C-Spine discussion

[JPINFV]

Here's an interesting article I came across a few days ago (searching EMTCity for the URL produced nothing). Comments, concerns. complaints, ideas about the article?

Best Practices: Myths and Realities of Spinal Immobilization

DAVID JASLOW, MD, MPH, FAAEM

EMSResponder.Com Contributor

Editor's Note: The following column is meant to stimulate critical thinking amongst EMS practitioners. It contains information and opinions that may be foreign to some readers and downright shocking to others.

This piece should be taken for what it is and not be misconstrued as an opportunity to disregard local protocol. Neither the author nor the editor advocates the practice of medicine without standards. The readership is encouraged to talk about the issues contained in this article with department leadership and their medical directors. As always, we welcome your comments.

For each of the numbered statements below, pick the answer that is the best fit from the following list:

a. There is a sound evidence basis for this statement (i.e. there is scientific evidence beyond a reasonable doubt which supports this practice or procedure)

b. Clear scientific support is lacking, but the procedure is considered a "best practice"

c. This is no evidence to support this practice, which is more myth than reality

1. Prehospital spinal immobilization prevents spinal cord injury.

2. Manual cervical stabilization is always required until a cervical collar is applied.

3. Cervical collars alone are inadequate to prevent cervical movement.

4. The standing backboard technique should always be employed when a patient who fits criteria for cervical immobilization is found standing.

5. Rapid extrication has been proven to save more lives than use of the KED.

6. Rapid extrication is now the preferred mode of removal of a patient from a vehicle after a crash of any magnitude.

7. The KED or similar devices have been proven to reduce paraplegia in patients with thoracic or lumbar fractures.

8. A cervical collar is adequate to provide temporary immobilization of a possible cervical spine fracture.

9. Cloth tape is a proven and acceptable method to secure a patient to a backboard.

10. Skin breakdown does not occur after a patient is placed on a backboard.

If you chose answer "a" for any of the above statements, I have good news and bad news for you. The bad news is that you are incorrect. It may come as a shock, but there has never been a randomized prospective trial conducted anywhere in the world and published in a peer-reviewed medical journal to determine if any of the aspects of spinal immobilization actually prevent spinal cord injuries or somehow lessen the morbidity of spinal column injuries. (For more information, see below.) The good news is that we can address many factual discrepancies in this column which may aid in the management of those patients who may have spinal column and/or cord injuries and help to reduce on-scene time.

The ten statements above are presented in no particular order, but represent a broad spectrum of the concerns surrounding spinal immobilization in the field. We will group them into several categories for a brief discussion. What is most interesting about many of these practices is how they developed into de facto industry standards (which is not the same as standards of care) in the absence of any scientific information to support their use. Of course, this information power vacuum itself probably contributed to the development of these practices. Note that the single most divisive issue currently, spinal clearance by EMS providers, is not listed here. This issue is complex and deserves its own discussion, which we will present later this year.

Cochrane Review

The readership is referred to the brief evidence-based emergency medicine report by Baez and Schiebel entitled, "Is Routine Spinal Immobilization an Effective Intervention for Trauma Patients?" which appeared in the Annals of Emergency Medicine in January 2006. The objective of this study was to quantify the effect of different methods of spinal immobilization (including immobilization versus no immobilization) on mortality, neurologic disability, spinal stability and adverse effects in trauma patients.

The authors searched all databases where peer-reviewed medical journal articles would be found, along with the Cochrane Controlled Trial Register for evidence of scientific trials. Then they contacted experts in the field and eight manufacturers of spinal immobilization devices to determine whether they were aware of any sound evidence for use of these devices that would not otherwise appear in the on-line search. The authors were unable to find a single randomized controlled trial of actual injured patients to support the efficacy and effectiveness of spinal immobilization strategies and spinal immobilization techniques. In other words, there has never been a study in the medical literature that proves that any form of spinal immobilization or any technique or device used during such immobilization actually prevents spinal cord injury or lessens morbidity from spinal column injury.

Furthermore, immobilization has some negative connotations, such as the inability to clear one's airway when vomiting and the skin breakdown that has been documented in healthy volunteers who lay on a long board for more than 60-90 minutes. There are also no prospective randomized trials to determine whether or not immobilization in certain circumstances contributes to mortality or morbidity. The authors quickly point out that lack of evidence for effectiveness does not necessarily mean a particular intervention is ineffective and this is true.

Here is a quick summary of what we now know. The only literature support for immobilization practices remains the NEXUS trial and the resultant out-of-hospital spinal clearance practices. Otherwise, how we immobilize patients and whether those patients we immobilize even by evidence-based medicine criteria are better off because they are immobilized remains to be seen.

Given this dark cloud that has descended over the EMS world, let's look at best practices concerning several common immobilization techniques and approaches to patients requiring out-of-hospital immobilization.

Manual cervical spine immobilization

Manual c-spine immobilization refers to the practice of holding a patient's neck still prior to the application of a cervical collar. The First Responder and EMT-Basic National Standard Curricula also teach that this "in-line stabilization" as it is known should be maintained until a CID or similar apparatus is in place. The theory here is that EMS practitioners must do anything and everything possible to prevent spinal cord damage which could occur if a patient with an unstable cervical spine fracture voluntarily or involuntarily moved their head and neck around with impunity. Manual c-spine stabilization is most commonly employed in vehicle crashes and during treatment of sports-related injuries.

Unstable c-spine fractures and several other traumatic conditions such as facet jumps and ligament rupture are the only circumstances in which there is a risk of spinal cord damage (as opposed to stable fractures). These injuries represent the minority of c-spine traumatic injuries encountered, which themselves are rare. However, these conditions can be extremely unstable and prone to further catastrophe. The question is not whether we should guard against the possibility of this occurrence but how to do so and, more importantly, whether any of these actions actually has the intended consequence, i.e. prevention of spinal cord injury. Since there is no evidence to disregard the practice of maintenance of spinal stabilization, and the potential outcome of lack of the technique is disastrous, the practice has become incorporated into the spinal immobilization standard of care.

I have often found this practice curious for several reasons. First, the majority of patients who have cervical fractures have pain associated with the injury unless they are intoxicated or have altered mentation. I have yet to find compliant patients with painful traumatic injuries who will intentionally move the injured part around because this creates further pain. Usually the opposite is true -- patients will avoid the action which causes pain. Second, patients with severe head trauma or other conditions which cause them to be combative and noncompliant with instructions not to move their head or neck by definition usually have behavior that is disruptive to the point that even a cervical collar, CID and "in-line stabilization" fail to prevent cervical motion. Thus, how could manual stabilization alone accomplish this? What was the patient doing during the EMS response interval? Third, in-line stabilization requires the dedication of an individual, usually an EMS provider unless there are other first responders at the scene who can accomplish the task, to commit to this procedure and nothing else. Thus, a two-person EMS crew finds that they are short-handed. Potentially, other more important procedures, such as physical exam, establishment of invasive procedures, etc. are unintentionally delayed as well. Finally, similar to the standing backboard maneuver, patients who present to emergency departments with the same complaints are placed in a cervical collar and ambulated to a stretcher where they lie down without anybody maintaining "in-line stabilization" initially, if at all.

What point am I trying to make? The average patient who is able to comprehend instructions (assuming he/she understands English or instructions provided in their native language) should have no difficulty maintaining their neck in a neutral "in-line" position on their own. Failure to do so due to cell phone conversations or other distractions usually indicates that there is a low likelihood of unstable condition in the neck. If additional manpower is available to assist in this endeavor, there is no harm in the practice. However, EMS practitioners, chief officers and EMS medical directors should give serious consideration to prioritization of clinical care procedures when manpower is limited given the lack of evidence that "in-line stabilization" offers any tangible benefit.

Standing backboard maneuver and "long board on the stretcher"

This term is used to describe the process of placing a patient onto a long backboard who is found standing or walking at the scene. The general concept is that a patient who requires spinal immobilization either by mechanism of injury or due to complaints of neck or back pain should not make any further movements once contacted by an EMS provider. Therefore, a cervical collar is placed on the patient and the long backboard is placed behind him/her. Using a minimum of three individuals, one holding "in-line stabilization" and one holding onto either side of the patient in addition to grasping the board, the patient is gently lowered onto a flat surface, usually the ground unless the litter is placed directly behind the patient.

There are various explanations for why a patient must be fully immobilized where they stand, but none are grounded in science. Despite the lack of evidence concerning spinal immobilization presented so far, few experienced paramedics or physicians would argue that placement of a cervical collar at the earliest possible time after suspicion of a cervical injury is not indicated. However, there is no precedent in hospital emergency departments (or anywhere else in the hospital) to perform standing immobilization techniques in Triage for those patients who present after trauma with complaints of possible spinal injury. Nor is there any outcry from the medical community or any other body that EMS practitioners are causing or risking spinal cord injuries by not applying long backboards more quickly, especially since these boards are removed during the initial evaluation of the trauma patient due to the risk of skin breakdown and the discomfort to the patient, which may itself lead to more patient movement.

Similarly, having a patient who has been ambulatory walk over to the stretcher and lie down on the backboard does not seem to offer any additional benefit to that conferred by cervical collar placement since most of the potential for additional motion is diminished once the patient is strapped to the stretcher. Again, if the patient is coherent and complaint enough to follow instructions to lie on the stretcher, it would seem intuitive that he/she could maintain themselves in a relatively immobile position during transport.

Cervical immobilization device (CID)

CIDs were invented to take the place of sandbags which were the most common form of lateral stabilization device used in the 1970s and 1980s. CIDs are now mostly disposable to be OSHA compliant. However, the devices have become more flimsy than in the days of non-disposable devices leading many to question their effectiveness in preventing lateral movement of the head. The perceived need for lateral stabilization is due to both clinical experience and in vitro studies in which cervical collars were found to do a relatively good job restricting anterior-posterior motion but an inadequate job restricting lateral motion, especially when the patient is unable to maintain their head in an "in-line" position. Such might be the case when the patient is lying supine on a backboard in a moving ambulance. Shifting of the patient's weight when the vehicle turns corners or makes other sudden maneuvers can pull their head to one side.

CIDs are also removed in the trauma bay or ED resuscitation area during the initial evaluation of the patient and are not replaced even if a cervical spine injury is identified. However, the chances for lateral patient movement are essentially nil unless this movement is self-induced. While placement of the CID is now considered standard of care as part of the "fully immobilized" package, the standard has been largely manufactured by the EMS equipment industry without any evidence that its use improves patient outcomes or prevents deleterious ones. Nonetheless, given the erratic driving conditions which are inherent in EMS response, use of some type of lateral support for the head of a patient immobilized on a long backboard seems to be reasonable from the perspective of patient comfort alone.

Backboard securing systems

There are a variety of methods in which to secure a patient to a long backboard. Most EMS agencies use non-disposable straps of some sort which either click into the side of the board or are secured onto themselves with Velcro.

Of concern is the practice of securing the patient with cloth tape and stretcher belts or stretcher belts only. Neither cloth tape nor belts can adequately support the weight of a patient to prevent him/her from sliding on the board in both a lateral and forward-backwards motion. Failure to adequately secure the patient on the backboard represents a safety issue for the patient and a potential liability issue for the EMS agency should the patient sustain an injury from falling off the stretcher during transport or should the ambulance be involved in a crash.

Finally, I must comment on the practice of carrying a patient on a long backboard without any securing devices whatsoever. All of us have been guilty of failure to adhere to SOPs regarding proper immobilization methods at one point or another. The instability of a patient on a long backboard as he/she is carried creates a huge risk that the patient may fall off the board.

Rapid Extrication versus KED board application

Just as there is no evidence to support spinal immobilization in general, there is no evidence to proclaim whether rapid extrication techniques popularized through PHTLS and BTLS courses in the last decade are safer or more appropriate than taking time to apply thoracic and lumbar devices such as the KED or short backboard. While those patients who sustain significant mechanism of injury are statically more likely to have a spinal column injury (and more likely to require a KED by "protocol") there are also no reported case series of spinal cord injuries that have been linked to failure to apply these devices in the field.

Ironically, despite the complete lack of evidence which precludes me from even providing any opinion about this subject matter based upon validated fact, we continue to spend a tremendous amount of time teaching EMS practitioners intricacies of spinal immobilization. We do this because we fear exacerbating injuries that carry a high degree of morbidity and can even be lethal. Despite the amount of education we deliver, I still see many incidents in which immobilization techniques are carried out haphazardly or the patient's spinal column is never truly maintained in a neutral position while he/she is extricated.

Clearly, we have a lot to learn about the out-of-hospital practice of spinal immobilization and much to think about when we apply medical treatments to patients that have little to no scientific validation. Regardless of whether or not you change your practice of walking patients to the backboard or holding their head in a vehicle, this column should open your eyes to the fact that much of what we teach in EMS is "one practice" and not necessarily the "best practice." In many cases, the best practice is not yet known even if a textbook or national curriculum convinces us that the practice is written in stone. Medicine may be a science, but its practice is an art. I always found painting difficult.

If you know of an EMS practice which is questionable, hotly debated amongst your fellow providers or downright dangerous, e-mail me at jaslowd@einstein.edu with your thoughts and what you think is the standard of care and we will discuss it in this open forum. Hopefully, we can improve care through education.

Dr. Jaslow is a board certified emergency medicine physician fellowship-trained in EMS and Disaster Medicine. He is the Chief of the Division of EMS, Operational Public Health and Disaster Medicine and Co-Medical Director of the Center for Special Operations Training within the Department of Emergency Medicine at the Albert Einstein Medical Center in Philadelphia. Dr. Jaslow is also the Medical Director and Lead Physician for the Pennsylvania Task Force-1 Urban Search and Rescue Team and an active firefighter/paramedic and EMS Medical Director in suburban Philadelphia. He currently serves as the Medical Editorial Consultant for EMS Magazine and as a member of the editorial board for Advanced Rescue Technology. He can be reached at jaslowd@einstein.edu.

http://www.emsresponder.com/features/artic...;siteSection=16

[Just Plain Ruff]

this was exceptional reading. I hear where he is coming from 100%. Now if someone will do a actual evidence based study to prove this article we will be better off. But until that day comes, we will still be immobilizing everyone.

[Camulos]

Very interesting article indeed!!! I suspected it was going to be a good one from the moment I read the disclaimer at the start. I have no doubt it will certainly “stimulate some debate amongst EMS practitioners”. Indeed it has inspired me to jot a few things down.

Dr Jaslow points out that there is no level I evidence to support, or refute, current spinal immobilisation practices. I’m sure this is not news to most of us. There is definitely a paucity of evidence regarding many EMS practices – pick your topic. I would however be keen to know how a randomised control trial could be done in this particular pt population. To prove, or disprove, current spinal immobilisation practices, I would imagine that one group of pts with documented injury would have to be immobilised and one group would not. Good luck finding an ethics committee to approve that, let alone gaining pt or next of kin consent. So herein lies the problem. Perhaps there is no level I evidence because it is simply just not feasible for it to be conducted. If anyone can think of a way to conduct a quality RCT in this population I am very keen to hear it. Then I can steal it and take the credit when I publish it – LOL.

In his column Dr Jaslow states “However, EMS practitioners, chief officers and EMS medical directors should give serious consideration to prioritization of clinical care procedures when manpower is limited given the lack of evidence that "in-line stabilization" offers any tangible benefit.” Surely this refocus would have to be predetermined, taught and documented in the cookbook. EMS practitioners and chief officers aside, I believe a reprioritisation of clinical care procedures at this level should come from medical directors. Realistically which medical director is going to sign off on that? I believe the possible medico-legal consequences are just too great – especially in the litigious society of the United States.

Dr Jaslow also states “While those patients who sustain significant mechanism of injury are statically (sic) more likely to have a spinal column injury (and more likely to require a KED by "protocol") there are also no reported case series of spinal cord injuries that have been linked to failure to apply these devices in the field.” Again I believe this is very difficult to prove. If it could be conclusively proved I believe that would be very costly for the EMS agency involved with the resultant compensation payout. I guess the only way to establish failure to apply spinal precautions as a causative factor in SCI is if the pt was fine before you moved them, and then suddenly developed symptoms when they had been moved inappropriately. Now that’s a run sheet I would like to read.

I am keen to hear others thoughts on this topic. It would be great to get Dr Jaslow’s further comments on this topic and to enquire if anything has changed since the publication of this article. We might have to send him an invitation to join here if not already a member. Oh yeah – I also found painting difficult. I think it has to do with that whole right brain, left brain thing.

Stay safe,

Curse :evil:

[JPINFV]

I think the closest that your going to get to a randomized study is the Hauswald[sup:707404d928]1[/sup:707404d928] study. This was the one in 1998 that compared trauma patients going to the University of New Mexico (all had c-spine precautions) with those that went to a hospital in Malaysia (where c-spine precautions is virtually unheard of). There was a slightly higher level of neurological deficit in the patients who received c-spine precautions.

[sup:707404d928]1[/sup:707404d928]Hauswald M, Ong G, Tandberg D, et al: "Out-of-hospital spinal immobilization: Its effect on neurologic injury." Academic Emergency Medicine. 5(3):214–219, 1998.

[Just Plain Ruff]

I printed acopy of this off for every one of my co-workers and the docs we work with. several of them have said WOW great article.

Thanks JP

[crotchitymedic1986]

I know there was a study performed that showed that less than 10% of MULTI-SYSTEM trauma patients had a C-Spine injury. I will see if I can find it.

[Camulos]

Damn – I can’t find the full text on this article. Even going through my “secret” work access site I cannot manage to get it. Found another article by Hauswald and co on spinal immobilisation though which I have quickly perused and that seems interesting.

Strangely, whilst writing my initial response on this topic I did actually think about comparing a standard industrialised Western centre approach to a “third world” (for lack of a better term) approach. I was thinking more like the African country’s as a possibility for this though. I do admit it was only a fleeting thought as I immediately saw too many detractions and am keen to see if Hauswald’s cited article managed to overcome these.

Having not read the article I am hopeful that someone who has a copy could answer some questions for me. They mainly centre around the problems I envisaged in undertaking such a study.

1) Was the study prospective or retrospective?

2) Did the study have comparable # types and locations between the two centres?

3) Was overall injury severity comparable between the two pt populations?

Again I have not read the study but I do assume it was not randomized as the treatment was predetermined based on which country, or medical facility, you were treated at. Please correct me if this is not the case.

Being aware of a study of this type does raise some interesting possibilities though. Perhaps the whole study could be conducted in a place like Malaysia where spinal precautions are presumably not the standard. Make it prospective and randomize the spinal immobilisation. However whether we could extrapolate these results to our system may be the difficulty. I guess some good food for thought. So who wants to go to Malaysia?

Stay safe,

Curse :evil:

[spenac]

I hate though that many debate the backboard issue they claim those against are just being lazy.

I just do not want to cause more harm and discomfort if it is of no real value.

[JPINFV]

I hate though that many debate the backboard issue they claim those against are just being lazy.

I just do not want to cause more harm and discomfort if it is of no real value.

I'd rather argue against that then the "Why take the chance?" crowd.