This document discusses the history and evidence surrounding spinal immobilization practices in EMS. It begins with a brief history of spinal motion restriction from the 1960s to present. It then discusses the anatomy of the spine, costs of spinal cord injuries, and mechanisms of injury that could cause spinal injuries. The majority of the document questions the evidence and potential harms of traditional spinal immobilization using backboards and cervical collars. It presents research showing low rates of spinal injuries from blunt trauma and questions whether immobilization benefits outweigh risks like respiratory compromise, pressure ulcers, and delayed treatment. Alternative approaches adopted by some agencies are presented, as well as calls from organizations to use immobilization more judiciously.

1. Spinal “Immobilization”
Treatment or
Torture?
By Luke Winkelman, PM, NRP, EMS-I 2017

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Session key: 112574

3. Poll results

4. Poll results

5. Poll results

6. Poll results

7. Poll results

8. Glossary
• Spinal Immobilization
• Spinal Motion Restriction - SMR
• Spinal Cord Injury - SCI
• Dogma
• Sacred Cow
• Evidence Based Medicine - EBM

9. History of SMR
• First Mentioned in 1965 by Col. Louis C
Kossuth[1]
• “move a victim from the vehicle with a minimum
of additional trauma”
• “due regard to maximum gentleness”

10. History of SMR
• 1967 by J.D. Farrington, MD in position article:
“Death In A Ditch”[2]
i. “…frequently mishandled injuries, made worse by hasty and
rough movement from a vehicle or other accident scene...”
• 1968 by J.D. Farrington in: ‘Extrication of
victims-surgical Principles.’[3]
i. “[I]mmobilization and in-line traction are the basic principles of
extrication.”

11. History of SMR
• The first EMT text to
include Spinal
Immobilization using
rigid board was
Emergency Care and
Transportation of the
Sick and Injured. [4]
• American Academy of
Orthopedic Surgeons, 1971

12. The Spine
• Structure
• Protection
• Flexibility

13. Injuries to the Spine
• Lost productivity
• Can be fatal
• Significant psychosocial impact
• High medical cost

14. Cost Of Spinal Cord Injury
• 253,000 people in US living with SCI
• 12,000 new cases each year
• In the US MVC related SCI estimated $34.8
billion per year -Spinal Cord Injury Information Network[5]
• SCI cost first year, $1,023,924
• SCI cost years 2+, $171,808 -National Spinal Cord Injury
Statistical Center[6]

15. Everybody Get’s a Backboard

16. MOI Indicators
• Fall from 2-3 times the patient’s
height
• Fall distance not the strongest
indicator
• Portion of body to strike first
• Surface that stops the fall
• Age, co-morbid pathophysiology

17. MOI Indicators
• Death in same
compartment
• Extended
Extrication
• Vehicle Damage
• Cabin intrusion >= 12 inches
• Rollover/roof deformity

18. Mechanism of Injury
https://www.youtube.com/watch?v=0HAGMb_jAdU [7]

19. MOI ALONE NOT RELIABLE
• Worst indicators: "motorcycle crash with separation
of rider," "pedestrian hit by motor vehicle," "motor vehicle
crash with rollover," and "motor vehicle crash with death
of occupant."
• Best Indicators: "ejection from a vehicle" and
"prolonged extrication time.“ - Kohn et’al. Acad Emerg Med. 2004[8]

20. MOI ALONE NOT RELIABLE
• Medics showed 80% accuracy predicting
disability by using patient and scene
assessment with MOI indicators.
• Decreased when MOI was only factor
Vaca FE, et al J Emerg Med. 2009 [9]

21. MOI Case Study
• A CLIMBER fell 1,000ft
down mountain
• Walked away
• Was found standing
up, reading a map.
NBC News 2011 [10]

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23. Poll results

24. Poll results

25. What are the odds?

26. Likelihood of Spine Injury
• “2000–6000 Newtons of force to fracture the
cervical spine” Maiman DJ, Sances A Jr, Myklebust JB, et al 1983 [11]
• Just under 1 million pt.'s immobilized, only 2–
3% of these patients actually had spinal injuries,
most were stable. Goldberg W, Mueller C, Panacek E, et al. 2001 [12]
• Common Blunt injuries (MVCs, falls from
standing & heights, assaults) only 1.2%–3.3%
had spinal injury and of those only 0.4%–0.7%
had potential to worsen. Kwan I, Bunn F. 2005; [13]

27. Likelihood of Spine Injury
• 7 months, Phoenix AZ
• 228 blunt force trauma patients
• 122 complaints of neck pain
• 3(0.98%)cervical injuries – stability
unknown -Am J Emerg Med. 1989 [14]

28. Blunt Force-MOI
No Injury Injury
Unstable InjuryStable Injury
3-5% [15]
No Damage-YETDamage Done
Conscious Obtunded
0.4-0.7% [16]
NNT=1032
NNH=66
Haut, Elliott R., et al 2010 [17]
0.38% [17]
SMR- Who MAY benefit???

29. So What If We Stopped?
• What if the patient was their own best
immobilizer?
• “Conventional techniques ~ up to four times more
cervical spine movement during extrication than
controlled self-extrication (Rigid Collar and patient
then self extricating)”-Engsberg JR et al; J Emerg Med. 2013 [18]

30. So What If We Stopped?
• Malaysia vs New Mexico 5 year study
– 120 pt’s seen at University of Malaya
• None immobilized
• 11% neurologic disability
– 334 pt’s seen at University of New Mexico
• All immobilized w/ C-Collar
• 21% neurologic disability -Acad Emerg Med. 1998 [19]

31. The Science Behind
“Immobilization”
…….Still waiting…….

32. Not Science

33. What could it hurt?

34. Pressure Ulcers
• Est. 14.8% of acute care
patients have pressure ulcers
Amlung SR, et al; 1999 [21]
• 29 wk cost per healthcare
acquired ulcer $129,248 -Am J
Surg. 2010 [22]
• Per ulcer cost $9.1-11.6
Billion/yr –Association for Healthcare Resource &
Materials Management [23]
• “Spinal immobilization for unconscious patients with
multiple injuries” Craig Norris, MD BMJ 2004 [24]

35. Respiratory Compromise
• Backboard Only Ann Emerg Med. 1988 [25]
i. 15 volunteers
ii. “Significant difference” in FVC and FEV1.
• Backboard & C-Collar Prehosp Emerg Care. 1999 [26]
i. 39 volunteers
ii. Wooden backboard or vacuum mattress.
iii. 15% decrease in FEV1 on average. (worse
at extremes of age).
iv. Vacuum mattress more comfortable.

36. Back Pain
• 21 healthy volunteers
• Immobilized for 30 minute period.
• Results: headache, sacral/lumbar pain, jaw pain
most common.
• 55% subjects moderate to severe symptoms.
• 29% developed symptoms 48 hours post
removal -Chan D Ann Emerg Med. 1994 [27]

37. Pop out the collar!
Journal of Trauma, 1983 [28]

38. Displaces Unstable Fractures
• Unstable cervical fractures
created in 7 fresh human
cadavers
• Rigid collar
• Assessed movement
• Avg 7.7mm±6.8mm axial
plane
• Avg 2.9mm±2.5mm
cranial-caudal plane
-J Trauma. 2011 [29]

39. Displaces Unstable Fractures
• Ankylosing Spondylitis
– 15 patients with traumatic
injury able to walk immediately
following the injury,
– 12 deteriorated
– 6 of these were due to over
extension of the kyphotic spine
(40% were complete injuries).
10-year review. Thumbikat P, et al; 2007 [30]

40. Cost Of a C-Collar
The EMS Store [31]

41. Cost Of a C-Collar
• Obligatory radiological exams >$200 [32]
• 5% patients who complain of neck pain
following blunt force have c-spine injury
Ersoy G et’al Eur J Emerg Med. 1995 [33]

42. Increased ICP
• 90% of pt’s with C-collar experienced significant
increases in ICP, 100% experienced decrease in GCS
- 10 consecutive pt’s Mobbs ET AL, ANZ J. Surg. 2002; [34]
• Estimates of ~34% of trauma pt’s meeting current
immobilization criteria have a head injury, and are
susceptible to rise in ICP-Daniel Kwan, MD 2014 [35]

43. Increased Risk of Aspiration
• Decreased ability to open mouth
• Difficulty swallowing
• Head Injury patients at increased risk for
emesis.
Br J Neurosurg. 1996 [36]

44. Difficult to Manage Airway
• Collar vs Manual Inline
Stabilization
– 50 surgical patients
– MILS Intubation success 66% better
than collar and board
-Heath KJ. Anesthesia 1994 [37]
MILS vs none
• 200 Elective surgery patients
• 50% failure rate in 30 seconds
with MILS vs 5.7% without.
-Thiboutot F, et al. 2009 [38]

45. Delayed Care/Resuscitation
• 30,956 Patients
• No group of penetrating trauma patients had any survival
benefit with spine immobilization.
• Spine immobilization was independently associated with
significantly decreased survival.
• Significantly decreased survival for GSW and for
hypotensive groups -Haut ER, Kalish BT, Efron DT, et al. 2010 [39]

46. So What If We Stopped?
• “Most patients who do have spinal
injuries are mechanically ‘stable’ at least
in the short term—stable in that
significant force would need to be applied
to the injured site to cause further
damage.” -Hauswald et al 2012 [40]

47. The Short of the Longboard

48. Endangered
ENDANGERED!

49. Technique

50. Technique
• Log roll? There’s GOT to be a better way
Surg Neurol Int. 2012 [41]

51. Technique
• The awkward log roll
“[S]tatistically significant displacements of the injured
spine.”
• Still no deterioration
Hyldmo, et’al. 2015 [42]

52. Poor Skill Performance
• 50 SMR subjects
• 15 (30%) at least one strap unsecured
• 44 (80%) at least 2cm slack in straps
-Duke University 2007 [43]

53. Liability

54. Liability
• 1987-1992 only 76 cases of EMS lawsuits
• Over 40% (31)of cases were dismissed
• Only 5 cases paid out $1+ Million
• Most were ambulance crash related
• Immobilization suits were less frequent than
Refusal, Consent, Abandonment, & Improper
restraint -World Association for Disaster and Emergency Medicine 1994 [44]
• 95% of EMS lawsuit “Root cause” is provider
poor attitude and patient dissatisfaction- PWW 2010 [45]

55. Liability
• 2002 Case Study [45,46]
• 24 yo intoxicated male
• Fell 8 ft from the top of a wall
• Pt. reports his head and neck hurt
• ”Get up, are you drunk?” “Get up, or we’re going
to call the police”
• “Snatched him up and threw each arm over their
shoulders and dragged him to the stretcher”

56. Liability
• 2002 Case Study Cont’d [45,46]
• Could not move his arms or legs
• Pt reports his neck “Snapped back”
• “It was like somebody hit a light switch and I just
went completely numb”
• Expert witness- “Mr. Smith’s quadriplegia is
directly attributable to the actions of the
paramedics.”

57. Liability
[47]
[48]

58. 2015 IDPH EMS Protocol
IDPH EMS [49]

59. Positions
• NAEMSP
• “Patients without a mechanism of injury with the potential
for causing spinal injury or those patients without one of
the above clinical findings may safely have spinal
immobilization omitted. ~ should be transported in a
position of comfort.”[50]

60. Positions
NASEMSO
[51]

61. Positions
• NAEMSP & ACS Joint Statement
• “Long backboards are commonly used to attempt to
provide rigid spinal immobilization ~~ However, the
benefit of long backboards is largely unproven”
• “Utilization of backboards for spinal immobilization during
transport should be judicious, so that the potential
benefits outweigh the risks” [52]

62. Positions
• International Liaison Committee On Resuscitation
2015 draft [53]

63. The Wise Guys
Systems that have removed the LSB from
spinal immobilization protocols[54]
•State of New Hampshire
•State of Pennsylvania
•Harris County Texas (ESD 5)
•Chaffee County Colorado
•Alberta Canada
•South Australian Ambulance Service
•Johnson County Kansas
•Sedgwick County Kansas (Witchita)

64. The Wise Guys
https://www.youtube.com/watch?v=OyFsV2CP15A [55]

65. Baby Steps
• We were immobilizing
anyone that fell from a
standing height
• Now - significantly less
LSB use
• Tomorrow’s headlines:

66. Poll time!
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Session key:678810

67. Poll results

68. Poll results

69. Poll results

70. Poll results

71. References

72. References
• [1] http://journals.lww.com/jtrauma/Citation/1965/11000/THE_REMOVAL_OF_INJURED_PERSONNEL_FROM_WRECKED.4.aspx
• [2] “Death in a Ditch,” by J.D. Farrington, MD, FACS May/June 1967 edition of the American College of Surgeons Bulletin
• [3] http://journals.lww.com/jtrauma/Citation/1968/07000/EXTRICATION_OF_VICTIMS_SURGICAL_PRINCIPLES_.2.aspx
• [4] Emergency Care and Transportation of the Sick and Injured. AAOS, 1971 LC Call No.: RC87.A528
• [5] www.spinalcord.uab.edu
• [6] https://www.nscisc.uab.edu/
• [7] https://www.youtube.com/watch?v=0HAGMb_jAdU
• [8] https://www.ncbi.nlm.nih.gov/labs/articles/14709422/
• [9] https://www.ncbi.nlm.nih.gov/pubmed/19561820
• [10] http://www.nbcnews.com/id/41334296/ns/world_news-europe/t/almost-flying-climber-survives--foot-fall/#.VO-YcvnF-OU
• [11] https://www.ncbi.nlm.nih.gov/pubmed/6621839
• [12] https://www.ncbi.nlm.nih.gov/pubmed/11423806
• [13] https://www.ncbi.nlm.nih.gov/pubmed/15748015
• [14] http://www.ncbi.nlm.nih.gov/pubmed/2920074
• [15] https://www.ncbi.nlm.nih.gov/pubmed/11423806
• [16] https://www.ncbi.nlm.nih.gov/pubmed/11597285
• [17] https://www.ncbi.nlm.nih.gov/pubmed/20065766
• [18] http://www.ncbi.nlm.nih.gov/pubmed/23079144
• [19] http://www.ncbi.nlm.nih.gov/pubmed/9523928
• [20] http://www.naemsp.org/pdf/spinal.pdf
• [21] http://www.ncbi.nlm.nih.gov/pubmed/11794440
• [22] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950802/
• [23] http://www.ahrmm.org/cqo-movement/files/leading-practices/hapu-uva-executive-summary.pdf
• [24] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC515204/
• [25] https://www.ncbi.nlm.nih.gov/pubmed/3415063
• [26] https://www.ncbi.nlm.nih.gov/pubmed/10534038
• [27] https://www.ncbi.nlm.nih.gov/pubmed/8273958
• [28] https://www.ncbi.nlm.nih.gov/pubmed/6864837

73. References
• [29] https://www.ncbi.nlm.nih.gov/pubmed/21217496
• [30] https://www.ncbi.nlm.nih.gov/pubmed/18091492
• [31] http://www.theemsstore.com/store/product.aspx/productId/1175/
• [32] http://www.jcl.com/hospitals/average-pricing-information/x-rays#72040
• [33] http://www.ncbi.nlm.nih.gov/pubmed/9422206
• [34] http://www.neurospineclinic.com.au/pdfs/journal-articles/hard-collar-icp.pdf
• [35] http://www.slideshare.net/danielkkwan/ems-sspinal-immobilization-time-for-a-change slide-17
• [36] https://www.ncbi.nlm.nih.gov/pubmed/8922712
• [37] http://www.ncbi.nlm.nih.gov/pubmed/7802175
• [38] https://www.ncbi.nlm.nih.gov/pubmed/19396507
• [39] https://www.ncbi.nlm.nih.gov/pubmed/20065766
• [40] https://www.ncbi.nlm.nih.gov/pubmed/22962052
• [41] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3422095/
• [42] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4573694/
• [43] http://www.ncbi.nlm.nih.gov/pubmed/17613902
• [44] http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8435291&fileId=S1049023X0004142X
• [45] https://www.ncemsf.org/about/conf2010/presentations/stark_liability.pdf
• [46]http://www2.ca3.uscourts.gov/opinarch/011895.txt
• [47] http://archive.boston.com/news/local/articles/2006/08/24/injured_woman_drowns_under_rescue_boat/?camp=pm
• [48] http://www.emsworld.com/news/10706794/settlement-reached-in-nh-fatal-airboat-rescue-lawsuit
• [49] http://www.idph.state.ia.us/ems/common/pdf/ems_protocols.pdf
• [50] http://www.naemsp.org/Documents/Position%20Papers/POSITION%20IndicationsforSpinalImmobilization.pdf
• [51] http://www.nasemso.org/Projects/ModelEMSClinicalGuidelines/documents/NASEMSO-Model-EMS-Clinical-Guidelines-DRAFT.pdf
Page 172
• [52] http://www.naemsp.org/Documents/Position%20Papers/POSITION%20EMS%20Spinal%20Precautions%20and%20the%20Use
%20of%20the%20Long%20Backboard.pdf
• [53] http://www.scancrit.com/wp-content/uploads/2015/02/ILCOR-Cervical-Collar-Guidelines-DRAFT-2015.pdf
• [54] https://www.facebook.com/groups/emtstudygroup/permalink/351267485065814/
• [55] https://www.youtube.com/watch?v=OyFsV2CP15A

74. Questions?