Spinal Immobilization Erin Burnham, MD - erinburner@gmail.com

To Cspine or not to Cspine? That is the Question!

Framework for Discussion Who should be immobilized? How should they be immobilized? How can we Assure Quality?

Who should be immobilized?

Goal Clearing C-spine in the field?

Case: 78 yo male An 78 yo male brought in Code-3 by EMS after cardiac arrest. Dispatched for “possible heart attack”. Hx: Had been fishing that morning with son with no complaints. Stood up from recliner chair and collapsed onto ground.

Case: 78 yo male Paramedics found patient apneic, pulseless EKG showed V-fib Patient was successfully defibrillated in field with ROSC.

Case: 78 yo male Pt arrives in ED in NSR, intubated with no spontaneous respiratory effort. He is placed in C-collar in ED because noted to have contusion on forehead.

Case: 78 yo male CT scan of head is normal CT scan of C-spine revealed type II odontoid fracture with displacement EKG and labs unremarkable

Case: 78 yo male Family elects to have patient extubated, and he expires in ED Would pre-hospital immobilization have effected outcome? Medico-legal liability?

Case: 49 yo male Motorcycle vs Deer Speed estimated at 45 mph. Patient can’t remember exactly what caused accident, but EMT’s find dead deer nearby. Was wearing full leathers/helmet He was not intoxicated

Case: 49 yo male Only c/o L. Shoulder pain Patient arrives not in spinal immobilization Placed in c-collar in ED L. Scapula fracture, 2 rib fractures and small L. PTX identified

Case: 49 yo male CT head and C-spine obtained CT head is normal C-5 transverse process fracture identified

Case: 49 yo male Fracture is stable and doesn’t effect his outcome He is transferred to a trauma center Uneventful recovery Out windsurfing a few weeks ago

Goal Clearing C-spine in the field? Provide clear, simple and safe guidelines for prehospital spinal immobilization.

Why should we immobilize patients?

Why immobilize? 253,000 people in US living with spinal cord injuries 12,000 new cases each year In US, cost of MVC related SCI estimated $34.8 billion per year 5 million patients in the US receive spinal immobilization each year Spinal Cord Injury Information Network (www.spinalcord.uab.edu)

Epidemiology 77.8% males Average age of injury is increasing: 28.7 yo in 1970’s 39.5 yo in 2005 Spinal Cord Injury Information Network (www.spinalcord.uab.edu)

Epidemiology MVC - 42% Falls - 27% Violence - 15% Sports - 7.4% Spinal Cord Injury Information Network (www.spinalcord.uab.edu)

Why immobilize? Why immobilize? AANS 2001 Guidelines for Pre-Hospital Cervical Spinal Immobilization following trauma: “There is insufficient evidence to support treatment standards” “There is insufficient evidence to support treatment guidelines.” American Association of Neurological Surgeons, 2001

Why immobilize? Why immobilize? “It is estimated that 3 to 25% of spinal cord injuries occur after the initial traumatic insult”: During extrication During transit American Association of Neurological Surgeons, 2001

Why immobilize? Why immobilize? Over the last 30 years there has been a dramatic improvement in the neurologic status of spinal cord injured patients arriving in the emergency department. 1970’s - 55% complete neurologic lesions 1980’s - 49% American Association of Neurological Surgeons, 2001

Why immobilize? Why immobilize? What about NHTSA? “This has been attributed to the development of Emergency Medical Services initiated in 1971, and the pre- hospital care (including spinal immobilization) rendered by EMS personnel. What about NHTSA? American Association of Neurological Surgeons, 2001

1999 NAEMSP Position Paper INDICATIONS FOR PREHOSPITAL SPINAL IMMOBILIZATION Robert M. Domeier, MD, for the National Association of EMS Physicians Standards and Clinical Practice Committee http://www.naemsp.org/pdf/spinal.pdf

1999 NAEMSP Position Paper “There have been no reported cases of spinal cord injury developing during appropriate normal patient handling of trauma patients who did not have a cord injury incurred at the time of the trauma.” http://www.naemsp.org/pdf/spinal.pdf

1999 NAEMSP Position Paper “Although early emergency medical literature identified mis-handling of patients as a common cause of iatrogenic injury, these instances have not been identified anywhere in the peer-reviewed literature and probably represent anecdote rather than science.” http://www.naemsp.org/pdf/spinal.pdf

1999 NAEMSP Position Paper Spine immobilization is indicated with a significant mechanism of injury and at least one of following criteria: Altered mental status Evidence of intoxication A distracting painful injury (e.g. Long-bone extremity fracture) Neurologic deficit Spinal pain or tenderness

1999 NAEMSP Position Paper Caveats: Language or communication barriers Extremes of age Difficult to assess intoxication in field Variable interpretation of spinal pain or tenderness http://www.naemsp.org/pdf/spinal.pdf

Why shouldn’t we immobilize everyone?

Adverse Effects of Spinal Immobilization Time Compliance Nausea/aspiration Pain/unhappiness Increased MD workup bias Ulcers Impaired ventilation Increased ICP

Kwan, et al 2004 Effects of Prehospital Spinal Immobilization: A Systematic Review of Randomized Trials on Healthy Subjects Irene Kwan, MSc;1 Frances Bunn, MSc2 http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf

Kwan, et al 2004 2004 Cochrane Review Systematic review of 17/4453 randomized controlled trials comparing types of spinal immobilization devices http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf

Kwan, et al 2004 Adverse effects of spinal immobilization included: Significant increase in respiratory effort Skin ischemia Pain/discomfort http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf

ATLS 2008 Several studies have shown correlation between the length of time on a rigid spine board and the development of pressure ulcers. “A paralyzed patient who is allowed to lie on a hard board for more than 2 hours is at high risk for serious decubitus ulcers.” 2008 ATLS Course Manual, 8th edition

Increased ICP Cervical collars have been associated with elevations of intracranial pressure (ICP) Prospective study of 20 patients Rigid Philadelphia collar Significant (p = .001) increase in ICP from 176.8 to 201.5 mm H20 Kolb, et al, Ann Emerg Med. 1999; 17:135-137

NEXUS National Emergency X-Radiography Utilization Study Prospective, multi-hospital Cervical spine clearance if no Intoxication Distracting injury Neuro deficit Midline spine tenderness 34,069 at risk for cervical fracture from blunt 818 (2.4%) cervical spine injuries Missed 8 (99% sensitive, 12% specific) Good confidence intervals (98-99.6%) Only 2 injuries deemed clinically significant Hoffman, et al, NEJM, July 13, 2000, Vol. 343, No. 2; p. 94 - 99

Pediatric Cervical Spines 3065 (9%) of NEXUS patients were <18 years 0.98% cervical spine injury No SCIWORA Decision rule 100% sensitive Confidence intervals 87-100% Viccellio, et al, Pediatrics, Aug 2001, Vol. 108, No. 2

Vaillancourt, et al 2009 The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics Ann Emerg Med. 2009;54:663-671

Vaillancourt, et al 2009 Prospective cohort study Alert and stable trauma patients Advanced and basic care paramedics interpreted rule All were then immobilized and evaluated in ED Ann Emerg Med. 2009;54:663-671

Vaillancourt, et al 2009

Vaillancourt, et al 2009 1,949 patients Paramedics classification showed: 100% sensitivity 37.7% specificity Ann Emerg Med. 2009;54:663-671

Vaillancourt, et al 2009 Paramedics conservatively misinterpreted the rule in 320 (16.4%) Paramedics were comfortable applying the rule in 1,594 (81.7%) Ann Emerg Med. 2009;54:663-671

Vaillancourt, et al 2009 Application of the criteria could have reduced 731 (37.7%) out-of-hospital immobilizations. Ann Emerg Med. 2009;54:663-671

Vaillancourt, et al 2009 Conclusion: Paramedics can apply the Canadian C-spine rule reliably without missing any important cervical spine injuries. Ann Emerg Med. 2009;54:663-671

Methods of Immobilization

ATLS 2008 “Cervical spine injury requires continuous immobilization of the entire patient with a semirigid cervical collar, head immobilization, backboard, tape, and straps before and during transfer to a definitive-care facility.” 2008 ATLS Course Manual, 8th edition

Kwan, et al 2004 The following methods were efficacious in restricting movement: Collars Spine boards Vacuum splints Abdominal/torso strapping http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf

Neutral Postion The “neutral position” is poorly defined: “The anatomic position of the head and torso that one assumes when standing and looking ahead” 12° of cervical spine extension on lateral radiograph American Association of Neurological Surgeons, 2001

Neutral Postion “McSwain et al determined that more than 80% of adults require 1.3 cm to 5.1 cm of padding to achieve neutral positioning.” This appears to be a reference to PHTLS text American Association of Neurological Surgeons, 2001

Quality Assurance

1999 NAEMSP Position Paper “Currently, spinal immobilization is often performed based only on the mechanism of injury without consideration of the patient’s symptoms and physical findings.”

1999 NAEMSP Position Paper “EMS systems adopting procedures for clearance from prehospital spinal immobilization must develop mechanisms for education and quality improvement to ensure safe and appropriate use of clearance protocols.”

Goal Clearing C-spine in the field? Provide clear, simple and safe guidelines for prehospital spinal immobilization.

Quality Assurance Protocol should be: Clear Simple Safe

Quality Assurance System should ensure: Efficacy Compliance

Myers et al, 2009 Retrospective study 2 gold standards: Radiographic findings Physician clearance without x-ray Myers, et al, Int J Emerg Med 2009; 2:13-17

Myers et al, 2009 Guideline allows exclusion of spinal immobilization if: No pain, stiffness, soreness or tenderness in the neck or back No alteration in LOC No intoxication No other painful or distracting condition No signs or symptoms of shock Myers, et al, Int J Emerg Med 2009; 2:13-17

Myers et al, 2009 Included 942 patients 384 did not meet criteria for clearance 36 (9.4%) had fractures 558 patients met criteria for clearance 7 (1.3%) had fractures Myers, et al, Int J Emerg Med 2009; 2:13-17

Myers et al, 2009 When immobilization was indicated Caregivers were 77.6% compliant Myers, et al, Int J Emerg Med 2009; 2:13-17

Myers et al, 2009

Myers et al, 2009 The median age of the fractures that were immobilized was 48 years The median age of the 7 fractures not immobilized was 82 years An age extreme criteria may enhance this guideline Myers, et al, Int J Emerg Med 2009; 2:13-17

Protocols for Immobilization

Columbia Gorge Protocol SPINAL STABILIZATION Trauma patients with the following injuries or signs/symptoms should be treated with full spinal immobilization. Head or facial injury Decreased level of consciousness Head, neck or back pain, consider spinal stabilization. Any patient meeting the trauma system criteria The level of treatment given other patients will be left to the discretion of the senior EMT. The mechanism of injury should be considered in this decision. This protocol is not intended to discourage the use of full spinal immobilization on any patient. Consider padding the upper half of the board for patient comfort if time and circumstances permit.

Multnomah County Protocol Selective Spinal Immobilization Immobilize  using  a  long  spine  board  if  the  patient  has  a  mecha nism  with  the  potential  for causing  spinal  injury  and  meets  ANY  of  the  following  clinical  cri teria:                       A.  Altered  mental  status. B.  Evidence  of  intoxication. C.  Distracting  pain/injury  (extremity  fracture,  drowning,  etc.). D. Neurologic deficit (numbness, tingling or paralysis) E.  Spinal  pain  or  tenderness. F.  Distracting  situation  (communication  barrier,  emotional  distr ess,  etc.).

State of Jefferson Protocol SPINAL IMMOBILIZATION First Responder, EMT-B, EMT-I, EMT-P INDICATIONS: Patients with a risk of cervical, thoracic, or lumbar spine injury based on mechanism of injury and findings of spinal pain, tenderness or neurologic abnormality. PROCEDURE: For actual or suspected penetrating trauma of the spine, then spinal immobilization indicated For blunt trauma with mechanism for spinal cord injury, then spinal immobilization if any of the following are answered “yes”:

Jackson County Protocol Criteria Yes No Age < 10 years or > 65 years Altered mental status or loss of consciousness Significant mechanism of injury, such as high speed motor vehicle crash axial loading rollover motor vehicle crash fall from greater than standing height Evidence of intoxication Distracting injury, such as significant fracture or laceration Neurological deficit Midline spine pain (subjective) Midline spine tenderness (objective) EMT suspects spinal cord injury based on mechanism, history or exam findings. Pain with active neck rotation or active ROM of neck rotation limited to < 45º If any answer is “yes”, then spinal immobilization indicated.

Case: 78 yo male Age < 10 years or > 65 years Altered mental status or loss of consciousness Evidence of intoxication Significant mechanism of injury, such as high speed motor vehicle crash, axial loading, rollover motor vehicle crash, fall from greater than standing height Distracting injury, such as significant fracture or laceration Neurologic deficit Midline spine pain Midline spine tenderness EMT suspects spinal cord injury based on mechanism, history or exam findings Pain with active neck rotation or active ROM of neck rotation < 45°

Case: 49 yo male Age < 10 years or > 65 years Altered mental status or loss of consciousness Evidence of intoxication Significant mechanism of injury, such as high speed motor vehicle crash, axial loading, rollover motor vehicle crash, fall from greater than standing height Distracting injury, such as significant fracture or laceration Neurologic deficit Midline spine pain Midline spine tenderness EMT suspects spinal cord injury based on mechanism, history or exam findings Pain with active neck rotation or active ROM of neck rotation < 45°

Jackson County Protocol Criteria Yes No Age < 10 years or > 65 years Altered mental status or loss of consciousness Significant mechanism of injury, such as high speed motor vehicle crash axial loading rollover motor vehicle crash fall from greater than standing height Evidence of intoxication Distracting injury, such as significant fracture or laceration Neurological deficit Midline spine pain (subjective) Midline spine tenderness (objective) EMT suspects spinal cord injury based on mechanism, history or exam findings. Pain with active neck rotation or active ROM of neck rotation limited to < 45º If any answer is “yes”, then spinal immobilization indicated.

Discussion

Discussion Who should be immobilized? How should they be immobilized? How can we Assure Quality?