Spinal Immobilization: Are we doing more harm than good ?

[vs-eh?]

And again these should be all based on BASIC assessments done on scene.

The differential diagnosis for spinal imobilization (FOR A SCENE CALL) isn't like a chest pain or abdo pain call. It's pretty cut and dry for treatment based on probably 30secs of assessment. Don't base it on protocols and what not...Base it on patient complaint and what you clinically and objectively observe...It ain't rocket science.

Will "mistakes" be made? Sure, happens in medicine. But then the doc clearing that same patient with a twist and a jerk right? USE YOUR HEAD. You don't have x-ray vision, true enough.

Clinical judgement is all that is needed.

[dgmedic]

In other words, you preferred to be baffled with mass quantities of BS than to be dazzled by brilliance. Lists of studies which do NOT back up your point look awful impressive if you are playing a numbers game. But the point is quality, not quantity. And no studies can be found which scientifically conclude that field clearance safely eliminates unnecessary immobilization AND assures that no spinal injuries are not immobilized. In fact, none of them even attempt to conclude that. That's the problem.

List of studies which do not back up my point? I'm disappointed you didn't take time to read the studies.

So, this post was a little more clear on what you needed.....So I will point out once again the Burton study...and R-E-A-D the study...the entire study. If you have trouble interpreting the results, find a statistician. The results of the study show: "Use of this prehospital spine-assessment protocol resulted in an EMS provider decision not to immobilize approximately 40% of EMS trauma patients" (that addresses your first "requirement"). You will also notice (again...you have to read the study...that would mean more than just the abstract just in case I'm not being clear) that all of the patients that were not immobilized...NONE OF THEM HAD SPINAL FRACTURES (that would hit your second "requirement").

So, there ya go....you were clear on what you wanted, I provided it. So now you can say that there is a valid study, conducted in the prehospital environment, published in a reputable journal which was peer-reviewed, that showed a reduction in unnecessary spinal immobilization with a protocol that identified all the fractures. Scientific validation...at least for the rest of the medical community. - quality - not quantity

Read a bit

-dg

[Ace844]

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.

Dec 21, 2005

"Rid,"

The bold portion of the study above is where i begin to take issue with it's efficacy. It was merely a review of H&P and the chart as opposed to a controlled clinical study, big difference between the 2 IMHLO...Although on the totherside of this there are a number of "clinical" trials which came to a similar conclusion, although personally, it certainly wasn't a "landmark" paper..Food for thought.

For more “Studies and info on and related to this subject for those interested which have been previously discussed here::

http://www.emtcity.com/phpBB2/viewtopic.php?t=3116

http://www.emtcity.com/phpBB2/viewtopic.php?t=2820

http://www.emtcity.com/phpBB2/viewtopic.php?t=1740

http://www.emtcity.com/phpBB2/viewtopic.php?t=2570

http://www.emtcity.com/phpBB2/viewtopic.php?t=2499

http://www.emtcity.com/phpBB2/viewtopic.php?t=2025

http://www.emtcity.com/phpBB2/viewtopic.php?t=319

http://www.emtcity.com/phpBB2/viewtopic.php?t=1405

For those that are interested, here are more studies for you all to look at and learn from...::

http://www.ispub.com/ostia/index.php?xmlFi...2/spinestab.xml

http://www.nata.org/jat/readers/archives/4...50-40-3-162.pdf.

http://www.pubmedcentral.nih.gov/articlere...gi?artid=233172

http://www.spineuniverse.com/pdf/traumaguide/1.pdf.

http://www.hartwellmedical.com/clinical.html

http://pdm.medicine.wisc.edu/20-1%20PDFs/Kwan.pdf.

http://www.geocities.com/rcrmced/AbsArt_fi...ne_Immobil.html

http://www.charlydmiller.com/RA/alltiedup3.html

http://www.fernoeducation.it/news/ACEP%20ABSTRACT.pdf.

http://www.caep.ca/004.cjem-jcmu/004-00.cj...001/v31-031.htm

...http://www.paramedicpractitioner.com/C-Spine%20Rule%20out_files/frame.htm#slide0016.htm , http://www.caep.ca/004.cjem-jcmu/004-00.cj...001/v31-031.htm://http://www.paramedicpractitioner.co...v31-031.htm://http://www.paramedicpractitioner.co...v31-031.htm://http://www.paramedicpractitioner.co...v31-031.htm , http://www.naemsp.org/Position%20Papers/ClinGdeSpine.html ://http://www.paramedicpractitioner.co...Spine.html

http://www.aafp.org/afp/20040615/tips/17.html

http://www.ohri.ca/programs/clinical_epide...Summary0211.pdf

http://www.jephc.com/full_article.cfm?content_id=261

References

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3. Stiell IG, Wells GA, Vandemheen K, Laupacis A, Brison R, Eisenhauer MA, et al. Variation in emergency department use of cervical spine radiography for alert, stable trauma patients. CMAJ 1997;156:1537-44.

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17.McArdle CB, Wright JW, Prevost WJ, et al: MR imaging of the acutely injured patient with cervical traction. Radiology 1986;159:273Ã274.

18.Mace SE: Emergency evaluation of cervical spine injuries: CT versus plain radiographs. Ann Emerg Med 1985;14:973Ã975.

19.Miller MD, Gehweiler JA, Martinez S: Significant new observations on cervical spine trauma. Am J Roentgenol 1978;130:659Ã663.

20.Montana MA, Richardson ML, Kilcoyne RF, et al: CT of sacral injury. Radiology 1986;161:499Ã503.

21.Ordog GJ: Missed cervical spine fractures. Ann Emerg Med 1987;16:726Ã727. Letter to the editor.

22.Perdue P: Urgent priorities in severe trauma: Life-threatening head and spinal injuries. RN 1981;44:36Ã41,102.

23.Podolsky S, Baraff LJ, Simon RR, et al: Efficacy of cervical spine immobilization methods. J Trauma 1983;23:461Ã465.

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25.Reid DC, Henderson R, Saboe L, et al: Etiology and clinical course of missed spine fractures. J Trauma 1987;27:980Ã986.

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28.Scher AT: Unrecognised fractures and dislocations of the cervical spine. Paraplegia 1981;19:25Ã30.

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30.Slack CM: The spine in sports. Compr Ther 1980;6:68Ã74.

31.Streitwiesser DR, Knoop R, Wales LR, et al: Accuracy of standard radiographic views in detecting cervical spine fractures. Ann Emerg Med 1983;12:538Ã542.

32.Sumachai AP: Missed cervical spine fractures. Ann Emerg Med 1987;16:726Ã727.

33.Suomalainen O, Kettunen K, Saari T: Computed tomography of spinal and pelvic fractures. Ann Chir Gynaecol 1983;72:337Ã341.

34.Tator CH, Ekong CE, Rowed DW, et al: Spinal injuries due to hockey. Can J Neurol Sci 1984;11:34Ã41.

35.Vines FS: The significance of Ã’occultÓ fractures of the cervical spine. Am J Roentgenol Redium Ther Nucl Med 1969;107:493Ã504.

36.Wales LR, Knoop RK, Morishima MS: Recommendations for evaluation of the acutely injured cervical spine: A clinical radiologic algorithm. Ann Emerg Med 1980;9:422Ã428.

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out here,

Ace844

[Ace844]

But, have upset some, as well, by advising that the board was the right thing to do, only to get to the ER and then watching the doc remove it right before my eyes without any x-rays or confirmation of injury (which really pissed me off) :x .

Let me think on this one for a bit...

I used to feel the same about that, until I went to a progressive medic program that acutally taught[>gasp<]..MEDICINE.. :shock: who'd have thunk it possible!?!? :shock: :!: :wink: 8) :arrow: ..But back on track, please check the literature posted, and the links below, the studies will point out the more than likely reasons why this occurred. More often than not as "rid," asserted in his original post, the patient recieved no "benefit" from the board and could have been "ruled out" clinically, as you saw the "doc" do first hand. Furtheremore, the board is for transport, extrication, and in rare cases confirmed Fx stabilization ONLY, not for long term "in-house" use...

Hope this helps,

ACE844

[Ace844]

CHANGES IN PHYSICAL EXAMINATION CAUSED BY USE OF SPINAL IMMOBILIZATION.

March JA, Ausband SC, Brown LH. Prehosp Emerg Care 2002 Oct-Dec;6(4):421-4.

BACKGROUND: The standard of care for patients following blunt trauma includes midline palpation of vertebrae to rule out fractures. Previous studies have demonstrated that spinal immobilization does cause discomfort.

OBJECTIVE: To determine whether spinal immobilization causes changes in physical exam findings over time.

METHODS: This was a single-blinded, prospective study at a tertiary care university teaching hospital. Twenty healthy volunteers without previous back pain or injuries, 13 male and seven female, were fully immobilized for one hour, with a cervical collar and strapped to a long wooden backboard. Midline palpation of vertebrae to illicit pain was performed at 10-minute intervals. In addition, the participants were asked to rate neck and back pain on a scale from 1 to 10 (1 for no pain, and 10 for unbearable pain), to see whether subjective pain from immobilization correlated with tenderness to palpation.

RESULTS: Three patients had point tenderness of cervical vertebrae within 40 minutes. Five patients developed point tenderness of vertebrae by 60 minutes. Eighteen of 20 participants complained of increasing discomfort over time. The median initial pain scale was 1 (range 1-1), in contrast to 4 (range 1-9) at 60 minutes, p < 0.05.

CONCLUSION: This study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness. In order to reduce this high false-positive rate for midline vertebral tenderness, the authors recommend that, initially on arrival to the emergency department, immediate evaluation occur of all immobilized patients. Furthermore, backboards should be modified to reduce patient discomfort to prevent the iatrogenically induced midline vertebral tenderness, thereby reducing subsequent false-positive examinations.

THE EFFECT OF SPINAL IMMOBILIZATION ON HEALTHY VOLUNTEERS.

Chan D, et al. Ann Emerg Med 1994 Jan;23(1):48-51.

STUDY OBJECTIVE: To determine the effects of standard spinal immobilization on a group of healthy volunteers with respect to induced pain and discomfort.

DESIGN: Prospective study.

SETTING: University teaching hospital.

TYPE OF PARTICIPANTS: Twenty-one healthy volunteers with no history of back disease.

INTERVENTIONS: Subjects were placed in standard backboard immobilization for a 30-minute period. Number and severity of immediate and delayed symptoms were determined.

MEASUREMENTS AND MAIN RESULTS: One hundred percent of subjects developed pain within the immediate observation period. Occipital headache and sacral, lumbar, and mandibular pain were the most frequent symptoms. Fifty-five percent of subjects graded their symptoms as moderate to severe. Twenty-nine percent of subjects developed additional symptoms over the next 48 hours.

CONCLUSION: Standard spinal immobilization may be a cause of pain in an otherwise healthy subject.

COMMENT: Yet another reason to get that patient off that backboard as soon as you can.

2005; Volume 3 : Issue 3 Article Number: CC930130

Spinal Immobilisation in Prehospital Trauma Patient

Ayan Sen

Keywords

cochrane corner hot topic; spinal immobilisation; spinal injury; trauma

Indications for prehospital spinal immobilization have changed dramatically over the history of modern Emergency Medical Systems.1 Prehospital practice currently comprises immobilization of essentially all patients with any potential for spinal injury based on mechanism of injury.1 Cost-effective care of trauma patients has advanced significantly, and numerous studies examining indications for spine radiographs in trauma patients have been published.2-7 The findings of these studies universally support the use of clinical criteria to determine the need for spinal radiographs. They also support the presumption that without symptoms and physical findings associated with spinal injury, no significant spinal injury exists. Spinal immobilization on a rigid backboard is not without complications. Besides the direct cost of the equipment, there are also significant effects on patient comfort and the cost of Emergency evaluation. Respiratory compromise due to the strapping techniques used and pressure complications from rigid immobilization have been reported.8,9 Head and back pain is a nearly universal complication of prolonged rigid spinal immobilization and can alter Emergency department presentation and evaluation, necessitating radiographs that might have been avoided by omitting spinal immobilization in asymptomatic patients.10-11Data SourceThe Cochrane Library 2005, Issue 1.Search TermsPrehospital Search Filter Version - 1.0 12Spine, spinal, cervix, cervic*, lumbar, thorac*, neck, whiplash, immobil*, stabili*, stable, collar, backboard, back-board, splint*, board*, strap*Search ResultsProtocolsNoneSystematic ReviewsKwan I, Bunn F, and Roberts I, on behalf of the WHO Pre-Hospital Trauma Care Steering Committee. Spinal immobilization for trauma patients. The Cochrane Database of Systematic Reviews, Date of Most Recent Substantive Amendment: 22 January 2001.Clinical TrialsNoneCommentaryThe authors of the systematic review did not find any randomized controlled trials (RCTs) quantifying the effect of spinal immobilization in trauma patients, and the possible adverse effects of its application. Therefore, the effects on mortality, neurological injury, spinal stability and adverse effects in this cohort of patients remain uncertain. Domeier11 conducted a study in 2002 to evaluate five pre-hospital clinical criteria-altered mental status, neurological deficit, spine pain or tenderness, evidence of intoxication, or suspected extremity fracture-the absence of which identified 94.9% of pre-hospital trauma patients without a significant spine injury. Hauswald and Braude13 in their review of literature mention that it is now clear that immobilization subjects most patients to expensive, painful, and potentially harmful treatment for little, if any, benefit. Low-risk patients can be safely cleared clinically, even by individuals who are not physicians. March et al14 reported that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness. Studies done on healthy volunteers have shown that the vacuum splint is more comfortable than long spinal boards with no loss of stability. Randomized controlled trials and large prospective studies are needed in trauma patients to validate the decision criteria for spinal immobilization in trauma patients with high risk of spinal injury.The Bottom LineThe Cochrane review conducted in 2001 did not find any randomized trials on pre-hospital spinal board immobilization but numerous reports, reviews and studies highlight use of clinical criteria along with mechanism of injury necessitating future RCTs for level 1 evidence.15 This Article should be cited as: Sen A. Spinal Immobilisation in Prehospital Trauma Patients. Journal of Emergency Primary Health Care [serial on the Internet]. 2005;3(3): Item No. CC990130. Available from: http://www.jephc.com/full_article.cfm?content_id=261

Padded vs unpadded spine board for cervical spine immobilization

R Walton, JF DeSalvo, AA Ernst and A Shahane

Department of Medicine, Louisiana State University, New Orleans, USA.

OBJECTIVES: To determine whether padding the long spine board improves patient comfort, affects cervical spine (c-spine) immobilization, or increases sacral transcutaneous O2 tension. METHODS: A prospective randomized, controlled crossover study of healthy volunteers was conducted over a two-week period. Participants included 30 volunteers with no previous history of c-spine injury or disease. The subjects were randomized to either padded or unpadded long spine board immobilization with serial measurements of discomfort (using a visual analog scale) and transcutaneous tissue O2 tension obtained at zero and 30 minutes. Measurements of ability to flex, extend, rotate, and laterally bend the c-spine were made using a goniometer. The subjects then returned a minimum of three days later to complete the opposite half of the study (padded vs unpadded boards). RESULTS: Subject discomfort was significantly reduced in the padded group compared with the unpadded group (p = 0.024). There was no significant difference in flexion (p = 0.410), extension (p = 0.231), rotation (p = 0.891), or lateral bending (p = 0.230) for the two groups. There was no significant difference in the actual drop in sacral transcutaneous O2 tension from time zero to 30 minutes for the padded and the unpadded groups (mean drop = 14.8% +/- 17.5% vs 12.2% +/- 16.8%, respectively; p = 0.906). CONCLUSION: Adding closed-cell foam padding to a long spine board significantly improves comfort without compromising c-spine immobilization. Sacral tissue oxygenation does not appear affected by such padding for healthy volunteers.

Backboard versus mattress splint immobilization: a comparison of symptoms generated.

Chan D, Goldberg RM, Mason J, Chan L.

Department of Emergency Medicine, University of Southern California Medical Center, Los Angeles 90033-1084, USA.

The study objective was to compare spinal immobilization techniques to a vacuum mattress-splint (VMS) with respect to the incidence of symptoms generated by the immobilization process. We used a prospective, cross-over study in a university hospital setting. Participants consisted of 37 healthy volunteers without history of back pain or spinal disease. Interventions consisted of two phases. In Phase I, subjects were randomly assigned to be immobilized on either a wooden backboard or a mattress-splint for 30 min. The incidence and severity of any symptoms generated by the immobilization process were recorded. In Phase II, the two groups were again tested after a 2-week washout period, with the method of immobilization being reversed. Symptoms and severity were again recorded. Pain symptoms were confined to four anatomic sites: Occipital prominence, lumbosacral spine, scapulae, and cervical spine. After adjusting for the effect of order of exposure, subjects were 3.08 times more likely to have symptoms when immobilized on a backboard than when immobilized on the VMS. They were 7.88 times more likely to complain of occipital pain and 4.27 times more likely to complain of lumbosacral pain. Severity of occipital and lumbosacral pain was also significantly greater during backboard immobilization. We conclude that, when compared to a VMS, standard backboard immobilization appears to be associated with an increased incidence of symptoms in general and an increased incidence and severity of occipital and lumbosacral pain in particular.

[medik8]

I used to feel the same about that, until I went to a progressive medic program that acutally taught[>gasp<]..MEDICINE.. :shock: who'd have thunk it possible!?!? :shock: :!: :wink: 8) :arrow: ..But back on track, please check the literature posted, and the links below, the studies will point out the more than likely reasons why this occurred. More often than not as "rid," asserted in his original post, the patient recieved no "benefit" from the board and could have been "ruled out" clinically, as you saw the "doc" do first hand. Furtheremore, the board is for transport, extrication, and in rare cases confirmed Fx stabilization ONLY, not for long term "in-house" use...

Hope this helps,

ACE844

I wholeheartedly agree with you, Ace, which is why...I think sometimes we have to make a call, and sometimes decide ourselves what is best for our patient. I, personally, think boards are excellent for extrication purposes, and in cases where you seriously suspect a fx, etc...great... But, to put EVERYONE on one, especially against their wishes, so to speak...hmmm...

I've seen them to do "good" as well as "harm". As I said before...unless you are almost damn sure I have a fracture (or other obvious need), I DO NOT want to be on one. I already have a bad back, and tying that in with the "confined" position and not allowing me to move...I would go postal. :x

I know that is a personal point of view...but still...

[Ace844]

I wholeheartedly agree with you, Ace, which is why...I think sometimes we have to make a call, and sometimes decide ourselves what is best for our patient. I, personally, think boards are excellent for extrication purposes, and in cases where you seriously suspect a fx, etc...great... But, to put EVERYONE on one, especially against their wishes, so to speak...hmmm...

I've seen them to do "good" as well as "harm". As I said before...unless you are almost damn sure I have a fracture (or other obvious need), I DO NOT want to be on one. I already have a bad back, and tying that in with the "confined" position and not allowing me to move...I would go postal. :x

I know that is a personal point of view...but still...

Unfortunately in my area we have a regular gathering of the "Protocol gestapo," whom by their own consensus have reached the conclusion that a fall or any "trauma which potential involves spinal injury" is all the "Mechanisim", one needs and all of those who have this get a board and collar. This is far from an educated, knowledgeable, or progressive approach. Sadly, although if one should choose not to board, they run the very real risk of losing thier job, house, car, etc....& so on...So, on the flip side and despite multiple attempts by colleagues, EMCAB here refuses to acknowledge the practice reality, so we are stuck with potentially causing our patients harm, to lower our litigous risk...sad but true..

out here,

ACE844

[medik8]

Well...the protocol police strike in my area, as well. However, we have a couple of docs at the hospital that will "split the difference" if you will... If you can give a good reason why you didn't board, they are willing to listen. Otherwise, you'd better have it in place. It's a touchy subject everywhere, I think. It, literally, is a toss up between protecting your patient or their wishes, and covering your own...ahem... Sad but true. There is nothing I hate more than to board and collar someone who just took a little fall, but is talking, moving all extremities, good PMS, no obvious deformaties, and due to the gash on their head, needs to go to the hospital and is hell bent on walking to the truck, but can't because of me.

GRRRRRRRRRRRR.........frustration!!!

I feel your pain, Ace. I really do.

[medic5587]

This is indeed a fun debate with very intelligent views and opinions, however we are obligated to follow protocol. I hope medical directors follow this debate and perhaps change accordingly. The protocol I work under does allow me to clear spinal immobilization in the field. The following is are standing orders

Spinal Precautions

Full spinal immobilization should be considered for all non-ambulatory trauma patients who sustain a mechanism of injury with the potential for causing spinal injury and have one of these clinical findings.

a. spinal pain or tenderness

b. altered LOC or Hx of loss of consciousness

c. evidence of ETOH

d. significant distracting painful injuries (long bone fracture)

e. any abnormal neurological findings

f. extremes of age (young-old)

Patients who are or who have been ambulatory and meet the criteria above should be considered for the following spinal precautions

a. hard cervical collar: if complaining of neck pain or the above listed.

b. secure to stretcher if complaining of neck, thoracic, or lumbar pain or above listed.

Back boards may be used at any time if the attending ambulance personnel feel it is useful. If the patient is back boarded prior to the ambulance arrival, they should remain on the backboard.

A cervical collar should be used on all patients with suspected neck injury unless the time taken to apply endangers the safety of the employee.

medic 5587

STP

[medik8]

I don't see it ever being changed. As long as we work under a doc's license, they are not going to put their profession and livelihood on the line for some EMT/Medic in the field who happens to make a poor decision, blindly, and someone doesn't walk again. Too much liability. As frustrating as that is to us, I have to admit I would feel uneasy giving some that power of discretion when it could possibly mean my med. license.

Until there is another way........... :?