Administration and Leadership, Columns

Study Questions Long Spine Boards as Clinically Necessary

Issue 7 and Volume 41.

The Research

Clemency BM, Bart JA, Malhotra A, et al. Patients immobilized with a long spine board rarely have unstable thoracolumbar injuries. Prehosp Emerg Care. 2016;20(2):266-272.

The Science

The authors looked at trauma victims transported to their Level 1 trauma centers on backboards to evaluate if their use is being performed unnecessarily.

They examined data from 5,593 patients over a four-year period from 2010 to 2013. They included all EMS trauma victims delivered on long spine boards, then examined each patient’s medical record to determine whether or not spinal X-rays and/or CT scans were performed of the spine.

The sample was 60.2% male with a mean age of 40.6 years. Patients who suffered blunt trauma made up 97.4% (5,448) of the cases, and imaging studies were ordered in 51.3% (2,782). Patients who had an acute thoracolumbar fracture, dislocation or subluxation made up 4.3% (233) of the cases.

Using the definition of “unstable thoracolumbar injury” to mean an injury that requires surgical intervention, they found that only 0.5% (29) had suffered such an injury. Of those, eight were a result of falls greater than 20 feet. No significant injuries were found in standing height falls.

Doc Wesley Comments

One of the most common questions I’m asked on the subject of long spine boards is, “So I put a C-collar on to protect the cervical collar but what about the rest of the spine?”

This study, along with many others, should convince you that the incidence of unstable spinal fracture is exceedingly low. However, that doesn’t calm the fears of providers. They respond with, “But what if you’re the 0.5% patient with the unstable injury? Do you want me to just throw you on the stretcher and haul you to the hospital?” My answer to that is, “You’ve clearly missed the point!”

Relegating the long spine board to an extrication device doesn’t mean you can’t take reasonable, careful measures to handle the patient. In fact, if the patient is in pain from a thoracolumbar injury, the last thing they want to do is lay flat on a hard, unyielding backboard.

I get it. I really do. We’re afraid of the unknown and worry about being sued for not using the long spine board. But now that you have position statements from three professional organizations denouncing the continued use of the backboard, one could argue that the “standard of care” has changed.

The National Association of EMS Physicians and the American College of Surgeons position statement promotes the “judicious” use of the spine board, having weighed the pros and cons.

However, the American College of Emergency Physicians has taken a stronger position, stating, “Backboards should not be used as a therapeutic intervention or as a precautionary measure.” I would suspect there are legions of medical experts now that would be willing to defend you in court for delivering care that’s evidence-based.

The new reality is that it’s simply not worth the potential pain and suffering to countless patients who are immobilized daily to calm our irrational fears of litigation.

Medic Wesley Comments

Change is difficult for all of us, and new spinal protocols are a big change from what we’ve done for many years. But we have to be lifelong learners and realize that many things that were once thought to be in our patients’ best interest have been found to have negative outcomes. That’s life and that’s medicine. It wasn’t that long ago that we took all our patients to the closest facility, and now we know that getting them to the closest appropriate facility has saved lives and reduced suffering.

This study provides the numbers from just one system over an extended period of time. It’s no coincidence that the number of patients with “unstable thoracolumbar injury” was low. It provides the facts. So how many of those patients suffered unnecessarily for hours on rigid spine boards while waiting to be cleared of injury by X-ray or CT? Clearly, the answer is too many. A great part of our career should be the role of patient advocate.

Along with change comes education, appropriate protocols and understanding-not just of what we’re doing, but why we’re doing it. A true advocate seeks out the reason and does what’s in the best interest of the patient, knowing that the science will support the care provided.