Are you afraid to throw out your spinal board? It’s time to change your mind about spinal immobilization

A PAPER TO KNOW MORE – Dr D Connor, K Porter, M Bloch and I Graves in the “Pre-hospital Spinal Immobilization: An Initial Consensus Statement”, reviews the current evidence available on the practice of spinal immobilization in the pre-hospital environment. This is a part of the conclusions from a consensus meeting held by the Faculty of Pre-hospital Care in the Royal College of Surgeons of Edinburgh in March 2012. The consensus group was absolutely clear that a change is needed from a policy of immobilizing necks as much for the protection of the clinician as for that of the patient, to a system of selective immobilization designed to reduce the risks to the trauma victim. It is important to remember, however, that voluntary aid organisations will be looking for guidance in this challenging area. For these practitioners, guidance for the ‘nonprofessional’ managing trauma should err towards the side of over triage. They could with benefit, however, be made aware that cervical collars are not the panacea that they are often made out to be and that manual inline stabilisation (MILS) is often a more beneficial and acceptable modality compared with triple immobilisation. They should also be encouraged to consider moving away from spinal boards towards non-metallic scoops and the concept of minimal handling.

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CONSIDERATION FROM MEDEST118 – As you know, spinal immobilization is performed in all trauma patients from the rescuers in EMS systems all over the world, regardless the mechanism of injury and the clinical signs. This kind of approach is nowadays been rebutted from the recents evidences and the actual guidelines. ACEP, in Jan 2015, released a policy statement entitled :”EMS Management of Patients with Potential Spinal Injury” clarifying the right indications, and contraindications, for spinal immobilization in prehospital setting. The lack of evidence of beneficial use of devices such as spinal backboards, cervical collars etc… is in contrast with the demonstrated detrimental effects of such instruments: airway compromise, respiratory impairment, aspiration, tissue ischemia,increased intracranial pressure, and pain, consequent to spinal immobilization tools, can result in increased use of diagnostic imaging and mortality. Already in 2009 a Cochrane review demonstrated the lack of evidences on use of spinal restriction strategies in trauma.

Recently the out of hospital validation of Nexus criteria and Canadian C-spine rules, strongly driven to a revisited approach to spinal immobilization.

So in 2013 American Association of Neurological Surgeons and the Congress of Neurological Surgeons “Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injurie”  and Faculty of Pre-Hospital Care “Pre-hospital Spinal Immobilisation: An Initial Consensus Statement” stated those changes.

Based on this statements:

1. Spinal immobilization should not be used for patients with penetrating trauma without evidence of spinal injury.
2. Spinal immobilization should be considered in all trauma patients with acervical spine or spinal cord injury or with a mechanism of injury having the potential to cause cervical spinal injury.
3. Spinal motion restriction should not be considered for patients with plausible blunt mechanism of injury and any of the following:
   • The patient is GCS 15 (normal lev el of alertness)
   • There is no posterior mid-line tenderness
   • There is no distracting injury (other painful injury)
   • There is no focal neurological signs and /or symptoms (e.g., numbness and/or motor weakness)
   • There is no anatomic deformity of the spine
   • There is no intoxication (alcohol or drugs, including iatrogenic)
4. The long spinal board is an extrication device solely.
5. Backboards should not be used as a therapeutic intervention or as a precautionary measure either inside or outside the hospital or for inter-facility transfers. For this purpose, a scoop stretch or vacuum mattress should be used.
6. EMS providers ahs to be properly educated on assessing risk for spinal injury and neurologic assessment, as well as on performing patient movement in a manner that limits additional spinal movement in patients with potential spinal injury.

References

1. 2015 ACEP Policy statements: EMS Management of Patients with Potential Spinal Injury
2. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. Oct-Dec 1999;3(4):347-352.
3. Cochrane Rewiev Spinal immobilisation for trauma patients
4. Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury.
5. The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
6. Evaluation of the Safety of C-Spine Clearance by Paramedics
7. 2013 American Association of Neurological Surgeons and the Congress of Neurological Surgeons Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injurie
8. Faculty of Pre-Hospital Care “Pre-hospital Spinal Immobilisation: An Initial Consensus Statement”