Smarter Spinal Immobilization


I’m teaching con-ed next month about spinal immobilization, so Rogue Medic and Ambulance Driver have given me lots of ideas about what to talk about.  Here’s my less-than-expert opinion about it:

1. Very few patients who get immobilized have a spinal injury.

2. Very few, if any,  spinal injuries can be made worse with movement.  We also don’t know how much movement would be needed to make an injury worse.

3. Using a log roll to put a patient on a back board causes movement of the spine.  Whether the amount of movement is significant is not known.

4. Real harm is done from making patient lay flat on a hard board with a collar.  We cause patients’ ICP to increase, make it harder for them to breathe, and increase their risk of aspiration.

I was in an accident a few years ago.  I got out of the truck, walked around, and had pain in the muscles on both sides of my neck.  I agreed to be boarded only because I was at work.  At the hospital a PA palpated my spine, had me turn my head a few different ways,  and said I did not need X-rays.  It took less than two minutes.  Now why can’t we do that before we put someone on a board?

We own immobilization, and it is up to us to change it.  I see two ways to attack this:

1. Do a study of low risk patients.  Start by learning how how PA’s and physicians clear spines.  Perform that exam on patients before we immobilize them, document whether or not this person’s spine could have been cleared, and compare our exam findings to the hospital’s.

2. For patients with permanent disability, look backwards.  Were they ever ambulatory after being injured?  Did another injury distract from their spinal injury?  Did a hard board, collar, and blocks prevent their injury from getting worse?

We know that the way we immobilize people’s spine causes harm, but for now we’re stuck with it.  The burden of proof is on us to show that we can safely identify patients with spinal injures, and to find better ways to protect ones who do.

Comments

  1. True C-Spine injuries are relatively rare in the real world. I can recall a handful over the years and all but one had immediate paralysis associated with them. The one that didn’t was ambulatory at the scene and more worried about us taking care of his dog than he was about going to the hospital. We took the dog home for him, transported him to the hospital, and a few hours later found out he had a cervical fracture. They only found it on Xray and only did an Xray because at the time it was their protocol to Xray all MVA patients that were transported.

    Maine has had a cervical spine evaluation program for all levels, including first responders, since about 1995. I haven’t heard of an epidemic of people confined to wheel chairs because of it.

    It’s not rocket science. I’ve taken a couple of wilderness EMT courses that include a protocol identical to the Maine one, it’s not very difficult.

    The only reason that it’s not more wide spread in EMS is that most medical directors and ambulance service managers are so risk adverse and have been scared by the same fairy tales as have generations of EMT students that the won’t even discuss the subject.

    • emspatientperspective says:

      I’ve been to a few con-ed sessions that discussed missed C-spine fractures. Fortunately none were calls that I was on. All were on calls for a medical event that preceded a fall, such as a seizure. None of the patients were paralyzed, but the message was that they could have been. I’ve heard stories about people becoming paralyzed after walking around and turning their head, but can this really happen?

  2. The problem with spinal clearance protocols is that they presume that spinal immobilization is beneficial/not harmful for patients with spinal injuries. That has never been demonstrated.

    Spinal clearance protocols can protect patients without spinal injuries from being harmed by spinal immobilization, but those injuries are minor compared to the patients who do have spinal injuries.

    We need to do something to protect the patients who do have spinal injuries from disability caused by spinal immobilization?

    .

  3. One of the major, major oversights with this type of research is that it’s assumed any missed cervical fracture — that is, they imaged and found a crack somewhere — is clinically significant, high-risk, and that risk would have been managed by immobilization. Occasionally I’ve seen them divided into significant vs. non-significant, but “significant” still normally assumes that if this patient had turned the wrong way they’d have collapsed into a heap — questionable — and that a collar and board would have prevented this — also questionable.

    This is one of those situations where trying to winnow out every last fracture is not just impossible, but a wrong-headed approach. We’re not interested in fractures, we’re interested in unstable fractures that we can do something about. And it’s far from convincing that 1) we’re unable to detect all or nearly all of these prehospitally; and 2) that our current immobilization methods are an effective treatment for these.

    • The Hauswald study showed a doubling of disability with immobilization, when compared to no immobilization at all.

      We should not be assuming that long spine board immobilization is protecting any patients who have unstable spinal fractures.

      Where is there any evidence to show that long spine board immobilization is safe, or protective?

      .

  4. Although I agree, Rogue, the intuitive “it makes sense” appeal of immobilization is strong enough that I doubt you’ll have much traction coming from that angle until there’s stronger evidence than the single study. To me, the situation unpacks as a “it reaaally seems like it would work, but after we accumulated a lot of evidence, we had to admit that it doesn’t, and may even hurt a little” gambit — something we should be familiar with after plenty of similar offenders in the past. It’s just that there’s not yet that body of evidence to heap on the table.

  5. If the goal of spinal immobilization is to not move the spine, the way we do it does not work. One example is here: http://www.ncbi.nlm.nih.gov/pubmed/16418091

    While there has been no demonstrated benefit of spinal immobilization for patients with spinal injuries, we can start changing this by learning how to safely determine which patients do not have one. I think this is possible for EMS with additional education.

    For now we should continue to immobilize patients with suspected spinal injuries, but we need to find a better way to do it. The log roll, hard board, collar, and head blocks have not changed significantly in the last 20 years. Why continue to do something that we know does not work and causes harm?

Trackbacks

  1. […] and struggling to reinvent itself.  How we administer CPR has changed (again), we question the effectiveness of C-spine immobilization that we do standard on nearly every trauma patient, or argue the very validity of the […]

  2. […] and struggling to reinvent itself. How we administer CPR has changed (again), we question the effectiveness of C-spine immobilization that we do standard on nearly every trauma patient, or argue the very validity of the “Golden […]

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