Spinal Immobilization

It’s been awhile since I’ve had a chance to write. I guess I’ve been hibernating (when not shoveling). I’ll make up for the absence with a long entry. I want to address a topic that has come up a number of times over the past few years. We need to have a discussion about spinal immobilization. Don’t roll your eyes and stop reading. While I realize it’s maybe not the most exciting EMS topic out there, it is an important one, and worth initiating a dialogue. I’ll try to keep the discussion moving and – hopefully – provide some new information and insight.

Over the course of my brief time as your medical director there have been several cases that I have been asked to review with questions or concerns about spinal immobilization. Either it was done and (the perception was) it shouldn’t have been, or it wasn’t done and should have been, or it was done the wrong way, or wrong device, wrong patient, wrong duration, etc. There have been many more questions and conversations with a number of you on an individual basis about this topic, as well.

As everyone is aware (or should be aware), we put in place a protocol to allow for selective spinal immobilization. This protocol is loosely based on the NEXUS criteria that are commonly used in the ER to clinically evaluate for possible C-spine injuries. This prehospital protocol was an effort to clarify some of these issues and allow you, the EMT’s, to use your judgment, in combination with the protocol, to forego spinal immobilization in some patients who meet specific criteria. And yet, problems and concerns remain. And this is understandable, particularly given the wide variety of patients, injuries, and mechanisms of injury that you all encounter. Before we delve into issues of who should – or should not – be immobilized, let’s look at some of the data that have been driving this controversy.

Back in 1993 (incidentally, about the time I was entering EMS) there was an eye-opening study that was published in the Annals of Emergency Medicine titled “The effect of Spinal Immobilization on Healthy Volunteers”. This small study looked at 21 healthy volunteers, aged 10-43 years, without injury, who volunteered to be immobilized on a backboard for 30 minutes, after which they were asked about a number of symptoms. Turns out, rather shockingly, that 100% of the volunteers developed pain during the 30 minute study period. These complaints were primarily occipital head pain, neck and back pain, and sacral pain, although a significant number also developed scapular and mandibular pain. Fifty-five percent of them graded their pain as moderate to severe. Even more interesting, after 48 hours, 29% of the study subjects still had pain. And remember, this study was in healthy young people. Imagine how these pain issues are magnified in elderly and/or injured patients?

Later, in 1998, there was an interesting study published in Academic Emergency Medicine, titled “Out-of-hospital Spinal Immobilization: Its Effect on Neurologic Injury”. In this study researchers investigated 454 patients at two hospitals, one in the U.S. and one in Malaysia. The difference being that in Malaysia spinal immobilization was not routinely performed. As the title suggests, they compared two groups of patients – one group having been immobilized and the other not – and looked at neurologic outcomes. I won’t go through the dry details but trust me that the two groups were fairly evenly matched in terms of age, sex, severity and mechanism of injury, etc. So, what would you expect here?...with one unfortunate group of patients in a third-world country receiving no prehospital spinal immobilization. Turns out, those patients did not have worse outcomes. In fact, the patients in the United States, all of whom were immobilized, faired worse. Furthermore, through some statistical gyrations, the authors determined that there is a 98% probability that spinal immobilization is either harmful or of no benefit. Well now that’s rather discouraging.

In a more contemporary study, published just this month in the Journal of Trauma and Acute Care Surgery, the authors performed a meta analysis, where they pooled data from a number of previous studies (from 1970-2011), to look at the incidence of pressure ulcers caused by cervical collars. They found these collar-related pressure ulcers to occur in 6.8% to 38% of immobilized patients. Some of these ulcers were severe requiring, in some cases, the need for surgical debridement. Admittedly, many of these patients were immobilized for long periods of time in ICU’s but, nonetheless, it is an important study to highlight the potential risks of these immobilization devices.

So where does all this leave us in terms of trying to figure out who should be immobilized and who can forego this uncomfortable procedure. This is where the selective spinal immobilization protocol comes in and, if you are not familiar with this protocol, you should make a point to review it closely. Unfortunately, however, there are a number of cases that I have been asked to review in which this protocol itself has led to confusion and disagreement. While protocols are the backbone of prehospital care, some protocols are designed to function primarily as a guideline, and require the provider to use the unique information they acquire on each call, along with common sense and good judgment, to determine on which patients to apply a certain protocol. The selective spinal immobilization protocol is an example of just such a guideline. It is designed to be used when, in your professional judgment, based on the specific characteristics of an individual’s presentation, you feel that spinal immobilization is not necessary. This does not mean that the patient does not need to be formally evaluated, and may even need x-rays or other imaging to exclude injury. It does, however, allow you to forego potentially uncomfortable spinal immobilization in a patient with low likelihood of neurologic injury.

That said, the protocol clearly identifies certain individuals who cannot safely be “cleared” in the field. Some of these are (or should be) obvious. For example, midline tenderness to the spine. The one that seems to cause problems, however, is the requirement that a patient not have an altered mental status. This includes being intoxicated, either with alcohol or other drugs. If a patient is legally intoxicated, he/she is “altered” and cannot be cleared in the field to transport without spinal immobilization. Now, there may be other reasons that you do not fully immobilize an intoxicated patient. For example, if they do not have traumatic injury (rather obvious), or if they are too belligerent to cooperate with spinal immobilization. Which do think would cause less neurologic injury, asking a patient to lie quietly on a stretcher, or tackling a patient and then strapping him down to a hard board while he tries to thrash and fight his way out of restraints? In such cases, just carefully document that, in your opinion, the risks to the patient or providers of trying to immobilize the patient would have outweighed the potential benefits…remembering that there is very little data to show benefit of immobilizing anyone anyhow (see above).

Even if a patient cannot be formally excluded based on the protocol, there are times when foregoing C-collars and longboards is simply the right thing to do. The classic, and unfortunate, case I see now and then is the elderly patient with severe kyphosis (curvature of the spine) who is forced into a supine position on a hard board with a hard plastic collar torquing their chronically curved spine straight as an arrow. This is not only very uncomfortable, but can also contribute to spinal and neurologic injury. In these cases, just immobilize the patient on the cot as best you can, in a position of comfort, and document why you did what you did.

Unfortunately, the situation occasionally occurs where a patient presents with a high likelihood of neurologic injury, either by mechanism or complaint, but is either not immobilized or there is a – sometimes heated – debate on scene regarding the need for immobilization. For example, a rollover MVC where a patient is complaining of numbness in their extremities. Such a patient clearly needs to be carefully and fully immobilized for transport, and there should be no misunderstanding or debate. Just trust me on this one; there are too many subtleties and important structures in the cervical spine to fully exclude injury in the field in the face of a significant mechanism of injury or obvious neurologic complaint.

I suppose the problem lies, in part, with the fact that the decision to immobilize – or not – relies on ones judgment and common sense. Like all things subjective, these traits can vary a lot between otherwise seemingly sensible and caring individuals. How to remedy these issues is well beyond the realm of my expertise. Maybe we’ll have to consult psychiatry. I dunno…

In the end, please remember to use the selective spinal immobilization protocol in combination with your sound clinical judgment. When in doubt, immobilize the patient and let us sort it out in the ER.

As always, I look forward to hearing your thoughts, questions, and concerns on this – or any other – issue. Keep up the good work.

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