Cervical and spinal immobilization techniques: an overview
Cervical and spinal immobilization techniques: emergency medical services (EMS) personnel continue to be the primary caregivers in the management of most out-of-hospital emergencies, including trauma situations
The ATLS (advanced trauma life support) guidelines, developed in the 1980s, continue to be the gold standard for assessing and prioritising the management of life-threatening injuries in a logical and efficient manner, although there has long been a serious debate about the methods of using this aid.
Spinal immobilization has been an essential part of teaching, in addition to pelvic binders and splints for long bone fractures
Different types of medical equipment have been developed to enable effectiveness and ease of application, as well as allowing flexibility and vital access for airway management and other procedures.
The need to immobilise the spine is determined by scene and patient assessment.
Consider spinal immobilisation when the mechanism of injury creates a high index of suspicion for head, neck or spinal injury
Impaired mental status and neurological deficit are also indicators that spinal immobilisation should be considered.[1][2][3][4]
Traditional ATLS teaching for appropriate spinal immobilisation of a patient in a major trauma situation is a well-fitted rigid collar with blocks and tape to secure the cervical spine, as well as a backboard to protect the rest of the spine.
The Kendrick extrication device allows the spine to be protected with the injured person in a seated position during rapid extrication from a vehicle or in other situations where access is limited to allow the use of a full backboard.
However, this device requires that rescue personnel take care to limit cervical spine movement by using inline mobilisation until assembly [5].
The 10th edition of the ATLS guidelines and the consensus statement of the American College of Emergency Physicians (ACEP), the American College of Surgeons Committee on Trauma (ACS-COT), and the National Association of EMS Physicians (NAEMSP) state that, in the case of penetrating trauma there is no indication for restriction of spinal movement [6], in line with a retrospective study from the American Trauma Database that showed a very low number of unstable spinal injuries requiring surgery in the context of penetrating trauma. The study also shows that the number of patients to be treated to obtain a potential benefit is much higher than the number of patients to be treated to obtain an injury, 1032/66.
However, in the case of significant blunt trauma, restrictions continue to be indicated in the following situations:
- Low GCS or evidence of alcohol and drug intoxication
- Midline or posterior cervical spine tenderness
- Obvious spinal deformity
- Presence of other distractive lesions
The recommendation for effective restriction continues to be a cervical collar with full-length spinal protection, which should be removed as soon as possible.
This is due to the risk of multi-layered injuries.
However, in the paediatric population, the risk of multilevel injuries is low and therefore only cervical spine precautions and not full spine precautions are indicated (unless signs or symptoms of other spinal injuries are present).
Cervical immobilization and rigid collar in a paediatric patient
- Neck pain
- Alteration of limb neurology not explained by limb trauma
- Muscle spasm of the neck (torticollis)
- Low GCS
- High-risk trauma (e.g. high-energy car accident, hyperextension injury of the neck and significant upper body injury)
Areas of concern
There is a growing body of evidence and concern that field triage has led to overuse of spinal immobilisation methods and that some patients are potentially at risk[7][8][9][10].
Potential problems of spinal immobilisation:
- Discomfort and distress for the patient[11].
- Lengthening of pre-hospital time with potential delay of important investigations and treatments, as well as interfering with other interventions[11].
- Restriction of breathing by the straps, as well as worse respiratory function in the supine position compared to the upright position. This is particularly important in cases of thoracic trauma, whether blunt or penetrating[12][13] Difficulty with intubation[14].
- The case of patients with ankylosing spondylitis or pre-existing spinal deformity, where actual harm could be caused by forcing the patient to conform to the predetermined position of a rigid cervical collar and backboard[15].
A new review of the Scandinavian literature, conducted to examine the available evidence for the restriction of spinal movement [16], provides very valuable insights into the comparison of prehospital spinal stabilisation methods with the evaluation of the strength of evidence.
Rigid collar
The rigid collar has been used since the mid-1960s as a method of cervical spine stabilisation, with low-quality evidence supporting its positive influence on the neurological outcome of cervical spine injury, with potential negative effects due to a significant increase in intracranial pressure and dysphagia [17].
The article also suggests that an alert and cooperative patient with muscle spasms caused by the injury is unlikely to have a significant displacement, as has been noted in cadaver studies that have attempted to study the effect of an injury.
The article suggests balancing the risks and benefits of this surgery.
However, the American Association of Neurological Surgeons continues to suggest the rigid collar as a method of stabilising the cervical spine in the pre-hospital scenario[18].
Rigid board: When is the spinal longboard used?
The original spinal longboard was used together with a rigid collar, blocks and straps to achieve immobilisation of the spine.
Potential damage, in particular pressure sores on the sacrum,[19][20] have now been demonstrated, especially in the case of spinal injuries without a feeling of protection.
The soft vacuum mattress offers a gentler surface that protects against the effects of pressure sores and at the same time provides sufficient support when extended above head level[16].
Blocks
Blocks are part of the inline mobilisation strategy for stabilising the spine and appear to be effective when strapping the patient to a spinal board to achieve a certain degree of immobilisation, without the added benefit of using a rigid collar in combination [21].
Vacuum mattress
Comparing the vacuum mattress with the rigid board alone, the mattress offers more control and less movement during application and lifting than the rigid board [22].
Taking into account the risk of pressure sores, the mattress seems to offer a better option for patient transportation.
Freeing the spine: modulation of spinal and cervical immobilization
The NEXUS criteria: an alert, non-intoxicated person without distractive injuries has a very low probability of injury in the absence of midline tension and neurological deficit.
This appears to be a sensitive screening tool with a sensitivity of 99% and a negative predictive value of 99.8%[23].
However, other observational studies have suggested that an alert patient with a cervical spine injury will try to stabilise the spine and that the presence of distractive lesions (excluding the thorax) does not affect the results of the clinical test of the cervical spine and therefore the spine could be clinically cleared without further imaging[24]. Other studies suggest the same results for the thoracolumbar spine[25][24].
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Clinical significance
Although pre-hospital spinal immobilisation has been performed for decades, current data indicate that not all patients need to be immobilised.
Now the National Association of Emergency Physicians USA and the American College of Surgeons Committee on Trauma suggest a limited application of spinal immobilisation.
These latest guidelines indicate that the number of patients who can benefit from immobilization is very small
The committee went on to state that the empirical use of spinal restraints during transport should be used with caution, as in some cases their potential risks outweigh their benefits.
Furthermore, in patients who have suffered a penetrating trauma and have no obvious neurological deficits, the use of spinal restraints is not recommended.
In the USA the EMS operator must use clinical acumen before deciding to use the spinal board.[26]
Finally, spinal immobilisation has been associated with back pain, neck pain and makes it very difficult to perform certain procedures, including imaging.
Spinal immobilisation has also been associated with breathing difficulties, especially when large straps are applied to the chest.
Although many EMS organisations in the US have adopted these new guidelines on spinal immobilisation, this is not universal.
Some EMS systems fear litigation if they do not immobilise patients.
Patients who should be immobilised at the spine include the following:
- Blunt trauma
- spinal pain
- patients with an altered level of consciousness
- neurological deficits
- obvious anatomical deformity of the spinal column
- High-intensity trauma in a patient intoxicated by drugs, alcohol.
Bibliographic references
[1] Hostler D,Colburn D,Seitz SR, A comparison of three cervical immobilization devices. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2009 Apr-Jun; [PubMed PMID: 19291567]
[2] Joyce SM,Moser CS, Evaluation of a new cervical immobilization/extrication device. Prehospital and disaster medicine. 1992 Jan-Mar; [PubMed PMID: 10171177]
[3] McCarroll RE,Beadle BM,Fullen D,Balter PA,Followill DS,Stingo FC,Yang J,Court LE, Reproducibility of patient setup in the seated treatment position: A novel treatment chair design. Journal of applied clinical medical physics. 2017 Jan; [PubMed PMID: 28291911]
[4] Lacey CM,Finkelstein M,Thygeson MV, The impact of positioning on fear during immunizations: supine versus sitting up. Journal of pediatric nursing. 2008 Jun; [PubMed PMID: 18492548]
[5] Engsberg JR,Standeven JW,Shurtleff TL,Eggars JL,Shafer JS,Naunheim RS, Cervical spine motion during extrication. The Journal of emergency medicine. 2013 Jan [PubMed PMID: 23079144]
[6] Fischer PE,Perina DG,Delbridge TR,Fallat ME,Salomone JP,Dodd J,Bulger EM,Gestring ML, Spinal Motion Restriction in the Trauma Patient – A Joint Position Statement. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2018 Nov-Dec [PubMed PMID: 30091939]
[7] Purvis TA,Carlin B,Driscoll P, The definite risks and questionable benefits of liberal pre-hospital spinal immobilisation. The American journal of emergency medicine. 2017 Jun; [PubMed PMID: 28169039]
[8] Lerner EB,Billittier AJ 4th,Moscati RM, The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 1998 Apr-Jun; [PubMed PMID: 9709329]
[9] Hauswald M,Ong G,Tandberg D,Omar Z, Out-of-hospital spinal immobilization: its effect on neurologic injury. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 1998 Mar; [PubMed PMID: 9523928]
[10] Haut ER,Kalish BT,Efron DT,Haider AH,Stevens KA,Kieninger AN,Cornwell EE 3rd,Chang DC, Spine immobilization in penetrating trauma: more harm than good? The Journal of trauma. 2010 Jan; [PubMed PMID: 20065766]
[11] Freauf M,Puckeridge N, TO BOARD OR NOT TO BOARD: AN EVIDENCE REVIEW OF PREHOSPITAL SPINAL IMMOBILIZATION. JEMS : a journal of emergency medical services. 2015 Nov [PubMed PMID: 26721114]
[12] Kwan I,Bunn F, Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Prehospital and disaster medicine. 2005 Jan-Feb [PubMed PMID: 15748015]
[13] Rasal Carnicer M,Juguera Rodríguez L,Vela de Oro N,García Pérez AB,Pérez Alonso N,Pardo Ríos M, Differences in lung function after the use of 2 extrication systems: a randomized crossover trial. Emergencias : revista de la Sociedad Espanola de Medicina de Emergencias. 2018 Abr [PubMed PMID: 29547234]
[14] Nemunaitis G,Roach MJ,Hefzy MS,Mejia M, Redesign of a spine board: Proof of concept evaluation. Assistive technology : the official journal of RESNA. 2016 Fall [PubMed PMID: 26852872]
[15] Kornhall DK,Jørgensen JJ,Brommeland T,Hyldmo PK,Asbjørnsen H,Dolven T,Hansen T,Jeppesen E, The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury. Scandinavian journal of trauma, resuscitation and emergency medicine. 2017 Jan 5 [PubMed PMID: 28057029]
[16] Maschmann C,Jeppesen E,Rubin MA,Barfod C, New clinical guidelines on the spinal stabilisation of adult trauma patients – consensus and evidence based. Scandinavian journal of trauma, resuscitation and emergency medicine. 2019 Aug 19 [PubMed PMID: 31426850]
[17] Hood N,Considine J, Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature. Australasian emergency nursing journal : AENJ. 2015 Aug [PubMed PMID: 26051883]
[18] The medical school and the surrounding community: discussion., Zimmerman HM,, Bulletin of the New York Academy of Medicine, 1977 Jun [PubMed PMID: 23417176]
[19] Main PW,Lovell ME, A review of seven support surfaces with emphasis on their protection of the spinally injured. Journal of accident & emergency medicine. 1996 Jan [PubMed PMID: 8821224]
[20]KOSIAK M, Etiology of decubitus ulcers. Archives of physical medicine and rehabilitation. 1961 Jan [PubMed PMID: 13753341]
[21] Holla M, Value of a rigid collar in addition to head blocks: a proof of principle study. Emergency medicine journal : EMJ. 2012 Feb [PubMed PMID: 21335583]
[22]Prasarn ML,Hyldmo PK,Zdziarski LA,Loewy E,Dubose D,Horodyski M,Rechtine GR, Comparison of the Vacuum Mattress versus the Spine Board Alone for Immobilization of the Cervical Spine Injured Patient: A Biomechanical Cadaveric Study. Spine. 2017 Dec 15 [PubMed PMID: 28591075]
[23] Hoffman JR,Mower WR,Wolfson AB,Todd KH,Zucker MI, Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. The New England journal of medicine. 2000 Jul 13 [PubMed PMID: 10891516]
[24] Konstantinidis A,Plurad D,Barmparas G,Inaba K,Lam L,Bukur M,Branco BC,Demetriades D, The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. The Journal of trauma. 2011 Sep [PubMed PMID: 21248650]
[25] So you want to own your own dental building!, Sarner H,, CAL [magazine] Certified Akers Laboratories, 1977 Apr [PubMed PMID: 26491795]
[26] Shank CD,Walters BC,Hadley MN, Current Topics in the Management of Acute Traumatic Spinal Cord Injury. Neurocritical care. 2018 Apr 12 [PubMed PMID: 29651626]
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