An overview of the current evidence on Spinal Motion Restriction. This is an Update of the #refresh21 presentation

1. Spinal Motion
Restriction in the
21st Century

2. Questions
and
Objectives
• What is wrong with boarding and collaring
everyone?
• Describe the adverse clinical
consequences and risks of the long
spine board and cervical collar
• What should I be doing?
• Discuss the current research and
practices for the use of selective spinal
immobilization
• Who should I be applying SSMR to?
• Describe the patients at higher risk for
actual spinal injury
• Are there any innovative solutions in SMR?
• Describe the role of soft and malleable
SMR devices in EMS

3. Some
terms…
• C-Collar – Referring to, unless
otherwise stated, a RIGID Cervical
Collar.
• Extrication Collar – C-Collar as above
• SMR – Spinal Motion Restriction
• SSMR – Selective Spinal Motion
Restriction – generically referring to
protocols that allow screening
patients and selecting who does ( and
does not) get SMR in the field.

4. Basic Assumptions
•Spinal Immobilization helps very few patients
•Spinal Immobilization can harm far more
patients than it helps

5. What is wrong with boarding
and collaring everyone?
Describe the adverse clinical consequences and risks of the long spine board and cervical collar

6. A long time ago in a galaxy far, far away…

7. Three main reasons why traditional SMR is
bad…
The Risks
• Increased pain and pressure sores
• Increased intercranial pressure
• Increased spinal Injury through “distraction” (separation) and
movement of vertebra
• And….little benefit
• It really does not protect the patient from injury

8. Pressure Sores
Occur quickly (30 min) in
the elderly but may occur
in as little as 2 hours in
general population.

9. 2012 Study: Application of
Cervical Collars causes more
motion in injured patients
than uninjured patients
• Cadaver Study
• Studied with and without C6-C6 injury
• Found that motion increased when there was instability (injury)
• Displaced between 3.6 and 4.4 mm

10. Rigid Cervical Collars raise ICP 5-10 mmHg
• Rigid Collars increased intercranial
Pressure
• Application of a cervical collar
consistently increased ICP 4-10
mmHg
• It is believed to be caused by
compression of venous structures
(i.e. the Jugular veins) preventing
venous outflow from the brain.

11. 2010 Study: Extrication collars can result in abnormal
separation between vertebra
• Cadaver Study
• CT and photos before and after simulation of cervical injury
• In cadavers with simulated cervical spinal injury: C-Collar application resulted in
7.3 mm +/- 4.0 mm of separation between C1 and C2 in a cadaver model.
• How does this apply to me? In patients with an actual spinal innury, a rigid
cervical collar may make them worse.

12. Ben-Galim, P., Dreiangel, N., Mattox, K. L., Reitman, C. A., Kalantar, S. B., & Hipp, J. A. (2010). Extrication collars can result in
abnormal separation between vertebrae in the presence of a dissociative injury. The Journal of trauma, 69(2), 447–450.
https://doi.org/10.1097/TA.0b013e3181be785a

13. Ben-Galim, P., Dreiangel, N., Mattox, K. L., Reitman, C. A., Kalantar, S. B., & Hipp, J. A. (2010). Extrication collars can result in
abnormal separation between vertebrae in the presence of a dissociative injury. The Journal of trauma, 69(2), 447–450.
https://doi.org/10.1097/TA.0b013e3181be785a

14. What should I be doing?
Discuss the current research and practices for the use of selective spinal immobilization

15. 2017 Lit review: “The definite risks and questionable
benefits of liberal pre-hospital spinal immobilization”
• “Local oedema and hypoxia were more likely to be contributors to secondary
neurological damage” than spinal fractures.
• “No reliable sources were found proving the benefit for patient immobilisation. In
contrast there is strong evidence to show that pre-hospital spinal immobilisation is not
benign with recognized complications ranging from discomfort to significant physiological
compromise.”
• “The literature supports the Consensus Guidelines but raises the question as to whether
they go far enough”

17. 2018: Spinal Motion Restriction in the
Trauma Patient – A Joint Position Statement
• Multiple Organizations:
• The American College of Surgeons Committee on Trauma (ACS-COT)
• American College of Emergency Physicians (ACEP),
• The National Association of EMS Physicians (NAEMSP)
• “This updated uniform guidance is intended for use by emergency medical
services (EMS) personnel, EMS medical directors, emergency physicians, and
trauma surgeons”
• Change from use of Immobilization devices to extrication devices
• Use of a LSB, Scoop, or vacuum mattress mentioned as acceptable
extrication devices.
• “transfer or extrication devices may be removed” prior to transport by
trained personnel (i.e. EMS providers) with SMR maintained.
• Acceptable methods of SMR during transport include:
• scoop stretcher, vacuum splint, ambulance cot, or other similar device
to which a patient is safely secured.
• Revised indications for SMR (discussed later)

18. Some new uses..
Alternative use for Spine Boards. (Image
source /u/Benutzerkonto, Reddit/r/EMS)
"5 Creative Uses For Backboards". EMS1.com
2015. Web. 3 Feb. 2017.

19. But not quite here yet…
"5 Creative Uses For Backboards". EMS1.com
2015. Web. 3 Feb. 2017.

20. REMEMBER: LSB are still
used for movement, CPR,
and extrication of
patients.
(But probably not like
this…)
American Academy of Orthopedic Surgeons,. Emergency
Care And Transportation Of The Sick And Injured. 1st ed.
Menasha Wisconsin: George Banta Company, 1971. Print.

21. New(er) approaches
• Assess the patient, determine if SMR is needed at all
• If the patient can ambulate on their own, let them.
• If the patient is questionable on ambulation, extricate/move them
with a scoop or LSB.
• Apply the cervical collar of choice
• Remove the extrication device
• Secure them to the orthopedic mattress on the cot

22. Is there any time we would leave the
LSB/SCOOP in place?
• Yes. Examples:
• CPR and anticipated need for CPR
• Other patient priorities (i.e. Airway Management)
• Anticipated need for further patient movement (i.e. rescue
operations)
• Goal is to minimize the time on rigid extrication devices (LSB and
scoop)

23. Who should I be applying
SSMR to?
Describe the patients at higher risk for actual spinal injury

26. NAEMSP Joint Position Paper
Blunt trauma
• Indications for SMR following blunt trauma
include:
• Acutely altered level of consciousness (e.g.,
GCS <15, evidence of intoxication)
• Midline neck or back pain and/or
tenderness
• Focal neurologic signs and/or symptoms
(e.g. numbness or motor weakness)
• Anatomic deformity of the spine
• Distracting circumstances or injury or any
similar injury that impairs the patient’s ability
to contribute to a reliable examination
Penetrating Trauma
• “There is no role for SMR in
penetrating trauma”
Pediatric Trauma
• “Age alone should not be a
factor in decision making for
prehospital spinal care, both for
the young child and the child
who can reliably provide a
history”

27. MOI is back (Kind of)
•“There is insufficient evidence to support
absolute criteria for mechanism of injury
(MOI) either as an inclusion or exclusion
criteria for any spinal immobilization
consideration.
•That said, a prudent prehospital provider
should carefully evaluate the role of
mechanism of injury in the total clinical
presentation with a tendency to err on the
side of immobilization, particularly with the
frail, chronically bedridden, or extremes of
age (< 12 or >65 years of age).”
Freeway Patrol - Episode 5 –
Mechanism of Injury - YouTube

30. Canadian Rule Risk Factors
Low Risk Factors
• Simple Rear End MVC
• Sitting Position when found
• Ambulatory at any time after accident
• “Delayed” onset of pain
• Not immediate onset
Dangerous Mechanisms
• Fall from > 3 feet/5 stairs
• Axial Load to head
• Confirmed
• MVC @ “high Speed”
• 100 km/hr ( 62 mph )
• Rollover
• Hit by large vehicle
• Hit hard enough to be “pushed”
• Auto-Ped or Auto-Bike
• “Motorized Recreational Vehicles”

31. Can Paramedics use this rule?
Bottom Line: 4,034 patients followed to 30+ days
• MVC most common
• Adults (16-99 yoa)
Conclusion: Paramedics could accurately apply the modified Canadian C-spine rule
to low-risk trauma patients and significantly reduce the need for spinal
immobilization during transport. This resulted in no adverse event or any spinal
cord injury.

32. Special comment about Diving
Injuries
• Actual axial loading and spinal injuries in drowning are
exceedingly rare.
• Use of SMR in drowning can delay lifesaving efforts and
increase morbidity
• Unless there clear indication of injury to head or spine,
SMR is not indicated.
• Actual diving incident
• Shallow Water diving
• Witnessed event

33. “… frail,
chronically
bedridden, or
extremes of age”
( >65 years of
age).

35. High impact
MVC
• defined as > 60 mph
(100 km/hr)
• or with intrusion > 6
inches
• Rollover or Ejection
• Vehicle vs. Pedestrian

36. Motorsports and extreme-sports injuries

37. What about
Fender
Benders?

38. Bicycle and
motorcycle
accidents.

39. Football and high impact athletic activities
(picture courtesy of http://www.amsvans.com/blog/paralyzed-football-player-
eric-legrand-returns-to-metlife-stadium/)

40. 2015 NATA guidelines on spinal injured
athletes • “ The athlete with a suspected spinal cord injury presents medical providers with challenges that are not
common with the general population. Equipment worn for protective purposes presents a treatment barrier
for basic or advanced life support to the airway and chest. Removal of equipment prior to transport is one of
our most important updated recommendations,”
• Recommendation 4: Protective athletic equipment should be removed prior to transport to an emergency
facility for an athlete-patient with suspected cervical spine instability.
• Recommendation 5: Equipment removal should be performed by at least three rescuers trained and
experienced with equipment removal at the earliest possible time. If fewer than three people are present,
the equipment should be removed at the earliest possible time after enough trained individuals arrive on the
scene
• Recommendation 7: A rigid cervical stabilization device should be applied to spine injured athlete-patients
prior to transport. A rigid cervical collar should be applied at the earliest and most appropriate time possible
during pre-hospital procedures. The medical team needs to continue manual in-line stabilization even after
the rigid cervical collar is applied.
• Recommendation 8: Spine injured athlete-patients should be transported using a rigid immobilization device.
• Sports medical care teams must now recognize the concepts of spinal motion restriction (SMR) as compared to spinal
immobilization. SMR implies that true spinal immobilization cannot be obtained even with the patient securely
strapped to a spine board.
• Recent literature has raised concern regarding the use of the long spine board due to potential harmful effects after
extended period of time on the board.
• However, in the case of a potentially spine injured athlete it is recommended that a long spine board or other
immobilization device be used for transport
• - 2015 NATA recommendations

41. Bottom Line
• ON FIELD: OK to leave pads/helmet on on-field and
extricate off-field with a LSB or remove on-field at
scene of injury (depending on AT guidance)
• This limits the possibility of conflict with AT on
which approach is better since both approaches
are likely in use
• ONCE OFF THE FIELD: Remove pads and helmet for
transport (if not already removed) in accordance with
current protocols.
• Make sure you have enough hands on scene to
do so (Typically 3 or more)
• Incorporate the help of the AT as appropriate.
• LSB comes off too as appropriate.

42. GSW to head
• Incidence of Spinal Injury from isolated GSW to head
originating above the nose is exceedingly rare (0 –
1.4%).
• Incidence of spinal injury from isolated GSW to head
originating below the nose and above the jaw is still <
10%
• Excludes GSW to back and neck
• GSW patients die from head injury, hypoxia, and
hypotension. Many require immediate airway control
which SMR can complicate.
• It is clinically advantageous to delay or defer altogether
SMR in isolated GSW to head until airway is managed.

43. Other GSW
• GSW to spine (particularly the neck and back) contributing to 13% - 17% of
all spinal injuries
• Either direct injury by path of bullet or indirect by cavitation or vascular damage
• Most spinal injuries are immediately evident with immediate neurological deficits
• Patients with penetrating trauma to the trunk, below the clavicle and no
evidence of spinal injury (neurological deficit) do not require
immobilization.
• In line with recommendations from the ACS Committee on trauma.
• Patients with penetrating trauma to the trunk, below the clavicle who are
altered or show signs of neurological deficits do require SMR.

44. Pay attention to LOC
• Altered LOC is one of the major commonalities in missed
injuries.
• An altered level of alertness can include any of the
following:
• A Glasgow Coma Scale score of 14 or less.
• Disorientation to person, place, time, or events,
including chronic disorientation (i.e. Dementia)
• A delayed or inappropriate response to external
stimuli, or other findings.

45. Why Dementia?

46. BEWARE THE ELDERLY
AND INFIRM

47. KEY POINT
When presented with an
altered level of alertness in a
blunt traumatic patient,
providers should err on the
side of spinal precautions
(i.e. a cervical collar).

48. What are Distracting
Injuries?
• While any injury may be considered
distracting in the right context, specific
injuries of concern would be:
• Any moderate injury to the
proximal upper extremity, shoulder,
clavicle, or lateral neck
• Facial injuries suspicious for
fracture or significant discomfort.
• Any injury requiring analgesia

49. KEY POINT
•If an injury is bad enough to require Analgesia, it
can be considered distracting.

50. Are there any innovative
solutions in SSMR?
Describe the role of soft and malleable SSMR devices in EMS

51. Soft Foam
Cervical
Collars are
back
(in some
places)

52. Sip Quick Collars

53. Wrapping up