Spinal column immobilisation using a spine board: objectives, indications and limitations of use
Spinal motion restriction using a long spine board and cervical collar is implemented in cases of trauma, when certain criteria are met, to help reduce the chances of spinal cord injury
Indications for the application of spinal motion restriction are a GCS of less than 15, evidence of intoxication, tenderness or pain in the midline of the neck or back, focal neurological signs and/or symptoms, anatomical deformity of the spine, and distracting circumstances or injuries.
Introduction to spinal trauma: when and why spine board is needed
Traumatic blunt injuries are the leading cause of spinal cord injury in the United States and many other countries, with an annual incidence of about 54 cases per million population and about 3% of all hospital admissions for blunt trauma.
Although spinal cord injuries account for only a small percentage of blunt trauma injuries, they are among the largest contributors to morbidity and mortality.
Consequently, in 1971, the American Academy of Orthopaedic Surgeons proposed the use of a cervical collar and long spinal board to restrict spinal movement in patients with suspected spinal cord injuries, based solely on the mechanism of injury.
At the time, this was based on consensus rather than evidence.
In the decades since spinal motion restriction, using a cervical collar and long spine board has become the standard in prehospital care
It can be found in several guidelines, including the Advanced Trauma Life Support (ATLS) and Prehospital Trauma Life Support (PHTLS) guidelines.
Despite their widespread use, the efficacy of these practices has been called into question.
In one international study comparing those who underwent spinal motion restriction to those who did not, the study found that those who did not receive routine care with spinal motion restriction had fewer neurologic injuries with disability.
However, it should be noted that these patients were not matched for the severity of the injury.
Using healthy young volunteers, another study looked at lateral spine motion on a long spine board compared to a stretcher mattress and found that the long spine board allowed the greater lateral motion.
In 2019, a retrospective, observational, multi-agency prehospital study examined whether or not there was a change in spinal cord injuries after implementing an EMS protocol that limited spinal precautions to only those with significant risk factors or abnormal exam findings and found that there was no difference in the incidence of spinal cord injuries.
There are currently no high-level randomized control trials to either support or refute the use of spinal motion restriction
It is unlikely there will be a patient to volunteer for a study that could result in permanent paralysis violates current ethical guidelines.
As a result of these and other studies, newer guidelines recommend limiting the use of long spine board spinal motion restriction to those with a concerning mechanism of injury or concerning signs or symptoms as described later in this article and limiting the duration that a patient spends immobilized.
Indications for using the spine board
In Denis’ theory, injury to two or more columns is considered an unstable fracture to injure the spinal cord that lies within the spinal column.
The purported benefit of spinal motion restriction is that by minimizing spinal motion, one can reduce the potential for secondary spinal cord injuries from unstable fracture fragments during extrication, transport, and evaluation of trauma patients.
The indications for spinal motion restriction are dependent on the protocol developed by local emergency medical service directors and may vary accordingly.
However, the American College of Surgeons Committee on Trauma (ACS-COT), the American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP) have developed a joint statement on spinal motion restriction in adult blunt trauma patients in 2018 and has listed the following indications:
- Altered level of consciousness, signs of intoxication, GCS < 15
- Midline spinal tenderness or pain
- Focal neurologic signs or symptoms such as motor weakness, numbness
- Anatomic deformity of the spine
- Distracting injuries or circumstances (e.g., fractures, burns, emotional distress, language barrier, etc.)
The same joint statement also made recommendations for pediatric blunt trauma patients, noting that age and ability to communicate should not be a factor in decision making for prehospital spinal care.
The following are their recommended indications:
- The complaint of neck pain
- Neurologic deficit
- Altered mental status, including GCS <15, intoxication, and other signs (agitation, apnea, hypopnea, somnolence, etc.)
- Involvement in a high-risk motor vehicle collision, high impact diving injury, or has substantial torso injury
Contraindications in the use of the spine board
A relative contraindication in patients with penetrating trauma to the head, neck, or torso without neurologic deficit or complaint.
According to studies published in the Eastern Association for the Surgery of Trauma (EAST) and The Journal of Trauma, patients with penetrating trauma who underwent spinal immobilization were twice as likely to die as patients who did not.
Immobilizing a patient is a time-consuming process, between 2 to 5 minutes, that not only delays transport for definitive care but also delays other prehospital treatments as this is a two-person procedure.
Necessary equipment for spinal immobilisation: the collar, the long and short spine board
The equipment necessary for spinal motion restriction requires a spine board (either long or short) and a cervical spine collar.
Long Spine Boards
Long spine boards were initially implemented, in conjunction with a cervical collar, to immobilize the spine as it was thought that improper handling in the field could cause or exacerbate spinal cord injuries.
The long spine board was also cheap and served as a convenient method to transport unconscious patients, reduce unwanted movement, and cover uneven terrain.
Short Spine Boards
Short spine boards, also known as intermediate-stage extrication devices, are typically more narrow than their longer counterparts.
Their shorter length allows for their use in closed or confined areas, most commonly in motor vehicle collisions.
The short spine board supports the thoracic and cervical spine until the patient can be placed on a long spine board.
A common type of short spine board is the Kendrick Extrication Device, which differs from the classic short spine board in that it is semi-rigid and extends laterally to encompass the flanks and head.
Similar to long spine boards, these are also used in conjunction with cervical collars.
Cervical Collars: the “C Collar”
Cervical collars (or C Collar) can be classified into two broad categories: soft or rigid.
In trauma settings, rigid cervical collars are the immobilizer of choice as they provide superior cervical restriction.
Cervical collars are generally designed to have a posterior piece that uses the trapezius muscles as a support structure and an anterior piece that supports the mandible and uses the sternum and clavicles as a support structure.
Cervical collars by themselves do not offer adequate cervical immobilization and require additional lateral support structures, often in the form of Velcro foam pads found on long spine boards.
Several techniques are available for placing someone in spinal motion restriction, one of the most common being the supine log-roll technique outlined below and is performed, ideally, with a 5-person team, but at minimum, a team of four.
For a Team of Five
Before immobilization, have the patient cross their arms over their chest.
A team leader should be assigned to the head of the patient who will perform inline manual stabilization by grasping the patient’s shoulders with their fingers on the posterior aspect of the trapezius and their thumb on the anterior aspect with the forearms pressed firmly against the lateral aspects of the patient’s head to limit motion and stabilize the cervical spine.
If available, a cervical collar should be placed at this time without lifting the patient’s head off the ground. If one is not available, maintain this stabilization during the log roll technique.
Team member two should be positioned at the thorax, team member three at the hips, and team member four at the legs with their hands positioned on the far side of the patient.
Team member five should be ready to slide the long spine board under the patient after they are rolled.
On team member 1’s command (typically on a count of three), team members 1 to 4 will roll the patient, at which time team member five will slide the long spine board under the patient.
Once again, on team member one’s command, the patient will be rolled onto the long spine board.
Center the patient on the board and secure the torso with straps followed by the pelvis and upper legs.
Secure the head by placing either rolled towels on either side or a commercially available device and then place tape across the forehead and secured to the edges of the long spine board.
For a Team of Four
Again, a team leader should be assigned to the patient’s head and follow the same technique outlined above.
Team member two should be positioned at the thorax with one hand on the far shoulder and the other on the far hip.
Team member three should be positioned at the legs, with one hand positioned on the far hip and the other on the far leg.
Note that it is recommended that the arms of the team members cross over each other at the hip.
Team member four will slide the long spine board under the patient, and the rest of the technique is followed as outlined above.
Complications of using the spine board in spinal immobilisation
A potential complication in those undergoing prolonged long spine board and cervical spine motion restriction are pressure ulcers, with an incidence reported as high as 30.6%.
According to the National Pressure Ulcer Advisory Panel, pressure ulcers have now been reclassified as pressure injuries.
They result from pressure, usually over bony prominences, for a prolonged time resulting in localized damage to the skin and soft tissue.
In the early stages, the skin remains intact but may progress to an ulcer in later stages.
The amount of time it takes to develop a pressure injury varies, but at least one study demonstrated that tissue injury might begin in as little as 30 minutes in healthy volunteers.
Meanwhile, the average time spent immobilized on a long spine board is around 54 to 77 minutes, approximately 21 minutes of which is accrued in the ED after transport.
With this in mind, all providers must try to minimize the time patients spend immobilized either on rigid long spine boards or with cervical collars as both may lead to pressure injuries.
Multiple studies have demonstrated a reduction in respiratory function due to the straps used on long spine boards.
In healthy young volunteers, the use of long spine board straps over the chest resulted in a decrease of several pulmonary parameters, including forced vital capacity, forced expiratory volume, and forced mid-expiratory flow resulting in a restrictive effect.
In a study involving children, there was a reduced forced vital capacity to 80% of baseline. In yet another study, both rigid board and vacuum mattresses were found to restrict respiration by an average of 17% in healthy volunteers.
Careful attention must be paid when immobilization patients, particularly to those with a pre-existing pulmonary disease as well as children and the elderly
The most common, well-documented complication of long spine board spinal motion restriction is pain, resulting in as little as 30 minutes.
Pain is most commonly manifested with headaches, back pain, and mandible pain.
Again, and by now a recurring theme, time spent on a rigid long spine board should be minimized to reduce pain.
Clinical significance of spinal cord injury: role of collar and spine board
Blunt force trauma can cause spinal column injury and, consequently, spinal cord damage that can result in serious morbidity and mortality.
In the 1960s and 1970s, spinal motion restriction was employed to reduce or prevent neurological sequelae thought to be secondary to spinal column injuries.
Though widely adopted as the standard of care, the literature lacks any high quality, evidence-based research that investigates whether or not spinal motion restriction has any impact on neurological outcomes.
Additionally, in recent years there has been a growing body of evidence highlighting the potential complications of spinal motion restriction.
Consequently, newer guidelines have recommended that spinal motion restriction be utilized judiciously in specific patient populations.
Although spinal motion restriction may be beneficial in some situations, the provider needs to be familiar with both the guidelines and potential complications for providers to be better equipped to apply these techniques and improve patient outcomes.
Enhancing Healthcare Team Outcomes
Patients who have been involved in blunt force trauma may present with a myriad of symptoms.
It is important for health care professionals responsible for the initial evaluation of these patients to be familiar with the indications, contraindications, potential complications, and proper technique of implementing spinal motion restriction.
Several guidelines can exist to help determine which patients meet the criteria for spinal motion restriction.
Perhaps the most well known and widely accepted guidelines is that of the joint position statement by the American College of Surgeons Committee on Trauma (ACS-COT), the National Association of EMS Physicians (NAEMSP), and the American College of Emergency Physicians (ACEP). Although these are the current guidelines and recommendations, there are no high-quality randomized control trials to date, with recommendations being based on observational studies, retrospective cohorts, and case studies.
In addition to being familiar with the indications and contraindications for spinal motion restriction, it is also important for health care professionals to be familiar with the potential complications such as pain, pressure ulcers, and respiratory compromise.
When implementing spinal motion restriction, all members of the interprofessional health care professionalsteam must be familiar with their preferred technique and exercise good communication to execute the technique properly and reduce excessive spinal motion. Health care professionals should also recognize that time spent on a long spine board should be minimized to reduce complications.
When transferring care, the EMS team should communicate the total time spent on the long spine board.
Utilizing the latest guidelines, being familiar with known complications, limiting time spent on the long spine board, and exercising excellent interprofessional communication outcomes for these patients can be optimized. [Level 3]
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