Clinical Review

The Changing Standard of Care for Spinal Immobilization

New guidelines suggest a more limited role for prehospital spinal immobilization based on increasing evidence that the practice often is not only unnecessary, but possibly harmful.

Emergency Medicine. 2016 April;48(4):152-157

Author(s):

References

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Prehospital spinal immobilization has long been the standard of care (SOC) to prevent spinal cord injury in trauma patients, but utilizing the best data currently available, some professional societies recently released new recommendations that question this practice. Guidelines released in 2014 from the National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACS-COT) support limited application of spinal immobilization.¹ These guidelines note, “Given the rarity of unstable spinal injuries in EMS trauma patients, the number that might benefit from immobilization to prevent secondary injury is likely extremely small. For each patient who has potential benefit, hundreds to thousands of patients must undergo immobilization with no potential benefit.” Further, they advise “utilization of backboards for spinal immobilization during transport should be judicious, so that potential benefits outweigh risks.”¹ Spinal immobilization should not be used at all in patients with penetrating trauma who do not present with obvious neurological injury and should be selective, based on objective findings of injury or the high potential for same.¹

Questioning a Long-standing Practice

Fear of the consequences of spinal cord injury from significant vertebral fractures has dictated prehospital spinal immobilization to manage injured trauma patients for decades. For almost 50 years, it has been the SOC. However, increasing evidence that spinal immobilization is not only unnecessary, but may even cause harm has resulted in questioning this paradigm, which has lead to promoting a change in the SOC.

Spinal immobilization dates back to the mid-1960s, when Geisler et al² reported on a cohort of patients who suffered long-term paralysis from what was believed to be improper handling and failure to discover spinal injuries. Soon after, Farrington^3,4 developed and published a systematic approach to spinal immobilization during extrication following blunt force trauma, supporting the widespread acceptance of backboards and cervical collars to immobilize the spine in injured trauma patients. Logic dictated that an unstable spine fracture could be worsened, or a cord injury could result, by unnecessary movement during extrication, transport, and initial evaluation in the ED, resulting in avoidable injury. This fear of potential secondary injury grew as more papers were published examining the link between prehospital handling of blunt force trauma patients and delayed paralysis. This resulted in the use of spinal immobilization on the majority of trauma patients, regardless of mechanism of injury or presenting symptoms.^5,6

One review estimated that over 50% of trauma patients with no complaint of neck or back pain were transported with full spinal immobilization.⁷ This immobilization on uncomfortable long backboards typically continued in the ED for prolonged periods, until the spine could be cleared by physical examination and/or imaging studies. Yet a 2001 Cochrane review found that despite increasing use of spinal immobilization, no prospective, randomized controlled trial of the appropriate use of spinal immobilization or patient outcomes had ever been conducted.⁸

What the Evidence Says

How much evidence exists that supports the benefits of spinal immobilization? Not much. Studies on healthy volunteers and cadavers evaluating spinal motion with immobilization have been contradictory.⁹ One study found there was less motion with a cervical collar in place than without,¹⁰ whereas others found that the use of a cervical collar did not effectively reduce motion in an unstable spine.^11,12 Perry et al¹³ studied the effectiveness of different head immobilization techniques and found that none could eliminate head and neck motion during emergency medical services (EMS) transport. Still other reports, including two biomechanical studies, demonstrated increased neck motion when using conventional extrication techniques (cervical collar with backboard) versus controlled self-extrication with cervical collar only.^14,15

An Abundance of Literature on the Risks

Whereas data regarding the actual benefits of spinal immobilization is lacking, an abundance of literature details the risks. One of the most frequently cited studies is also one of the most controversial. Hauswald et al¹⁶ compared the outcomes of two groups of patients with blunt force trauma who were either immobilized during transport (in New Mexico) or non-immobilized (in Malaysia) and found that the risk of disability was higher in the immobilized group (odds ratio, 2.03). Although these environments are very different, the authors noted that mechanism of injury, resources, and the size of the hospitals were similar.¹⁶

Studies of spinal immobilization in patients with penetrating trauma report even worse outcomes. In separate studies, Haut et al¹⁷ and Vanderlan et al¹⁸ demonstrated increased mortality when immobilization led to increased transport times and interference with other resuscitative measures. These and other studies have led the American College of Emergency Physicians, NAEMSP, ACS-COT, the Prehospital Trauma Life Support Executive Committee, and other national organizations to recommend no spinal immobilization in patients with penetrating neck trauma.^1,19,20