1. Spinal Immobilization
Erin Burnham, MD -

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

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

4. Who should be immobilized?

5. Goal
Clearing C-spine in the field?

6. 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.

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

8. 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.

9. 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

10. 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?

11. 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

12. 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

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

14. 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

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

16. Why should we immobilize patients?

17. 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 (

18. 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 (

19. Epidemiology MVC - 42% Falls - 27% Violence - 15% Sports - 7.4%
Spinal Cord Injury Information Network (

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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.”

26. 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.”

27. 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

28. 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

29. Why shouldn’t we immobilize everyone?

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

31. 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

32. Kwan, et al 2004 2004 Cochrane Review
Systematic review of 17/4453 randomized controlled trials comparing types of spinal immobilization devices

33. Kwan, et al 2004 Adverse effects of spinal immobilization included:
Significant increase in respiratory effort
Skin ischemia
Pain/discomfort

34. 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

35. 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 to mm H20
Kolb, et al, Ann Emerg Med. 1999; 17:

36. 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 ( %)
Only 2 injuries deemed clinically significant
Hoffman, et al, NEJM, July 13, 2000, Vol. 343, No. 2; p

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

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

39. 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:

40. Vaillancourt, et al 2009

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

42. 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:

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

44. 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:

45. Methods of Immobilization

46. 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

47. Kwan, et al 2004
The following methods were efficacious in restricting movement:
Collars
Spine boards
Vacuum splints
Abdominal/torso strapping

48. 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

49. 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

50. Quality Assurance

51. 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.”

52. 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.”

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

54. Quality Assurance
Protocol should be:
Clear
Simple
Safe

55. Quality Assurance
System should ensure:
Efficacy
Compliance

56. 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

57. 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

58. 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

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

60. Myers et al, 2009

61. 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

62. Protocols for Immobilization

63. 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.

64. 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.).

65. 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”:

66. 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.

67. 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°

68. 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°

69. 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.

70. Discussion

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