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September 1, 2011

Spinal immobilization: Tipping the sacred cow once again

Spinal immobilization (SI) may be one of the most common trauma interventions implemented by pre-hospital professionals.

The goal of SI is to maintain an open spinal canal that allows flow of blood and cerebrospinal fluid (CSF) to the spinal cord. This has traditionally been accomplished by maintaining a neutral position. SI is also thought to reduce the risk of additional spinal injuries by limiting movement of bony fragments in unstable (displaced) fractures from causing further cord damage. How to most effectively achieve a neutral position remains a topic of enthusiastic professional discussion. It has driven our professional problem-solving as well as our industry's creative engineering for over three decades.

Scope of the Problem
Motor vehicle collisions (MVCs) account for the largest number of spinal cord injuries across all age groups. Falls, violence, and sports injuries remain frequent causes. More than 64% of spinal cord injuries in people in the 75 and above age group are associated with falls. Every year since 2002 over 12,000 Americans have sustained spinal cord injuries. Most of these injured victims (over 79%) are males between 16 and 30 years of age.1 The practice of spinal immobilization has traditionally been protocol driven and varies greatly among EMS systems.

The adverse effects of spinal immobilization
Any intervention places the patient at risk for possible adverse effects and implications. While the incidence of secondary spinal cord injuries (SCI) caused from spinal manipulation has never been statistically measured (but often alleged),2,3,4,5 other secondary soft-tissue injuries and adverse effects have been documented in the literature. Adverse effects of SI include: the incidence of "false positives" in which a patient who has no previous spine pain complains of spine pain upon exam due to immobilization;6 risk of aspiration and inadequate airway clearance often expressed by the inability to cough lying on a rigid board; decreased pulmonary function and hypoxia especially in elderly patients and patients with a history of pulmonary disease; thoracolumbar, lumbosacral pain and occipital pain; joint, heel and sacral pressure sores; hemodynamic changes resulting in hypotension; and the burden of overtaxed emergency departments (ED) and ethical considerations of insurance costs due to unneeded diagnostic tests.4

Dispelling myths and legends
Like many pre-hospital interventions, evidence-based best practices regarding methods of SI do not exist. Therefore, the onus remains upon pre-hospital professionals to stay up-to-date on the latest pre-hospital best practices. It is suggested from empirical data that a mattress device or full vacuum splint may be more effective in maintaining neutral position, be more comfortable, and produces less adverse effects than a rigid long backboard device.5 It has also been demonstrated that transporting patients with suspected SI to specialty trauma centers improves outcome.

The role of the pre-hospital professional
With growing attention to the adverse effects of SI, there is an increasing trend toward the process of Selective Immobilization, sometimes called Spinal Clearance, which was developed from a study commonly known as the NEXUS trial.

Successfully implemented by EMS agencies throughout North America for over a decade, pre-hospital professionals applied evidence-based physical exam criteria to select patients who were low-risk, or who met the spinal immobilization criteria outlined in the trial.6 The impetus for spinal clearance is also supported by recent literature that demonstrates that some trauma patients with penetrating trauma experience worse outcomes when spinal immobilization is implemented. In addition, there are a growing number of patients who refuse SI because it is uncomfortable.

It has been over ten years since Fresno County EMS and others successfully implemented selective immobilization protocols. Yet, many EMS entities have not implemented similar clearance protocols despite the growing body of evidence. Taking the "bull by the horns," some EMS agencies report increased patient satisfaction scores after implementation of SI protocols.

The spirit of spinal clearance reflects the case of other major trauma injuries -- mechanism of injury (MOI) may serve as a poor predictor of SCI. Therefore, a meticulous and systematic assessment process may best predict and identify trauma injuries.

For instances in which SI is indicated, EMS must advocate for the usage of more comfortable spinal immobilization devices. We must work proactively with ED staff to rapidly clear patients and remove them from immobilization. EMS agencies must seek opportunities to actively participate in the development of spinal clearance protocols. As patient advocates, we must demand active SI quality assurance programs, maintain our competencies, and stay informed of current evidence-based practices.

References:
1. Jackson, A., M. Dijkers, M. Devivo, and R. Poczatek. "A Demographic Profile of New Traumatic Spinal Cord Injuries: Change and Stability over 30 Years." Archives of Physical Medicine and Rehabilitation 85, no. 11 (2004): 1740-748. doi:10.1016/j.apmr.2004.04.035.

2. Bernhard, M., A. Gries, P. Kremer, and B. Bottiger. "Spinal Cord Injury (SCI)—Prehospital Management." Resuscitation 66, no. 2 (March 1, 2005): 127-39. doi:10.1016/j.resuscitation.2005.03.005.

3. Vaillancourt, C., M. Charette, A. Kasaboski, J. Maloney, G. A. Wells, and I. G. Stiell. "BioMed Central | Full Text | Evaluation of the Safety of C-spine Clearance by Paramedics: Design and Methodology." BioMed Central | The Open Access Publisher. February 1, 2011. Accessed July 18, 2011. http://www.biomedcentral.com/1471-227X/11/1.

4. Orledge, Jeffrey D., and Paul E. Pepe. "Out-of-hospital Spinal Immobilization: Is It Really Necessary?" Academic Emergency Medicine 5, no. 3 (March 1998): 203-04.

5. Hauswald, M., M. Hsu, and C. Stockoff. "Maximising Comfort and Minimizing Ischemia: A Comparison of Four Methods of Spinal Immobilization." Prehospital Emergency Care 4, no. 3 (2000): 250-52.

6. Stiell, Ian G., George A. Wells, Katherine L. Vandemheen, Catherine M. Clement, and Howard Lesiuk. "The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients." JAMA 286, no. 15 (October 17, 2001): 1841-848.



About the Author

Dean Meenach, RN, BSN, CEN, CCRN, CPEN, EMT-P has taught and worked in EMS for more than 20 years and currently serves as Director of EMS Education/Paramedic Instructor and co-teacher in the Paramedic to RN Bridge Program at Mineral Area College. He has served as a subject matter expert, author, national speaker, and collaborative author in micro-simulation programs. Dean continues to serve patients part time as a member of a stroke team and in a pediatric and adult trauma center. He can be reached at dmeenach@mineralarea.edu.
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