Vacuum spine boards: Transport devices of the future
An unstable spinal column with an undamaged spinal cord probably represents one of the greatest management challenges for emergency medical personnel.
In 2010, the National Spinal Cord Injury Statistical Center reported approximately 12,000 new cases of spinal cord injury in the United States each year. Injuries to the spinal cord can produce catastrophic consequences — usually immediately following the traumatic event, although some effects do not fully develop until sometime after. In some patients, damage to the boney vertebrae may occur but the cord itself may be intact.
Rescue devices such as long backboards, short backboards, and extrication vests offer restrictions to movement, but they do not immobilize.
Advanced care providers have long recognized the potential harm that accompanies the use of rigid spinal immobilization, especially if prolonged.
Rescue work involves movement, as paramedics and EMTs must relocate the patient from hostile to more stable environments. Every device applied in the field only fastens externally to the patient; the skin and muscle will continue to slide across the skeletal frame and produce bone movement. Additional movement occurs during transport as the patient’s body is subject to the laws of physics and inertia.
The spine board was developed as an extrication tool, for EMS to use in conjunction with a cervical collar and restraining straps to prevent secondary spinal cord injury resulting from patient movement to the hospital. In many areas, this procedure has remained a standard of care for almost half a century, despite the lack of convincing evidence that the procedure improves patient outcome. 
Rigid spine boards
Researchers in North Carolina found similar reductions in pulmonary function testing associated with immobilization on a long spine board in children ages 6 to 15.
Immobilization on a rigid backboard altered subsequent physical examination findings in about 20 percent of healthy volunteers by inducing cervical and lumbar midline point tenderness where none previously existed. This could result in unnecessary and expensive testing when the patient arrives in the emergency department.
Research also demonstrates that immobilization on a rigid spine board can result in the development of pressure ulcers. Pressure ulcers develop over bony prominences in individuals that are immobilized on hard surfaces. The weight of the body and the unforgiving nature of the surface impair blood flow to the area, resulting in localized ischemia, cellular death and tissue necrosis.
Increasing the duration of immobilization or the magnitude of the applied pressure will increase the rate of pressure ulcer formation. A study of patients with spinal cord injury found that all in-patients who developed skin ulcerations recalled no attempt to move or rotate them off the backboard within the first two hours after injury to relieve the pressure.
In contrast, all patients who did not develop ulcerations had the pressure relieved within the first two hours by someone who rotated their body off the spine board.
Researchers in New Orleans demonstrated a direct relationship between the duration spent on a spine board and the development of pressure ulcers within the first eight days of hospitalization. As many as 31 percent of trauma patients will develop pressure ulcers as the result of immobilization on a backboard.
Berg (et al) found that immobilization for periods as short as 30 minutes can produce significant reductions in localized tissue oxygenation in healthy patients. Lerner and Moscoti found that trauma patients spend an average of 64 minutes on a backboard including the time spent in the field. However, if radiographs were required for spinal injury clearance and backboard removal, total backboard time exceed three hours.
Cooney, Wallus, Asaly, and Wojcik found the total time spent immobilized on a backboard can exceed seven hours when EMS first transports patients to a tertiary center and then transfers the patient to a Level 1 trauma center.
Vacuum spine boards
Early in the application process, the splint is soft and malleable. Rescuers can push the beads into the recesses and voids between a patient and the splint. However after withdrawing the air, the splint conforms to the shape of the patient and becomes rigid.
In a side by side comparison with a rigid backboard, the vacuum splint device was judged more comfortable by the patient, was faster for rescuers to apply, and resulted in less body movement in the event the patient required tilting. Healthy volunteers reported significantly less pain at 30 and 60 minutes when immobilized on a vacuum rather than a rigid spine board.
Pressure of about 35 mm Hg applied to the surface of the skin will significantly reduce blood flow through a capillary bed. Interface pressures on good to high quality hospital mattresses vary between 30 and 60 mm Hg.
Researchers using pressure-mapping sensors on 20 healthy volunteers demonstrated that rigid spine boards produce the highest tissue interface pressures at the patient’s scapulae, sacrum, and heels when compared to the use of a standard, soft overlay mattress or a vacuum mattress.
The volunteers also rated the rigid spine board as the least comfortable device. This is consistent with a study by Lovell and Evans that demonstrated tissue interface pressures as high as 147 mm Hg with a rigid spine board, 115 mm Hg when the board was padded, but 37 mm Hg with a vacuum mattress.
The U.S. Army Institute of Surgical Research has designated the vacuum spine board to be the immobilization method of choice during transport of patients suffering from potentially unstable thoracolumbar fractures. Unfortunately, military researchers could not demonstrate a significant reduction in pressure ulceration development associated with vacuum spine board use compared to historical controls using rigid spine boards.
However, more patients in the vacuum spine board group required endotracheal intubation, and thus were motionless for longer periods of time. There are anecdotal reports of awake and oriented patients becoming claustrophobic during prolonged transport while immobilized in a vacuum spine board.
Nonetheless, vacuum spine boards appear to provide a very promising alternative to the rigid spine boards historically used in EMS. These devices immobilize as well as backboards, are more comfortable for the patient, and reduce tissue interface pressures, which may reduce the development of pressure ulcerations resulting from the immobilization procedure itself.
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20. United States Army Institute of Surgical Research. (2012). Joint theater trauma system clinical practice guideline: Spine injury surgical management and transport. Retrieved from http://www.usaisr.amedd.army.mil/assets/cpgs/Cervical_and_Thoracolumbar_Spine_Injury_9_Mar_12.pdf
21. Mok, J. M., Jackson, K. L., Fang, R., & Freedman, B. A. (2013). Effect of vacuum spine board immobilization on incidence of pressure ulcers during evacuation of military casualties from theater. Spine Journal, 13(12), 1801-1808. doi:10.1016/j.spinee.2013.05.028Kenny Navarro is an Assistant Professor in the Department of Emergency Medicine at the University of Texas Southwestern Medical School at Dallas. He also serves as the AHA Training Center Coordinator for Tarrant County College. Mr. Navarro serves as an Emergency Cardiovascular Care Content Consultant for the American Heart Association, served on two education subcommittees for NIH-funded research projects, as the Coordinator for the National EMS Education Standards Project, and as an expert writer for the National EMS Education Standards Implementation Team. Send correspondence concerning any articles in this section to Kenneth W. Navarro, The University of Texas Southwestern Medical School at Dallas, 5323 Harry Hines Blvd MC 8890, Dallas, Texas 75390-8890, or e-mail firstname.lastname@example.org.
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