Spinal Immobilization: Are we doing more harm than good ?

[Ridryder 911]

Out-of-hospital spinal immobilization: its effect on neurologic injury

by

Out-of-hospital spinal immobilization: its effect on neurologic injury.

Hauswald M, Ong G, Tandberg D, Omar Z

Department of Emergency Medicine, University of New Mexico, School of Medicine, Albuquerque 87131-5246, USA. mhauswald@salud.unm.edu

OBJECTIVE: To examine the effect of emergency immobilization on neurologic outcome of patients who have blunt traumatic spinal injuries.

METHODS: A 5-year retrospective chart review was carried out at 2 university hospitals. All patients with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site to the hospital were entered. None of the 120 patients seen at the University of Malaya had spinal immobilization during transport, whereas all 334 patients seen at the University of New Mexico did. The 2 hospitals were comparable in physician training and clinical resources. Neurologic injuries were assigned to 2

categories, disabling or not disabling, by 2 physicians acting independently and blinded to the hospital of origin. Data were analyzed using multivariate logistic regression, with hospital location, patient age, gender, anatomic level of injury, and injury mechanism serving as explanatory variables.

RESULTS: There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).

CONCLUSION: Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal

injuries.

Dec 21, 2005

So are we doing more harm than good?

Be safe,

R/R 911

[AnthonyM83]

I'd say we don't have enough information.

You need a study done where both the Malaysia and New Mexico hospitals both held c-spine and then both didn't hold c-spine.

The results could be attributed to one hospital getting worse type of injuries in the first place (or seatbelt laws or any number of other factors)

[jedicoop89]

I agree 100% with anthony.

[AZCEP]

Could this be a case of not providing the optimal care in order to follow an outdated protocol?

Some patients need to have their spinal movement restricted, some don't. I feel pretty certain that most of us have been in either of the two categories at some point. The knee-jerk response of immobilizing everything is ridiculous, don't you think. A recent study in Canada showed that prehospital providers could accurately apply the NEXUS criteria to determine which patients needed to be strapped to a board, and which didn't.

For fun have yourself strapped to an LSB for a while, and see how you like it. Anything over 20 minutes without padding properly will begin to cause pressure ulcers.

[Ridryder 911]

Awwww.... guess what they just studied AZEP..?

The effects of neutral positioning with and without padding on spinal

by

Prehosp Emerg Care. 1998 Apr-Jun;2(2):112-6

The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects.

Lerner EB, Billittier AJ 4th, Moscati RM.

Department of Emergency Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo 14215, USA.

lerner@acsu.buffalo.edu

OBJECTIVES: To compare the incidences and severity's of pain experienced by healthy volunteers undergoing spinal immobilization in the neutral position with and without occipital padding. To compare the incidence of pain when

immobilized in the neutral position with the incidence in a non neutral position.

METHODS: Thirty-nine healthy volunteers over the age of 18 years who had no acute pain or illness, were not pregnant, and had no history of back problems or surgery voluntarily participated in a prospective, randomized, crossover study conducted in a clinical laboratory setting. Appropriately sized rigid cervical collars were applied to the subjects, who were then immobilized on wooden backboards with their cervical spines maintained in the neutral position using towels (padded) or plywood (unpadded) under their occiputs. The subjects were secured to the board with straps, soft head blocks, and tape for 15 minutes to simulate a typical ambulance transport time. The straps, head blocks, and tape were removed, and the subjects remained on the board for an additional 45 minutes to simulate a typical emergency department experience. The subjects were then asked to identify the location(s) of any pain on anterior and posterior body outlines and to indicate the corresponding severity of pain on a 10-cm

visual analog scale. The subjects were also asked questions about movement, respiratory symptoms, and strap discomfort in an attempt to distract them from the true focus of the study (i.e., pain). A similar survey was given to each participant to complete 24 hours later. The same subjects were immobilized with the alternate occipital material a minimum of two weeks later utilizing the same procedure. They again completed both surveys.

RESULTS: Pain was reported by 76.9% of the subjects following removal from the backboard for the unpadded trial and 69.2% of the subjects following the padded trial (p < 0.45). Twenty-three percent (23.1%) of the subjects reported neck pain after the unpadded trial, while 38.5% reported neck pain after the padded trial (p < 0.07). Occipital pain was reported by 35.9% in the unpadded trial and 25.6% in the padded trial (p < 0.29). Twenty-four hours later, pain was reported by 17.9% of the subjects following the unpadded trial and 23.1% of the subjects following the padded trial (p < 0.63). Eight percent (7.7%) reported neck pain 24 hours after the and unpadded trial and 12.8% after the padded trial (p < 0.5). Occipital pain was reported by 7.7% of the subjects 24 hours after the unpadded trial and 2.6% after the padded trial (p < 0.63). This study had a power of 0.90 to

detect a difference of 30% between the trials. The authors found a significantly lower incidence of pain (p < 0.01) and occipital pain (p < 0.01) in their unpadded trial compared with that reported by Chan et al., who used neither padding nor neutral positioning to immobilize subjects.

CONCLUSIONS: Pain is frequently reported by healthy volunteers following spinal immobilization. Occipital padding does not appear to significantly decrease the incidence or severity of pain. Alignment of the cervical spine in the neutral position may reduce the incidence of pain, but further studies should be conducted to substantiate this observation.

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I believe this area should be studied definitely more. I think it is ignorant to state immobilization is not effective. Although probably >90% of immobilization is done for prophylactic use, the 1% is worth it. The same is true in any medicine such as x-rays, lab etc..

I do agree there should be more emphasis on "clearing C-spine".. there are too many times I see grandma type "fully immobilized" from a fall from chair to carpeted floor, with the chief complaint was in the coccyx... now they are hurting of course "all-over".. and now have to be "cleared".. before placing off the back board.

Pressure or compression of tissue while laying on a LSB is a significant risk, causing poor circulation of tissue and possible nerve damage. If one has ever worked in a surgical suite, one knows the importance of positioning & padding to help prevent nerve damage when a patient is unconscious. These things should be addressed in medic school if we plan on continuing to place patients on LSB & CID's. Even transporting an immobilized patient, an EMT should consider these.

I am wondering a well how many actually truly pad and immobilize or simply place the patient on a LSB & simple CID. I too am guilty of this for most of my clients in simple MVC. I do attempt to blanket roll and pad the sides and joint areas on truly spinal injury presentations. I am shocked on how many EMT's and Paramedics that are familiar with proper packaging of patients.

Be safe,

R/R 911

[reaper]

The only problem I see with makeing that clinical decsion is we open ourselves up to major malpractice suites, just like a DR.

Imagine you decide that a pt doesn't need backboarded, then that pt ends up paralized. You get sued for the decsion and your livley hood is done!

We don't get that now, because we BB anyone that meets MOI. It may be uncomfortable for the pt, but covers are butts.

I have been on one for 8 hrs, and it sucked. But, I am walking right now, so I could care less how it felt then! :wink:

[Dustdevil]

I have been on one for 8 hrs, and it sucked. But, I am walking right now, so I could care less how it felt then!

Exactly. The entire premise is absurd. Are we to stop performing all procedures that might cause the patient discomfort? Great! Our job just got a lot easier!

You won't find a single study which points to the occurrence of pressure sores. Why not? Because they are about as real as the tooth fairy. It's BS. It doesn't happen. So to keep up their idiotic theory they have to change the language from "pressure ulcers" to "pain and discomfort."

All these studies are interesting. Relevant? No. But interesting.

Don't even get me started again on this nonsense. :roll:

[PRPGfirerescuetech]

After a motor vehicle crash, I was on a spineboard for 31 hours, from pre hospital to clearence from a head of trauma.

From that, pressure ulcers, nerve pain, and muscular atrophy in the neck. Not after the crash, but after hour ten on the board.

I have to agree with AZCEP...some need it, some dont. Does it cause them more harm that good?

Only in patients who dont need it...

[Dustdevil]

Only in patients who dont need it...

And that is the key phrase. Unfortunately, none of the protocols or associated studies have given us any conclusive information which safely makes that determination. Consequently, although spinal clearance is a nice theory for the future, it simply has not been perfected yet. Just like you would have to be a complete idiot to put an unproven experimental drug on your ambulance for haphazard use, you would also have to be a complete idiot to blindly follow any of the current spinal protocols. They are just theories. They have not been proven sound by the scientific evidence.

[PRPGfirerescuetech]

So were working off the "wear a rubber just in case" theory in spinal immobilization?

There has to be another way....