Brace Yourself.

Spinal immobilisation is a hot topic in the world of trauma and prehospital care at the moment. 

Historically spinal immobilisation (Spinal Motion Restriction, as it's now called) has been one of the main priorities in managing a trauma patient. I mean, we prioritise c-spine along side 'Airway' if you follow the ABCDE assessment algorithm [1,2].

 Ambulance Victoria (AV) Clinical Practice Guidelines (CPGs) document that spinal immobilisation should be provided in patients with a suspected spinal injury. Suspected spinal injury is identified in one of two ways, by mechanism of injury including:

• Ejection from vehicle
• Motorcycle/bicycle impact >30km/h
• Fall from height >3 metres
• Struck on head by falling object >3 metres
• Explosion
• High speed Motor Vehicle Collision(MVC) >60km/h
• Any Pedestrian impact
• Prolonged extrication >30 minutes

or by assessment of risk of injury through considering:

• Physiological Risk of injury
•  >55 Years old
• History of bone disease or muscular weakness disease
• Difficult Patient Assessment
• Acute or chronic altered conscious state
• Drug or Alcohol affected
• Significant distracting injury
• Actual evidence of spinal cord injury
• Spinal column pain/bony tenderness
• Actual evidence of spinal cord injury
• Neurological deficit or changes

However if doubt exists spinal immobilisation is to be provided, and the CPGs are not to be applied to paediatric patients.

The AV CPGs further go on to state that application of a cervical collar alone is not suitable, spinal immobilisation should include the use of head rolls and spine boards [2].

However, research suggests that the application of a rigid cervical collar, and use of long spinal board may have detrimental affects for our patients. Airway access difficulties, raised intracranial pressure and pressure injuries are some of the commonly cited complications of spinal immobilisation [3].

As a rural clinician, the consideration of immobilisation for long periods time is important. Rarely do rural hospitals have Computerised Tomogroaphy (CT) scanners and they are certainly not something that paramedics have access to in the field, so in order to 'clear the spine' it's essential to transport patients to a larger centre for radiological investigations. The use of alternative immobilisation tools other than the famous long spinal board, rigid cervical collar and head blocks such as vacuum mattresses and soft collars should be considered to combat risk of pressure injury associated with long periods of immobilisation [4].  

Whilst variables such as decreased mobility, hypo-perfusion, co-morbidities, and malnutrition are all factors in the increased risk of pressure injury, 'application of medical devices' is a key consideration. Normal measures to protect against pressure areas, such as repositioning and encouragement of mobilisation are not always available to clinicians managing patients subject to spinal immobilisation [5]. 

So, the research suggest that use of these devices should be limited but to what extent?
There exists two criteria based spinal clearance decision tools that can be used to guide clinicians in decisions to use radiological imaging in spinal injury, these algorithms have been successfully used in hospital to 'clear the spine' of conscious patients and appear to be the basis of the Ambulance Victoria spinal injury clearance CPG. 

The Canadian C-Spine Rules and National Emergency X-Radiography Utilisation Study (NEXUS) criteria are widely debated as to the sensitivities each, however both have been determined as highly sensitive in reducing necessary imaging of the cervical spine which contribute to increased time in cervical collars [6]. 

Great, so we have a choice of rules that can be used to potentially clear cervical spines, but what if the rule determines that cervical spinal injury is likely? What interventions do we put in place?

This is where we run into issues. Most research states openly states that further research would be required to determine best practice management for these patients, but alternatives to the aforementioned are not provided. But all is not lost;

The Queensland Ambulance Service has begun using soft cervical collars in response to growing research. The Soft Cervical Collar is applied in-lieu of the Rigid Cervical Collar, however boasts a decreased risk of  Pressure Areas, Increased Intracranial Pressure, Impaired Ventilation, Aspiration and discomfort [7].

International Trauma Life Support (ITLS) advocates for a decrease in use of Long Spinal Boards, stating that they are 'designed to move a patient to a transport stretcher.'. This is a move that has been widely adapted by many Emergency Medical Services (EMS) in the United States [8]. 

Disposal of Spine Boards. (Image credit: Emergency Medical Services of the University of Southern California)

With that, what of the extrication of patients from Motor Vehicle Collisions? It's thought that spinal boards can be used for effective and safe removal of patients from motor vehicles, however there is evidence to suggest that self-extrication (where possible) from a motor vehicle actually increases the amount of movement the cervical spine movement when compared to traditional extraction techniques [9,10].
The anatomy of it all

Basically speaking we know the spinal column consists of the spinal cord and 32 vertebrae that have a distinct curvature, that may be more pronounced in some patients, it comprises of five segments and is the centre for distribution and reception of motor and sensory input and output [11].

The theory that goes with spinal immobilisation comes from long standing practices that state that a fractured bone must be splinted. However splinting the spine against a hard, straight board doesn't accommodate the spines curvature, and strapping a patient to board my in fact result in a forced kyphosis, pain or pressure injury [12]. Vacuum Mattresses should be considered as an alternative to long spine boards, as the allow for natural spinal curves [13].

It appears as though culture around spinal immobilisation is changing, however it takes time to change old habits. For the time being, considerations must be made in relation to the specialist care requirements of those spinally immobilized.

Advocacy to quick imaging or use of the NEXUS or Canadian C-Spine Decision tools is vital, removal of long spine boards (if in use) immediately upon completion of initial assessment & resuscitation phase should also be enforced. 

However your service's policies and procedures surrounding spinal immobilisation, radiological imaging and clearance of cervical spines should be heeded at all times, lobbying for change of policy should be done in adherence to the appropriate service policies.

Alternative use for Spine Boards. (Image source /u/Benutzerkonto, Reddit/r/EMS)

 References: 

[1] Queensland Health, Royal Flying Doctor's Service. (2013). In Primary Clinical Care Manual. Retrieved May. 25,  2015, from http://www.health.qld.gov.au/pccm/pdfs/pccm-pt-assess-transport.pdf 

[2] Ambulance Victoria,. (2013). Clinical Practice Gidlines.   

[3] Smyth, M., & Cooke, M. W. (2013). Value of a rigid collar: in need of more research and better devices. 

Emergency Medicine Journal, 30(6), 516. doi:10.1136/emermed-2012-201413

[4] Moss, R., Porter, K., & Greaves, I. (2015). Minimal patient handling: a Faculty of Pre-hospital Care consensus statement*. Trauma, 17(1), 70-72. doi:10.1177/1460408614556439 

[5] Pressure ulcers in cervical spine immobilisation: a retrospective analysis. (2012). Journal of Wound Care, 21(7), 323-326.

[6] Michaleff, Z. A., Maher, C. G., Verhagen, A. P., Rebbeck, T., & Lin, C. C. (2012). Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ: Canadian Medical Association Journal, 184(16), E867-E876. doi:10.1503/cmaj.120675

[7] (2015). Clinical Practice Procedure: Cervical Collar. [Brochure]. Queensland:Queensland Ambulance Service.

[8] A, Roy, and Darby. C. (2014). Long backboard use for spinal motion restriction of the Trauma Patient. International Trauma Lide Support

[9] Dixon, M., O'Halloran, J., & Cummins, N. M. (2014). Biomechanical analysis of spinal immobilisation during prehospital extrication: a proof of concept study. Emergency Medicine Journal, 31(9), 745-749. doi:10.1136/emermed-2013-202500 

[10] Hauswald, M. (2013). A re-conceptualisation of acute spinal care. Emergency Medicine Journal, 30(9), 720-723. doi:10.1136/emermed-2012-201847 

[11] Sarhan, F., Saif, D., & Saif, A. (2012). An overview of traumatic spinal cord injury: part 1. Aetiology and pathophysiology. British Journal Of Neuroscience Nursing, 8(6), 319-325  

[12] Bledsoe, B. E. (2013). The Evidence Against Backboards. EMS World, 42(8), 42-45. 

[13] D, L. M., & L, W. J. (2003). Comparison of a long spinal board and vacuum mattress for spinal immobilisation. Emergency Medicine Journal, 20(5), 476-8