EBQ:Prehospital Spine Immobilization

Clinical Question

Which patients require spine immobilization (Cervical or Thoracic/Lumbar) in the prehospital environment

NAEMSP Position Statement

The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma advises the targeted use of backboards with emphasis on high risk patients.

Immobilization NOT Necessary in the Following:

• Normal level of consciousness (Glasgow Coma Score GCS 15)
• No spine tenderness or anatomic abnormality
• No neurologic findings or complaints
• No distracting injury
• No intoxication

Immobilization the following patients:

• Blunt trauma and altered level of consciousness
• Spinal pain or tenderness
• Neurologic complaint (e.g., numbness or motor weakness)
• Anatomic deformity of the spine
• High-energy mechanism of injury and any of the following:
  • • Drug or alcohol intoxication
• Inability to communicate
  • Distracting injury

"Whether or not a backboard is used, attention to spinal precautions among at-risk patients is paramount. These include application of a cervical collar, adequate security to a stretcher, minimal movement/transfers, and maintenance of inline stabilization during any necessary movement/ transfers." -NAEMSP

Potential Harm with C1-C2 injuries

In the presence of severe injury, collar application resulted in 7.3 mm +/- 4.0 mm of separation between C1 and C2 in a cadaver model

Self Extrication vs Provider Extrication

Conventional extrication techniques record up to four times more cervical spine movement during extrication than controlled self-extrication (Rigid Collar and patient then self extricating).

Penetrating Trauma

Prehospital spine immobilization is associated with higher mortality in penetrating trauma and should not be routinely used in every patient with penetrating trauma.

Intubating with Cervical Collar

There is significant decreases in mouth opening when the cervical collar is left in place. In-line stabilization should be used for intubation with the cervical collar removed.

Conclusion

• Evidence does not support routine prehospital spinal immobilization for all trauma patients
• Immobilization may cause harm including increased pain, respiratory compromise, pressure ulcers, and aspiration risk
• Selective spinal motion restriction based on validated clinical criteria is recommended

Major Points

• There are no randomized controlled trials demonstrating benefit of prehospital spinal immobilization
• Backboards cause pain, skin breakdown, and respiratory restriction, particularly in elderly patients
• Cervical collars do not fully immobilize the cervical spine and may increase ICP in head-injured patients
• The evidence supports a shift from "spinal immobilization" to "spinal motion restriction"
• Clinical decision rules (NEXUS, Canadian C-spine) can safely identify patients who do not need immobilization

Study Design

• Evidence review and position paper summarizing available literature on prehospital spinal immobilization
• Reviewed observational studies, biomechanical data, and comparison studies

Population

• Prehospital trauma patients with potential spinal injury
• Includes both blunt and penetrating trauma mechanisms

Interventions

• Spinal immobilization techniques reviewed: long spine board, cervical collar, head blocks, strapping
• Alternative approaches: self-extrication, vacuum mattress, selective immobilization protocols

Outcomes

• No studies demonstrate neurological benefit from prehospital spinal immobilization
• Documented harms of immobilization include: pain, respiratory restriction (up to 15% reduction in FVC), pressure injury, aspiration risk
• Penetrating trauma: immobilization associated with increased mortality in one large observational study
• Selective immobilization protocols successfully identify patients who can be safely cleared in the field

Criticisms

• Absence of evidence of benefit is not the same as evidence of absence; ethical constraints prevent RCTs
• The medicolegal implications of not immobilizing remain a barrier to practice change
• Clinical decision rules were validated in the ED, not the prehospital setting, limiting direct applicability
• Changing longstanding EMS protocols requires significant training and cultural change

Funding

• Not applicable (evidence review)