Spinal Immobilization: Friend or Foe? Tales from the EMJ Prehospital Spinal Immobilization Consensus Statement

Due to the tremendous popularity of my previous post highlighting the EMJ pelvic fracture consensus statement, I decided to add in highlights from this one too. This paper, written by Connor et al, highlights the 7 conclusions from the consensus meeting held by the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh in March 2012. Again, I think these authors hit this one out of the park; I agree 100% with their conclusions. Without further ado, here's what they concluded:

1) The long spinal board is an extrication device solely. Manual in-line stabilization is a suitable alternative to a cervical collar.

• The authors speak here about the scant evidence for the use of a spine board. The authors then go on to mention: 

current guidance is founded upon expert opinion rather than definitive evidence and current protocols have a strong historical rather than scientific precedent.

• They then go on to talk about how spinal immobilization on a long spine board is not without risk.

 [Spinal immobilization] is uncomfortable; takes time and delays initiation of specialist treatment in time-critical patients; raises intracranial pressure; increases aspiration risk and the risk of decubitus ulceration; and also potentially reduces airway opening and respiratory efficacy.

• As an aside - it seems like the unanimous favorite for the type of spinal immobilization by the authors is either the scoop stretcher, or the vacuum mattress. 

 2) An immobilization algorithm may be adopted although the content of this remains undefined.

• They mention that although scoring systems like "NEXUS" or the Canadian C-Spine Rule are highly sensitive for spinal injury, they are not at all specific. Both of these criterion were designed to be decision aides for imaging, not to determine whether or not the patient requires a spine board. For the purpose of imaging, the ultra-high sensitivity for any injury is a must. Because of this, we can accept the low specificity. For the purpose of backboarding a patient, we would require a test to be highly sensitive for a severe/unstable injury while also being moderately specific to avoid over-utilization of spine boards (this paper states currently approx 1/100 backboarded patients have have any SCI). For these reasons, this paper recommends better decision aides be sought.

3) There may be potential to vary the immobilization algorithm based on conscious level of the patient.

• They state that in the conscious, cooperative patient with potential life-threatening injuries, it would be reasonable to delay immobilization until first completing the primary survey.

4) Penetrating trauma with no neurological signs does not require immobilization.

• This is fairly well described in the current literature. Not much to say here.

5) 'Standing take down' practice should be avoided.

• The authors here basically just agreed that it is silly to backboard a patient who is already standing up and walking using the "standing take down" method that I'm sure you all absolutely love.

6) In the conscious patient with no overt alcohol or drugs on board and with no major distracting injuries, the patient, unless physically trapped, should be invited to self-extricate and lie on the trolley cot. Likewise, for the non-trapped patient who has self-extricated, they can be walked to the vehicle and then laid supine, examined, and then if necessary immobilized.

• The recommendation here is quite descriptive. Not much to say here other than I agree.

7) Further research into effective, practical, and safe immobilization practice, and dissemination of this, is required.

• Yep.

So there you have it! Very controversial stuff here! I applaud the authors on their recommendations. Leave your thoughts in the comments. I'd love to hear them!

Bibliography:

• Connor D, Greaves I, Porter K, et al. "Pre-hospital spinal immobilisation: an initial consensus statement" Emerg Med J 2013; 30:1067-1079