9, 2015, from http://emedicine.medscape.com/article/793582-treatment.

18. Parent S, Barchi S, Lebreton M, et al. The impact of specialized centers of care for spinal cord injury on length of stay, complications, and mortality: A systematic review of the literature.J Neurotrauma. 2011;28(8):1363–1370.

19. Pimentel L, Diegelmann L. Evaluation and management of acute cervical spine trauma.Emerg Med Clin North Am. 2010;28(4):719–738.

20. Fehlings M, Cadotte D, Fehlings L. A series of systematic reviews on the treatment of acute spinal cord injury: A foundation for best medical practice. J Neurotrauma. 2011;28(8):1329–1333.