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Spinal Immobilization in Trauma Patients

Posted by Marco Torres on

Background: It has been common practice in trauma to place patients in cervical collars and on long backboards (LBBs) to achieve spinal immobilization. LBBs are used to help prevent spinal movement and facilitate extrication of patients. Cervical collars (C-Collars) are used to help prevent movement of the cervical spine and often are combined with lateral head blocks and straps. The theory behind this is that spine immobilization prevents secondary spinal cord injury during extrication, transport, and evaluation of trauma patients by minimizing movement. Most of this information has been passed on from historical teachings, like the Advanced Trauma Life Support (ATLS) courses, and not from scientific research. To date there has been no high-quality evidence that use of spinal immobilization improves patient outcomes. In this post, we will review the evidence associated with spinal immobilization in trauma patients.

Study #1: Spinal Immobilization Does NOT Help Immobilize the Cervical Spine [5]

What They Did:

  • Randomized, unbalanced, controlled crossover trial of healthy volunteer subjects who were randomly assigned to either a long backboard (LBB) or stretcher mattress.
  • All subjects fitted with rigid cervical collar and secured to assigned device (Including FOAM head blocks)
  • Patients driven on a course at <20mph with lasers affixed to a scaffold for lateral movement measurements at head, chest, and hip

Outcomes:

  • Primary: Amount of Lateral movement
  • Secondary: Difference in Pain and Anxiety Experience

Inclusion:

  • Healthy adult volunteers

Exclusion:

  • Medically treated spinal problems
  • Relevant medications (anxiolytics or prescription pain control medications)
  • Pregnancy
  • Feeling ill the day of the study

Results:

  • Lateral Movement at Head:
    • LSB: 0.97 +/- 0.7cm
    • Stretcher Mattress: 0.46 +/- 0.4cm
  • Lateral Movement at Chest:
    • LSB: 2.22 +/- 1.4cm
    • Stretcher Mattress: 1.22 +/- 0.9cm
  • Lateral Movement at Hips:
    • LSB: 1.88 +/- 1.2cm
    • Stretcher Mattress: 1.20 +/- 0.9cm

Strengths:

  • Drivers blinded to the method of immobilization
  • Participants randomly selected packets that contained their randomization card
  • Analysis was carried out with and without BMI adjustments
  • First study to evaluate the differences in lateral movement

Limitations:

  • Not a clinical study. Healthy volunteers are less likely to self-splint due to lack of injury, unlike trauma patients
  • Small sample size
  • This study does not specifically establish how much movement is clinically relevant
  • Subjects only exposed to LSB for 10 minutes which may be why there was no statistical difference in pain and anxiety
  • Spine board not fixed to stretcher, therefore movement of the board itself may be the cause of lateral movement
  • Low speed transport which means the measurements may have underestimated true lateral movement in a real life setting
  • Data gathering was unblinded
  • This study evaluated gross lateral movement of the external body and not a direct clinical correlation to possible spine movement
  • Only evaluated effectiveness of 2 different spinal restriction modalities

Discussion:

  • LSB allowed 0.8cm greater mean lateral motion for all measurements in aggregate than did the stretcher mattress alone
  • The amount of movement from each patient as a function of BMI revealed a direct correlation of increased movement with increased BMI
  • No statistical differences in pain or anxiety after completion of the study with LSB or stretcher mattress alone

Author Conclusion: “The stretcher mattress significantly reduced lateral movement during transport.”

Clinical Take Home Point: This study confirms that long spine board immobilization does not limit lateral movement, however the clinical correlation to possible spine movement and neurologic outcomes cannot be evaluated based on this trial alone.

Study #2: Spinal Immobilization Does NOT Decrease Rates of Spinal Cord Injury[6]

What They Did:

  • A 5-year retrospective chart review of all patients admitted to inpatient service or ED with spinal or spinal cord injuries at 2 hospitals (One in Malaysia and One in New Mexico)
  • Separated Neurologic injury into two categories: Disabling or Not Disabling

Outcomes:

  • Neurologic Injury with Disability: Complete quadriplegia or paraplegia, inability to ambulate without assistance, incontinence, or need for chronic catheterization, and death
  • No Neurologic Injury

Inclusion:

  • All patients with blunt injuries to the spine or spinal cord transported from the injury scene to a study hospital

Exclusion:

  • Compression fractures due to osteopenia or disease

Results:

  • All patients with acute blunt traumatic spinal or spinal cord injuries
    • 0/120 patients had spinal immobilization at Malaysian Hospital
    • 334/334 patients had spinal immobilization at New Mexico Hospital
  • Neurologic Injury with Disability:
    • US Hospital: 21%
    • Malaysian Hospital: 11%
  • Less neurologic disability in in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03 – 3.99; p = 0.04)
  • Results similar when analysis limited to patients with cervical injuries (OR 1.52; 95% CI 0.64 – 3.62; p = 0.34)

Strengths:

  • Anatomic distribution of injuries were similar at the 2 hospitals as well as what is found in the literature

Limitations:

  • Patients in Malaysia more likely to be injured from a fall rather than an MVC
  • Patients who died at injury site or during transport excluded
  • No matching of patients for severity of non-spinal injuries
  • Severity and instability of spine injuries may not have been equal between the two sites
  • Number of patients available for comparison are rather small

Author Conclusion: “Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries.”

Clinical Take Home Point: Acute spinal immobilization may not have benefit for the prevention of neurologic deterioration from unstable spinal fractures

Study #3: Spinal Immobilization Increases the Difficulty of Airway Management[7]

What They Did:

  • Randomized open label cross over study
  • 70 healthy adult patients with normal airways intubated using the Airtraq with and without rigid cervical collar

Outcomes:

  • Ease of insertion of Airtraq into oral cavity (-2 to +2; very difficult to very easy)
  • Intubation time
  • Intubation difficulty score (IDS)
  • Ease of intubation via a visual analogue scale (VAS) (0 – 10; easiest intubation to most difficult intubation/failed intubation)

Inclusion:

  • ASA I and II patients
  • Aged 19 – 50 years
  • Weight between 40 – 70kg
  • Undergoing elective surgical procedures under general anaesthesia with oral endotracheal intubation

Exclusion:

  • Restricted mouth opening
  • Mallampati IV
  • Thyromental distance <5cm
  • Neck circumference >42cm
  • Body mass index > 30%
  • Pregnant
  • Patients with risk of pulmonary aspiration of gastric contents
  • Patients with cervical spine pathology, reactive airway disease, cardiac disorders

Results:

  • 70 patients enrolled
    • 2 patients excluded due to difficult mask ventilation
    • 3 patients refused to participate
    • 65 patients included in the study
  • Ease of insertion of airtraq into oral cavity was more difficult with cervical collar
    • Likert Score of -2:
      • Cervical Collar: 10.8%
      • No Cervical Collar: 1.5%
    • Likert Score of -1:
      • Cervical Collar: 44.6%
      • No Cervical Collar: 23.1%
    • Airway Trauma:
      • Cervical Collar: 7.6%
      • No Cervical Collar: 1.5%
    • Failure to Intubate
      • Cervical Collar: 3%
      • No Cervical Collar: 0%
    • Intubation Time:
      • Cervical Collar: 30.0sec
      • No Cervical Collar 26.9sec
    • Median Visual Analogue Scale for Ease of Intubation:
      • Cervical Collar: 3
      • No Cervical Collar: 2
    • Need for Additional Manuevers (i.e. Use of Bougie):
      • Cervical Collar: 18.5%
      • No Cervical Collar: 6.2%

Strengths:

  • Estimated a sample size based on intubation difficulty score (IDS)

Limitations:

  • Intubations requiring more than one attempt were excluded from the analysis for intubation time
  • Open labelled design may have created bias (i.e. hard to conceal collar vs no collar)
  • Unclear if difficulty in intubation was specific to the Airtraq or if this would be the case with other tools for intubation

Author Conclusion: “Tracheal intubation using Airtraq in the presence of rigid cervical collar has equivalent success rate, acceptable difficulty in insertion, and mild increase in IDS.”

Clinical Take Home Point: Tracheal intubation is more difficult, takes a longer time, and requires more maneuvers for success when cervical collar is applied.

Study #4: Spinal Immobilization Can Cause Pressure Ulcers [1]

What They Did:

  • Systematic review of studies from 1970 – September 2011 via multiple databases reviewing the development of pressure ulcers with spinal immobilization

Outcomes:

  • Spinal Immobilization Devices and Occurrence of Pressure Ulcers
  • Severity of Pressure Ulcers
  • Risk Factors for Pressure Ulcers
  • Preventive Interventions of Pressure Ulcers

Inclusion:

  • Healthy volunteers or trauma patients under spinal immobilization until spine injuries diagnosed or excluded

Exclusion:

  • Abstracts not available

Results:

  • Total of 998 Studies Reviewed
    • 13 Studies (1,180 patients) included in systematic review
  • Incidence of collar-related Pressure Ulcers:
    • NO studies described occurrence of pressure ulcers related to application of backboards and vacuum mattresses, BUT there was significant increase in pain
    • 4 studies described occurrence of pressure ulcers related to application of C-spine immobilization with C-Collars (Incidence of Pressure Ulcers: 6.8 – 38%)
    • NO studies evaluated the use of lateral head blocks on tissue interface pressure (TIP)
  • Locations of Pressure Ulcers: Occiput, Chin, Clavicle, and Shoulders
  • Severity of Pressure Ulcers: Stages 1 – 4
  • Risk Factors for Pressure Ulcers:
    • High Pressure
    • Pain from Immobilizing Devices
    • Length of Time in/on Device
    • Intensive Care Unit Admission
    • High Injury Severity Scores (ISSs)
    • Mechanical Ventilation
    • Intracranial Pressure Monitoring
  • Preventive Interventions for Collar-Related Pressure Ulcers
    • Early Replacement of the Extrication Collar
    • Regular Skin Assessment
    • Collar Refitting every 4 – 8 hours
    • Position Change

Strengths:

  • Used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for evaluation of studies
  • Included all types of clinical designs in their review without restriction in language, publication date, or publication status
  • Used the Research Appraisal Checklist (RAC) for nursing reports to assess quality of included studies
  • Just over half (7/13) of studies were considered high quality studies. The remaining 6/13 were considered “average” quality studies.

Limitations:

  • Meta-analysis of results was not feasible due to the wide variations in design and variables assessed
  • 9/13 studies did not perform power calculations and may have had insufficient sample sizes to detect an effect
  • 5/13 studies did not describe the reliability and validity of applied instruments to measure tissue interface pressure (TIP)
  • 5/8 studies with crossover design did not describe washout times. Short or no washout times may influence the observations of the next treatment by the previous treatment
  • 5 studies included were from 15 years ago. The devices we are using today may not generalize to these studies
  • Of the 13 studies only 4 were clinical studies on C-collar related pressure ulcers in trauma patients

Discussion:

  • Length of time in immobilization seems to be the biggest risk factor for pressure ulcer development.
  • Perfusion and oxygenation of tissues are significantly decreased in trauma patients with higher severity of illness (i.e. ICU admission, mechanical ventilation, high ISSs, and ICP monitoring). This is also a risk factor for development of pressure ulcers.
  • Pain and discomfort were clinical indicators of increased tissue pressure from the immobilization devices. In addition, pain can bias clinical evaluation, which results in prolonged immobilization due to imaging delays.

Author Conclusion: “The results from this systematic review show that immobilization with devices increases the risk for Pressure Ulcer Development. This risk is demonstrated in nine experimental studies with healthy volunteers and in four clinical studies.”

Clinical Take Home Point: Spinal immobilization can cause the development of pressure ulcers. Extrication backboards should be removed as soon as possible to prevent prolonged times on hard surfaces. The time of rigid/semi-rigid C-collar devices should also be minimized by standardizing the procedure for C-collar clearance (i.e. NEXUS or Canadian C-spine rules). If patients require prolonged C-collar time, the rigid/semi-rigid extrication collars should be exchanged out for more comfortable soft collar devices.

Study #5: Spinal Immobilization Changes the Physical Exam [2]

What They Did:

  • Single blinded, prospective study to determine if spinal immobilization causes changes in physical exam findings over time
  • Twenty healthy volunteers without previous back pain or injuries were fully immobilized for one hour, with a cervical collar and strapped to a long wooden backboard
  • Midline palpation of vertebrae was performed every 10 minutes up to an hour

Outcomes:

  • Number of patients reporting pain on palpation
  • Location of pain

Exclusion:

  • <18 years of age
  • Pregnancy
  • Alcohol Use or any form of Analgesic within 24 hours prior to participation
  • Prior history of back injury

Results:

  • 20 Consecutive Volunteers
    • Time 0 Min: 0/20 with pain on palpation
    • Time 40 Min: 3/20 with pain on palpation
    • Time 60 Min: 5/20 with pain on palpation
  • 18/20 patients reported increased discomfort over 60 minutes
    • Median initial pain was 1/10
    • Median pain at 60 min was 4/10
  • Location of pain at 60 min was identified at C7, L2, and L3

Strengths:

  • Subjects blinded to the nature of the study question
  • To avoid interrater reliability, each participant had only one individual performing all pain scoring and all assessments for point tenderness

Limitations:

  • Participants were not real trauma patients
  • Small sample size

Discussion:

  • Only one patient developed point tenderness in <30 minutes, therefore rapid evaluation of patients on initial arrival to the ED may decrease the incidence of induced vertebral point tenderness
  • Another option is to have protocols in place for emergency medical service providers to clinically clear patients in the field and prevent spinal immobilization altogether

Author Conclusion: ‘This study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness. In order to reduce this high false-positive rate for midline vertebral tenderness, the authors recommend that, initially on arrival to the emergency department, immediate evaluation occur of all immobilized patients. Furthermore, backboards should be modified to reduce patient discomfort to prevent the iatrogenically induced midline vertebral tenderness, thereby reducing subsequent false-positive examinations.”

Clinical Take Home Point: Prolonged spinal immobilization (>30min) can increase the rate of midline spine tenderness, likely resulting in unnecessary health care costs due to radiologic evaluations.

Study #6: Spinal Immobilization Worsens Pulmonary Function [3]

What They Did:

  • Unblinded, randomized, crossover laboratory study of 39 volunteers ranging from age 7 to 85 years
  • Respiratory function, via spirometry, measured 3 times at baseline (seated or lying), immobilized with a Philadelphia collar on a wooden backboard, and on a Scandinavian vacuum mattress with a vacuum collar

Outcomes:

  • Spirometry Results
  • Patient Comfort

Exclusion:

  • Inability to tolerate positions
  • Request to terminate participation
  • Inability to understand instructions
  • History of dyspnea at rest
  • History of respiratory compromise

Results:

  • 39 total volunteers
    • Children: n = 11 (Age Ranges 7 – 12 years)
    • Young Adults: n = 11 (Age Ranges 22 – 32 years)
    • Elderly: n = 17 (All >60 years)
  • Forced Vital Capacity (FVC)
    • Baseline: 2.72L
    • Wooden Board: 2.34L
    • Vacuum Mattress 2.33L
  • Forced Expiratory Volume in 1 Sec (FEV1)
    • Baseline: 2.26L
    • Wooden Board 1.94L
    • Vacuum Mattress: 1.83L
  • Patient Comfort Level (From 1 – Very Uncomfortable to 6 – Very Comfortable)
    • Wooden Back Board: 2.8 (Range 1 – 6)
    • Vacuum Mattress: 4.8 (Range 2 – 6)

Strengths:

  • Evaluated patients in a diverse age range, with subcohort analysis
  • Randomized, cross-over study
  • Evaluated results with a 3×2 analysis of variance (ANOVA)

Limitations:

  • Long-term effects of immobilization of vacuum mattress alone not studied
  • Cost-effectiveness of vacuum mattress compared to wooden/platic hard board not compared
  • Small study
  • Laboratory study not a clinical study
  • Unblinded nature of study may cause some bias in results

Discussion:

  • It is important to note that the largest respiratory restrictions were in extremes of age. Participants in the 20 – 60 year age group, generally had better respiratory performance than patients who were younger or older.
  • 17% decrease in pulmonary function tests may not be clinically significant in healthy subjects, but may be in trauma patients

Author Conclusion: “This study confirmed the previously reported respiratory restriction caused by spinal immobilization. Vacuum mattresses are more comfortable than wooden backboards.”

Clinical Take Home Point: When comparing baseline pulmonary function tests to spinal immobilization, there is a significant restrictive decrease in patient’s pulmonary function (average of 17%) when fully immobilized.

Study #7: Spinal Immobilization Increases Intracranial Pressure [4]:

What They Did:

  • Prospective case series of 10 head-injured patients with post-resuscitation GCS ≤9 and ICP measurements before and after cervical hard collar application
  • Following collar reapplication mean ICP measurements were recorded after 3 and 5 minutes, at which time the collar was removed immediately

Outcomes: ICP

Inclusion:

  • Head trauma patients with post-resuscitation GCS ≤9
  • Radiologic clearance of cervical spine at presentation
  • ICP monitoring

Results:

  • Preapplication Mean ICP Value: 20.5 +/14.2 mmHg
  • Postapplication Mean ICP Value 25.8 +/- 11.5 mmHg
  • Mean ICP Difference: 4.4 mmHg

Strengths:

  • Clinical trial of head injured trauma patients
  • Marks were made o hard collar so that conditions for reapplication were standardized and therefore the same application pressure during the testing period as the initial presentation
  • Before reapplication of collar a 30 minute period of minimal stimulation was given to not bias the results

Limitations:

  • Small sample size
  • Not a randomized clinical trial
  • No correlation between collar application and neurologic outcomes made in this study

Discussion:

  • In this paper, the authors reviewed previous studies looking at intracranial pressure changes with application of cervical collars (6 papers with 78 total patients). Unanimously, ICP was increased with application of cervical collars (Range 0.7mmHg – 13.5mmHg).
  • The extent of ICP increase can vary depending on the type of cervical collar used
  • The explanations of the ICP elevation have been proposed as obstruction of venous drainage and persistent painful stimulation form the collar itself
  • An interesting suggestion made in the paper is, if spine injury is suspected, the use of sandbags on either side of the neck and tape across the forehead may be a preferable option

Author Conclusion: “Early assessment of the cervical spine in head-injured patients is recommended to minimize the risk of intracranial hypertension related to prolonged cervical spine immobilization with a hard collar.”

Clinical Take Home Point: Although this is a case series, looking at the surrogate outcome of increased ICP, removal of rigid collars at the earliest time should be recommended. Future studies should evaluate the correlation of collar placement and secondary brain injury.

Position Statement from National Association of EMS Physicians and American College of Surgeons Committee on Trauma [8]

  • “Long backboards are commonly used to attempt to provide rigid spinal immobilization among emergency medical services (EMS) trauma patients. However, the benefit of long backboards is largely unproven.”
  • “The long backboard can induce pain, patient agitation, and respiratory compromise. Further, the backboard can decrease tissue perfusion at pressure points, leading to the development of pressure ulcers.”
  • “Utilization of backboards for spinal immobilization during transport should be judicious, so that the potential benefits outweigh the risks.
    Appropriate patients to be immobilized with a backboard may include those with:
    • Blunt trauma and altered level of consciousness
    • Spinal pain or tenderness
    • Neurologic complaint (e.g., numbness or motor
    • weakness)
    • Anatomic deformity of the spine
    • High-energy mechanism of injury and any of the following:
      • Drug or alcohol intoxication
      • Inability to communicate
      • Distracting injury”
  • “Patients for whom immobilization on a backboard is not necessary include those with all of the following:
    • Normal level of consciousness (Glasgow Coma
      Score [GCS] 15)
    • No spine tenderness or anatomic abnormality
    • No neurologic findings or complaints
    • No distracting injury
    • No intoxication”

THE BOTTOM LINE:

  • There is no high-level evidence that prehospital spinal immobilization positively impacts patient oriented outcomes
    • Spinal Immobilization Does NOT Help Immobilize the Cervical Spine
    • Spinal Immobilization Does NOT Decrease Rates of Spinal Cord Injury
    • Spinal Immobilization Increases the Difficulty of Airway Management
    • Spinal Immobilization Can Cause Pressure Ulcers
    • Spinal Immobilization Changes the Physical Exam
    • Spinal Immobilization Worsens Pulmonary Function
    • Spinal Immobilization Increases Intracranial Pressure
  • There is no evidence that immobilizing awake, alert patients without deficits/complaints provides benefit
  • Selective spinal immobilization protocols can help identify patients at low risk for injury and avoid immobilization

References:

  1. Ham W et al. Pressure Ulcers From Spinal Immobilization in Trauma Patients: A Systematic Review. J Trauma Acute Care Surg 2014; 76(4): 1131 – 41. PMID: 24662882
  2. March J et al. Changes In Physical Examination Caused by Use of Spinal Immobilization. Prehosp Emerg Care 2002; 6(4): 421 – 4. PMID: 12385610
  3. Totten VY et al. Respiratory Effects of Spinal Immobilization. Prehosp Emerg Care 1999; 3(4): 347 – 52. PMID: 10534038
  4. Mobbs RJ et al. Effect of Cervical Hard Collar on Intracranial Pressure After Head Injury. ANZ J Surg 2002; 72(6): 389 – 91. PMID: 12121154
  5. Wampler DA et al. The Long Spine Board Does not Reduce Lateral Motion During Transport – A Randomized Healthy volunteer Crossover Trial. Am J Emerg Med 2016; 34(4): 717 – 21. PMID: 26827233
  6. Hauswald M et al. Out-of-Hospital Spinal Immobilization: Its Effect on Neurologic Injury. Academic Emergency Medicine 1998; 5(3): 214 – 219. PMID: 9523928
  7. Durga P et al. Effect of Rigid Cervical Collar on Tracheal Intubation Using Airtraq. Indian J Anaesth 2014; 58(4): 416 – 422. PMCID: PMC4155286
  8. White CC et al. EMS Spinal Precautions and the Use of the Long Backboard – Resource Document to the Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. Prehosp Emerg Care 2014; 18(2): 306 – 14. PMID: 24559236

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Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

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