Is spinal immobilization necessary in the pre-hospital setting? What is the evidence behind spinal immobilization?

1. EMS: Spinal Immobilization
Daniel Kwan, MD

2. Objectives
 Present a spinal immobilization patient case.
 Review the current Fresno County spinal
immobilization policy.
 Review reasons for spinal immobilization.
 Discuss the problems with spinal
immobilization
 Go over the new NAEMSP and ACSCT
position statement.
 Go over San Joaquin’s spinal immobilization
policy.
 Present new revision to CCEMS Policy.
 Review the original case in light of new
evidence.

3. EMS Case
 53 yo F found laying next to her Ford Ranger
truck. Pulled out in front of a Semi-truck
traveling Southbound traveling at approx
55mph. Pt was self extricated, & assisted to
the roadway.
 Major passenger front-end damage to her
truck noted w/ airbag deployment. Pt amnesic
to the event. Pt noted lower abd pain, w/
abrasions/bruising to area of hip bones &
across chest w/ mid-line lumbar pain, &
poss LOC.
 Pt GCS 15. Wanted to remove c collar
because she needed to vomit.
 Should we allow her to remove the collar?

4. Fresno County Policy
 Implement spinal immobilization
◦ Posterior midline spinal pain or tenderness with h/o or suspicion
of trauma.
◦ H/o blunt trauma with a trauma score of <= 14
◦ Injuries distracting patient from distinguishing spinal pain (e.g.,
pelvic fracture, multi-system trauma, crush injury to hands or feet,
long bone fracture proximal to the knee/elbow, or to the
humerus/femur.
◦ Severe head or facial trauma.
◦ Numbness or weakness in any extremity after trauma.
◦ LOC 2/2 trauma
◦ AMS (including drugs, alcohol, and trauma) and :
 No history available; or
 Found in setting of possible trauma (e.g. lying at the bottom of stairs or in street);
or
 Near drowning with a history of probability of driving injury.
 Patients with need spinal immobilization are determined by
above criteria and not mechanism of injury alone.

5. Reasons for Spinal
Immobilization
 Injured patients may have unstable
injury of the spine. Need to splint “joint
above and below”.
 Prevent further injury to the spinal
cord as this can have high morbidity.
 Determining pre-hospital spinal injury
can be difficult, so immobilize “just in
case”.

6. C Collars
Philadelphia
Soft
Miami J
Aspen

7. Backboards

8. Immobilize Everyone!
 ATLS- Standard of care. Part of
ABCDE
 ACS (Published new guideline in
2013)
 Prehospital Trauma Life Support (Until
2011)
 National Association of Emergency
Medical Technicians

9. Immobilize Everyone!
 Missed C spine Injury in Trauma patients*
◦ 740 out of 32,117 trauma pts with CSI.
◦ Delayed or missed in 34 pts (4.6%)
◦ 10 of those 34 developed permanent sequelae.
◦ However, 31/34 missed 2/2 inadequate 3 view C spine XR
 ER evaluation not adequate for spinal injury**
◦ Retrospective study from 1979
◦ Symptoms and physical exam findings not sufficient
◦  Immobilization of essentially all patients with potential
for spinal injury
*Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine
injuries. J Trauma. 1993;34(3):342-6.
** Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three
hundred hospitalized patients and review of the literature. J Bone Joint Surg Am.
1979;61(8):1119-42.

10. Good or bad?
 Patients still should get spinal
immobilization because the benefits
outweigh the risk
 … right?
 There are three types of patients
◦ Stable spinal fracture
◦ Unstable spinal fracture with neurological
deficit
◦ Unstable spinal fracture without neurological
deficit
 Do we help those in the 3rd category?

11. Injured Patients May Have
Unstable Injury of Spine
• 1-5 million patients receive spinal immobilization per year in
the US.
• Rate of c spine fx is 2-5%
– Unstable C spine fx is 1-2%.
– Among these, ½ showed neuro deficits upon arrival. (0.5-
1%)
• Blunt trauma
– C spine fx rate is 1.2-3.3%
– C spine injury is 0.4-0.7%
• Penetrating Trauma*
– 1.43% had spinal fractures
– 0.38% had unstable spine fractures
• 74% had completed spinal injury prior to immobilization
• NNT: 1032; NNH 66
*Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm
than good?. J Trauma. 2010;68(1):115-20.

12. Further Movement Can Cause
Additional Injury
 Is the force enough?
◦ C spine fractures when >2,000-6,000
Newtons.
◦ L spine requires >4200 Newtons (even in
elderly).
◦ Hanging 4 kg head off the end of a stretcher-
40 Newtons
◦ Force after injury is diffused.
 Malaysia vs New Mexico Study
 Awake pts may protect their own spine if
they are awake.

13. Application of Spinal
Immobilization Prevents Motion
 Correctly fitted collars allow over 30 degrees
of flexion/extension. 16 degrees of lateral
bending. Rotation about 27 degrees.
 Could increase motion C1-C2 level.
Paradoxical extension.
 Approx 7.7 mm motion in axial plane and 2.9
mm in the cranial caudal direction in cadaver
models.
 During extrication, no movement reduction is
added to C-collar by using a backboard.

14. Immobilization is a relatively
harmless measure, so apply as
“a precaution”.
 Complications
◦ Back pain
◦ Respiratory Compromise
◦ ICP increase
◦ Increased aspiration
◦ Airway management difficulty
◦ Distracting an unstable fracture
◦ Delay in arriving to trauma center
◦ Cost

15. Back Pain
 Small Prospective Study*
◦ 21 healthy volunteers
◦ Immobilized for 30 minute period.
◦ Results: occipital headache, sacral/lumbar
back pain, mandibular pain most
common.
◦ 55% subjects graded their symptoms as
moderate to severe.
◦ 29% developed symptoms 48 hours later
*Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal
immobilization on healthy volunteers. Ann Emerg Med. 1994;23(1):48-51.

16. Respiratory Compromise
 Backboard alone*
◦ 15 nonsmoking male volunteers
◦ Zee Extrication Device and Long Spinal board
◦ Sig differences in FVC and FEV1.
 Backboard and cervical collar**
◦ 39 randomized crossover laboratory study
◦ Immobilized with philadelphia collar on hard wooden
backboard or Scandinavian vacuum mattress.
◦ 15% decrease in FEV1 on average. (worse at extremes of
age).
◦ Vacuum mattress more comfortable.
*Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary
function in the healthy, nonsmoking man. Ann Emerg Med. 1988;17(9):915-8.
**Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp
Emerg Care. 1999;3(4):347-52.

17. Increased ICP
 Head injury occurs in 34% of trauma
patients
 27% of trauma deaths
◦ More common than c spine injury
◦ AMS difficult to clear c spine.
 Rise in ICP is 4.5 mm Hg on average. *
 Mechanism
◦ Painful stimulus
◦ Disrupted Venous Flow**
*Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on intracranial and cerebral
perfusion pressures. Anaesthesia. 2001;56(6):511-3.
**Stone MB, Tubridy CM, Curran R. The effect of rigid cervical collars on internal jugular vein
dimensions. Acad Emerg Med. 2010;17(1):100-2.

18. Increased Aspiration
 Decreased ability to open mouth
 Difficulty swallowing
 Head Injury patients can vomit.
Houghton DJ, Curley JWA. Dysphagia caused by a hard cervical
collar. British Journal of Neurosurgery 1996;10(5):501–2.

19. Difficulty Managing Airway
 Collar vs Manual Inline Stabilization (MILS)
◦ Manual inline stabilization (MILS) better than collar
and board.
◦ 56% had 1 grades better and 10% had 2 grades better
with MILS
 MILS only **
◦ 200 Elective surgery patients
◦ Single blinded randomization to MILS vs not
◦ 50% had failure rate in 30 seconds with MILS vs 5.7%
without.
*Heath KJ. The effect of laryngoscopy of different cervical spine immobilisation techniques. Anaesthesia.
1994;49(10):843-5.
** Thiboutot F, et al. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult
orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth.
2009;56(6):412-8.

20. Distracting Unstable Fracture
 Ankylosing Spondylitis
◦ Extension of spine during
immobilization neuro deficits.
 Malaysia (No collar) vs New Mexico
(routine collar)
◦ Increased frequency of neurological
deterioration
◦ More overall neuro disability.

21. Delayed Resuscitation
 Prehospital care
◦ Trauma pts may have better outcomes with
less.
◦ Severe trauma pts had better outcomes
when transported with private vehicle.
◦ Canadian study- ALS programs worsened
outcomes in those with severe TBI.
 Penetrating trauma patients
◦ Retrospective analysis of 45,284 patients
◦ OR 2.06 (1.35-3.13) of death in those
immobilized
◦ NNT 1032, NNH 66

22. Cost
 Backboards/C-collars
 C-collars beget imaging to “clear the c
collar”.
 Increased morbidity.

23. Prehospital Trauma Life
Support
 Recommendations (2011)
◦ There are no data to support routine spinal
immobilization in patients with penetrating
trauma to the neck or torso.
◦ There are no data to support the routine spinal
immobilization in patients with isolated
penetrating trauma to the cranium.
◦ Spinal immobilization should never be done at
the expense of physical examination or
correction of life-threatening conditions in
patients with penetrating trauma.
◦ Spinal immobilization may be performed when a
focal neurological deficit is noted although there
is little evidence of benefit even in these cases.

24. National Association of EMS
Physicians and ACS on Trauma
 Position Statement on Backboards 2013
 Utilization of backboards should be
judicious.
◦ Appropriate patients for immobilization
 Blunt trauma and AMS
 Spinal Pain or Tenderness
 Neurologic Complaint
 Anatomic deformity of the spine
 High energy mechanism of injury or any of the
following
 Drug or ETOH intoxication
 Inability to communicate
 Distracting injury

25. National Association of EMS
Physicians and ACS on Trauma
 Backboard Immobilization not
necessary
◦ Normal level of consciousness (GCS 15)
◦ No spine tenderness or anatomic
abnormality
◦ No neurologic findings of complaints
◦ No distracting injury
◦ No intoxication
 Penetrating trauma to the head, neck,
and torso and no evidence of spinal
injury should not be immobilized on a
backboard

26. National Association of EMS
Physicians and ACS on Trauma
 Spinal precautions can be maintained
by application of a rigid cervical collar
and securing the patient firmly to the
EMS stretcher, and maybe most
appropriate for:
◦ Pts who are ambulatory at scene
◦ Pts who must be transported for
protracted time, particularly prior to
interfacility transfer
◦ Pts for whom backboard is not otherwise
indicated

27. San Joaquin County Policy
 Apply C spine immobilization in blunt force trauma pts
◦ Posterior midline cervical tenderness or pain
◦ Distal numbness, tingling, weakness, paresthesia
◦ Paralysis
◦ Neck guarding or restricted ROM
◦ GCS motor score 5
◦ Unconscious pt except GLF
 Do not apply c spine immobilization
◦ Penetrating Trauma
◦ Unconscious adult GLF
◦ Cardiac arrest
 Backboards may be used for extrication or movement at
scene, but not for transport to the hospital.

28. CCEMS Policy Revisions
Spinal Immobilization
No Neck Pain
or Tenderness
Neck Pain or
Tenderness
Neuro Signs
or Symptom
Altered
Mental Status
Ambulatory
Position of
Comfort
Gurney
Position of
Comfort
with/without
Support
Full
Position of
Comfort
Non-ambulatory
Position of
Comfort
Gurney
supine
Position of
Comfort with
extrication
support
Full Full
Severe
Multisystem
Trauma
Full Full Full Full

29. Back to the case…
 Pt is GCS 15 and ambulatory (self-extricated)
 Back pain, abd pain but no neck pain.
 No neurological symptoms
 Per our new policy, this could be a
person that could be transported
without cervical collar or backboard.

30. Summary
 True unstable spinal injuries are rare.
 Ambulatory patients may protect their own
spine.
 C collars do not fully immobilize neck
movement.
 Spinal immobilization is not without
complications.
 New guidelines do not recommend routine
backboard usage.
◦ Use NEXUS and Canadian C spine as guides
 Other systems are changing their policies to
have more judicious usage of spinal
immobilization.
 CCEMS is revising the current policy as well

31. References
1. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed
cervical spine injuries. J Trauma. 1993;34(3):342-6.
2. Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis
of three hundred hospitalized patients and review of the literature. J Bone Joint
Surg Am. 1979;61(8):1119-42.
3. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma:
more harm than good?. J Trauma. 2010;68(1):115-20.
4. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal
immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214-
9.
5. Bandiera G, Stiell IG, Wells GA, Clement C, De Maio V, Vandemheen KL,
Greenberg GH, Lesiuk H, Brison R, Cass D, Dreyer J, Eisenhauer MA,
Macphail I, McKnight RD, Morrison L, Reardon M, Schull M, Worthington J, on
behalf of the Canadian C-Spine and CT Head Study Group The Canadian C-spine
rule performs better than unstructured physician judgment. Ann Emerg
Med. 2003;42:395–40.
6. James CY, Riemann BL, Munkasy BA, Joyner AB: Comparison of Cervical
Spine Motion During Application Among 4 Rigid Immobilization Collars. J Athl
Train 2004, 39(2):138-145.
7. Hughes SJ. How effective is the Newport/Aspen collar? A prospective
radiographic evaluation in healthy adult volunteers. J Trauma. 1998;45(2):374-
8.
8. Chin KR, Auerbach JD, Adams SB, Sodl JF, Riew KD. Mastication causing
segmental spinal motion in common cervical orthoses. Spine. 2006;31(4):430-
4.

32. References
1. Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim
RS. Cervical spine motion during extrication. J Emerg Med. 2013;44(1):122-7.
2. Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal
immobilization on healthy volunteers. Ann Emerg Med. 1994;23(1):48-51.
3. Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary
function in the healthy, nonsmoking man. Ann Emerg Med. 1988;17(9):915-8.
4. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp
Emerg Care. 1999;3(4):347-52.
5. Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on
intracranial and cerebral perfusion pressures. Anaesthesia. 2001;56(6):511-3.
6. Stone MB, Tubridy CM, Curran R. The effect of rigid cervical collars on internal
jugular vein dimensions. Acad Emerg Med. 2010;17(1):100-2.
7. Thumbikat P, Hariharan RP, Ravichandran G, Mcclelland MR, Mathew KM.
Spinal cord injury in patients with ankylosing spondylitis: a 10-year review.
Spine. 2007;32(26):2989-95.
8. Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS Major Trauma Study: impact
of advanced life-support on survival and morbidity. CMAJ. 2008;178(9):1141-
52.
9. EMS spinal precautions and the use of the long backboard. Prehosp Emerg
Care. 2013;17(3):392-3.

33. Thanks!