1. Spinal Motion Restriction
Modernizing Our Management of Injured Patients
A Valley Medical Directors Collaboration

2. Objectives Historical perspective
Understand injury based on biomechanical principles
Review current evidence
Learn spinal motion restriction concept

3. Historical Perspective
Clinical Suspicion = IMMOBILIZE
Any Trauma Above Clavicles = IMMOBILIZE
Not Sure = IMMOBILIZE
Fear of Punishment = IMMOBILIZE
Don’t Feel Like Checking = IMMOBILIZE
For the past 30 years, EMS providers were taught to have a very low threshold to apply spinal immobilization. Most EMS textbooks emphasis “mechanism;” what happened to vehicle, guess how far a person has fallen. Mechanism essentially trumped the patient interview and physical exam.
As recently as 2005, a major review article stated “historically, it is estimated that up to 25% of SCI maybe aggravated at the initial insult, either during transport or early in the course of treatment. It should be mentioned that these data are more than 20 years old, and no data are available from actual studies. Careful movement and the use of appropriate extrication techniques are crucial in all trauma patients with spinal cord injury (SCI) or in mechanisms of injury with the potential to cause spinal injury and SCI. Immobilization of the entire spine is a management priority and should be undertaken in a systemic fashion.”
Because of this mindset, based on outdated, unproven theory, some have used SI as a replacement for a thorough exam, thinking CYA, while simultaneously attempting to reduce work for themselves. Complacency.

4. Historical Perspective
How bad is it?
> 50% of trauma patients with no complaint of back/neck pain get full spinal immobilization
13% get immobilized without being asked about pain

5. The Facts
1-5 million EMS patients per year with suspected c-spine injury
2% have a fracture
1% develop neuro deficits

6. Why Do We Do It?
To avoid further patient injury caused by us during movement and transport
Focus is on stopping gross visible spinal movement
Patient packaging stops movement
No movement = spine, cord, and patient are safer, right???
The generally accepted theory of further neurological deterioration after the initial injury is that visible movement of the spine is an adequate measure for movement at the injured site; we worry that movement at the injured site causes unstable segments or sharp bony fragments to cut the cord.
How do we actually know if any of this is true? We design studies to prove it.

7. Evidence Is Weak Large meta-analysis on spinal immobilization
“Effect on mortality, neurologic injury, spinal stability… uncertain.”
“possibility that immobilization may increase mortality and morbidity cannot be excluded”
In 2001, a group of medical researchers performed a meta-anaylsis. This type of study is when investigators combine all the results of several similar individual studies that previously asked the same or similar research question. In this case, the researchers looked for all studies around the world that looked at the effects of spinal immobilization (including immobilizing versus not immobilizing) on mortality, neurologic disability, spinal stability, and and negative effects on trauma patients. They tried to find any high-quality randomized controlled trials on these subjects, but FOUND NONE.

8. Evidence is Weak
Hauswald, et al. This study was a retrospective chart review comparing patient outcomes between University of New Mexico and University of Malaya. All patients with acute blunt traumatic spine injuries were transported directly from the injury site to the hospital. None of the 120 patients seen a the University of Malaya had immobilization during transport, but all of the 334 patients seen at UNM did. The hospitals were comparable in physician training and clinical resources. Neuro injuries were deemed either disabling or non-disabling. Patients in Malaysia were TWICE as likely to have LESS disability than the UNM patients. Stated another way, this meant that there was less than a 2% chance that immobilization has any beneficial effect.
Criticisms of this study: not powered enough to catch differences in the groups due to small sample size, less MVCs in Malaysia, groups not matched in severity for their non-spinal injuries, data did not include the types of spinal fractures found.

9. What Really Matters? Visible movement is only one threat What about…
Pulmonary function compromise
Risk of aspiration/airway compromise
Increased intracranial pressure
Delays in transport
Concealment of other injuries
Soft tissue ischemia/necrosis
Cost of unnecessary diagnostics
The truth is that further movement of the injured spine or spinal cord is just one threat to your trauma patient.
What about the other threats like the ones listed here? This list is made up of all the threats to your patients that have actually been PROVEN to occur when you apply spinal immobilization to a patient. Remember that only about 2% of these patients will have spine fractures and only 1% develop neuro deficits. Is it ok to subject the other 98% of patients to all these potential complications?

10. Column and Cord Movement
Significant amount of force needed to break bone and tear ligament
Subsequent movement by EMS is less than force required to cause damage
The spine consists of a complex structure of interlocking and reinforcing vertebral bodies and intervertebral disks all held together by self-reinforcing ligaments and muscles. These components fail at about the same level of force. The majority of trauma patients will either experience minor injuries or catastrophic irreversible injuries. Neither of these populations will benefit from EMS spinal immobilization processes at all.
It takes significant force to produce component failure in the spine. Specifically, it takes about Newtons of force to fracture the cervical spine. By comparison, hanging a 4 kg head off the end of a treatment table generates about 40 Newtons.
Subsequent force and energy deposition produced by EMS movement is several orders of magnitude less than the force required to cause new damage or worsen pre-existing damage. As such, experts argue that cord damage occurs only at the time of initial impact. Energy deposition during emergency treatment and extrication after impact that we try to prevent using SI are not sufficient to cause more injury.

11. Column and Cord Movement
Normal range of motion = non-destructive distortion
Movement within normal range requires almost no energy
Resistance to movement within normal range is essentially zero
No such thing as “less than zero”
Here is the basic biomechanical concept of the human spine: normal range of motion is defined as “the amount of non-destructive distortion tolerated by spine and soft tissues.” It requires almost no energy to move the spine within the normal range of motion Since resistance to movement is essentially zero in uninjured segments of the spine, resistance CANNOT be significantly less than zero in injured areas of the spine. You can’t have “less than zero” resistance. In fact, resistance to movement is generally greater in the injured segments of the spine.

12. Column and Cord Movement
Viscoelastic tissues of spine stiffen and spasm post-injury
Swelling increases preload on intact ligaments
Locked facets and bone-on-bone impingements functionally immobilize spine
Normal patients “self-splint” to avoid pain
Why is resistance generally greater in the injured areas? It is greater due to preloading of tissues by edema, spasm, and mechanical impingement from bony structures.
The bottom line is that it is only when the normal range of motion is exceeded that excess energy can cause tissue destruction at damaged spinal segments and unwanted force is applied to the injured site.

13. Column and Cord Post Injury Deterioration
Tissue hypoxia (local/global)
Direct contusion
Biochemical cascade, cell death
Generally speaking, when it comes to trauma, our most important job will be to reduce tissue hypoxia for the entire patient, certainly the entire central nervous system, of which the spinal cord is only one part. This requires sophisticated comprehensive care of the patient, including possible advance airway management, blood transfusion, and surgical intervention. Most of this comprehensive care can only happen in the hospital.

14. Column and Cord Post Injury Deterioration
Mitigated by getting to definitive care FAST
EMS focus should be reducing delays
Patient packing with full SI is a potential delay
The way you curtail tissue hypoxia the most will be to transport rapidly and safely to definitive care. Stated another way, you should work most to minimizing delays in transport. Spinal immobilization on the wrong patient might be one of those delaying factors. We already get that immobilization will not improve irreversible damage and it cannot make intact spines and more safe. But even patients with the unstable spine injury can be potentially harmed by delays in reaching definitive care. Also, patients with unstable injuries are often going to have other critical, time-sensitive injuries. So, we have to honestly consider the potential harm caused by SI as we consider the potential benefit.

15. Summary We immobilize way too many patients
Most injured patients will be mechanically stable
Totally unstable patients probably have maximum damage at time of impact
All immobilized patients can be potentially harmed
So, we summarize the first part of this discussion:
Spinal immobilization is significantly over utilized.
Most injured patients are mechanically stable enough that only significant addition force will create more damage.
Those few patients whose injuries are so unstable, to the point that there is literally ZERO resistance to further movement compared with uninjured segments, probably suffered irrevocable damage during the initial impact.
The bottom line is that everyone subject to collar and backboard has the potential to be harmed.

16. Spinal Immobilization
SI is a method of transport, not a therapy
SI is a misnomer
Just say “no” to the standing takedown
“Spinal Motion Restriction”
Reducing of gross movement
Prevention of duplicating damaging mechanism
There really is no such thing as “spinal immobilization.” Cervical collars and rigid and constricting; smooth spine boards might minimize visible movement, but they do so by transferring force, often distracting force, to other areas of the spine. Patients are prone to slip motion on smooth spine boards; this can cause worse spine motion when the head and neck are fixed in place. Standard extrication techniques used by EMS personnel can cause up to 4x more cervical spine movement than controlled self-extrication by the patient.
The ritualized standing takedown is probably the worst example of nonsensical practice. First of all, if the patient is ambulatory, it automatically makes it very unlikely that he has suffered an unstable injury. Secondly, strapping a standing patient to a backboard and then laying it flat causes significant distracting force along the entire spine. This practice should never be used.
With this understanding, we introduce the new nomenclature of spinal motion restriction - to remind us that everything we do while we handle the patient, causes spinal movement, but movement with minimal force and minimized, dissipated energy is highly unlikely to cause further harm.

17. Just To Be “Safe” SI harms patients
Cannot justify an intervention known to do harm just for small possibility of benefit
Simple risk/benefit decision
Not convinced yet? You may tell yourself: but I just don’t want screw up even once and be blamed for that one bad outcome; immobilization has to be in the best interest of the patient regardless; it’s the safe and conservative thing to do.
This is simply not true. We do not know that any SI techniques actually help. But we have proven that it hurts - in several ways. You cannot mindlessly apply an intervention that is known to do harm when the chance of benefit is theoretical at best. That is not how medicine works.

18. How Does SI Hurt? Cervical collars Proven to increase ICP
Produce axial distracting force
Transfer force to ends
Obscure neck injuries
Make airway management more difficult
When applied to the patient, a cervical collar can cause vascular obstruction of blood draining from the brain. This effect was prospectively observed in the study published in The authors tested standard Stifneck rigid collars on injured patients requiring ICP monitoring. They observed a mean rise in ICP of 4.5 mm Hg. At the same time, mean arterial pressure was not changing significantly, so they new this rise was specifically from distortion of venous drainage in the neck.

19. How Does SI Hurt? Rigid long back boards Cause iatrogenic pain
Cause 15-20% reduction in respiratory capacity
Causes delays in transport
Possible risk o pressure ulcers
It has been proven that backboards cause neck and back pain in previously asymptomatic patients; clinically this often results in the ordering of costly diagnostic testing that initially may not have been necessary. Studies have shown that spinal immobilization in a supine position results in a reduction of respiratory capacity by as much as 15-20% and furthermore, respiratory effectiveness is markedly reduced by commonly used restraint systems. We all know that spinal immobilization takes time and multiple personnel. Delays in transport are known to worsen outcomes for critically ill trauma patients. Rigid backboards are known to cause elevations in tissue interface pressure enough to potentially cause pressure necrosis (aka decubitus ulcers); this risk is highest in the patient who is numb from spinal cord injury and cannot feel pain from a pressure spot.

20. Backboards Still reasonable for… Blunt trauma with ALOC
Spine pain/tenderness and neuro complaint
Anatomic deformity of spine
High-energy mechanism with ALOC, distracting injury, inability to communicate

21. How Does SI Hurt? Penetrating trauma victims NNT = 1,032 NNH = 66
So how about victims of penetrating trauma? Well, Elliot Haut and colleagues looked at over 45,000 patients using the National Trauma Data Bank. They found mortality to be twice as high in the immobilized group compared to those not immobilized. Only 30 patients, 0.01% had an incomplete cord injury and needed operative spine fixation. The number needed to treat with spinal immobilization to potentially benefit one patient was 1,032. The number needed to harm with spinal immobilization to potentially contribute to one death was 66.
*NNT is a measure used in testing the effectiveness of a medical treatment (in this case, spinal immobilization). It is the average number of patients who need to be treated in order to prevent one additional bad outcome (the number needed to be treated to actually benefit one person). The higher the number, the less effective is the treatment.
*NNH is the number of patients that need to be exposed to a risk factor (in this case spinal immobilization) in order to actually harm one personal that otherwise would not have been harmed. The lower the number, the worse the risk factor.

22. How Does SI Hurt? “Time Zero” Myth
Patient evaluation and treatment does not begin at the exact time of arrival to the ED
What about time spent by the patient in spinal immobilization? Patients are not supposed to remain on back boards. However, we know both through personal experience and medical studies that patients might remain immobilized for substantial amounts of time after they arrive to the ED. At the very least, they have to be seen by a provider and examined before removal, but some locations might have protocols stating that removal can only take place after radiographic imaging. That could mean hours on a backboard.

23. Now What? Allow EMS to selectively immobilize
Allow EMS to use the least amount of package needed for safe transport
Monitor outcomes

24. Empowering EMS Several studies show EMS capable of deciding
Tools derived from NEXUS and CCR
*NEXUS and CCR are the National Emergency X-Ray Utilization Study and Canadian C-Spine Rule; two of the most respected and largest studies on clearing c-spines and considered the gold standard used by doctors. Our new protocol, like many other similar protocols used around the USA are derived from these two studies.
Warning: of the studies showing that EMS is capable of selectively immobilizing trauma patients safely, the few patients that were found with missed injuries were because of protocol violations or extremes of age (elderly and very young).

25. Spinal Motion Restriction

26. SMR - Blunt Adult Walk through entire decision-tree.
Highlight the bold language in “High-Risk Characteristics/Mechanisms” box. These are different from the peds version. Trauma triage criteria appears on next slide.
Highlight the “Low-risk Characteristics/Mechanisms” box. These are not meant to automatically allow omission of SMR, just to help guide a decision by the EMT and help the EMT document why the decision was made.
Highlight “unreliable patient interactions” box.
Highlight “Motor/sensory exam” box. The exam will be shown in detail on video.
Adult

27. Review the dangerous mechanisms from the adult Trauma Triage page
Review the dangerous mechanisms from the adult Trauma Triage page. For adults, these mechanisms justify the use of SMR.

28. SMR - Penetrating Adult Walk through entire decision-tree.
Highlight concept of patient with both penetrating and blunt injury - this patient should be handled with SMR-Blunt protocol.
Differentiate the patient with FOCAL neuro deficit, like arm paralysis after being stabbed in the spine, from patient with global neuro dysfunction (ie, comatose) from GSW to the brain. The second patient will not benefit from SMR.
Adult

29. SMR - Blunt Peds Pediatric differences highlighted in red boxes.
CAREFULLY highlight the differences in “High-risk caracteristics/mechanisms” box. Lots more weigh placed on MVC factors in pecs patients compared to adults.
EMPHASIS on additional exam step checking neck range of motion. If a peds patient does not show voluntary range of motion due to pain, you should apply SMR. This is not necessarily true of adults.
EMPHASIZE that the “Low-risk characteristics/mechanisms” box is NOT INCLUDED for pecs because there is no medical evidence to verify their accuracy in children.
Peds

30. SMR - Penetrating
This is totally the same as adults.
Peds

31. Backboards Still reasonable for… Blunt trauma with ALOC
Spine pain/tenderness and neuro complaint
Anatomic deformity of spine
High-energy mechanism with ALOC, distracting injury, inability to communicate
One more time… review this consensus-based list.

32. What About the Equipment?
Scoop stretchers same or superior than log roll and lift-and-slide techniques
Kendrick devices, short boards?
Self-extrication with collar may be better, but ONLY for normal, reliable patients
Plug for scoop stretchers. It is our hope that all agencies will convert to scoop stretchers as primary tool and use backboards as an extrication tool only when necessary.

33. What About the Equipment?

34. What About the Equipment?
“Backboards are like spatulas; at some point that burger has to be put on a bun…”
Backboards are an extrication tool, not a medical treatment.

35. This is the Procedures page of the new SMR algorithm.
Highlight areas in red.
Fowler’s position means sitting up at close to 90 degrees. Semi-folwer’s is sitting up sat any angle between totally supine and 90 degrees.
It is considered acceptable to use a back board to move patient from scene to ambulance gurney, then remove board using a lift-slide technique, leaving patient on gurney pad with appropriate safety belts, c-collar in place, along with appropriate supplemental padding. Leave patient on back board if time is limited or based on provider judgement.

36. Backboards Still reasonable for… Blunt trauma with ALOC
Spine pain/tenderness and neuro complaint
Anatomic deformity of spine
High-energy mechanism with ALOC, distracting injury, inability to communicate
One more time… review this consensus-based list.

37. Procedures page, continued.

38. Spinal Immobilization Algorithm: Blunt Trauma
Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. 69
Spinal Immobilization Algorithm:
Blunt Trauma
Altered level of consciousness (GCS less than 15) No
Yes
IMMOBILIZE
Rapid transport
Spinal pain or tenderness? or
Neurological deficit or complaint?
Anatomic deformity of spine?
Concerning mechanism of injury?
(Cont’d)
Reminder that SMR is not new. This is already taught in PHTLS!

39. Spinal Immobilization Algorithm: Blunt Trauma (Cont’d)
Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. 71
Presence of:
Evidence of alcohol/drugs or
Distracting injury
Inability to communicate
Concerning Mechanism of Injury No
Yes
IMMOBILIZATION NOT INDICATED
Rapid transport
Transport
IMMOBILIZE
Spinal Immobilization Algorithm:
Blunt Trauma (Cont’d)
This PHTLS algorithm, originally authored by Maricopa’s Jeff Salomone, was published back in This concept is supported by NAEMT, National Association of EMS Physicians, and the American College of Surgeons, Committee on Trauma.

40. ED Transfer of Care
Helpful to discuss with ED why you decided to package or not package patient
Share your information and decision-making
Patient packaging no longer a contextual clue to guide radiography needs
ED providers will have to independently re- examine and decide if radiography indicated

41. Interfacility Transfers
Medical directors need to reconsider protocols
How is first hospital “clearing?”
Crews should independently examine patients
Implications of GCS < 15?
Collar reasonable, but rigid long board???
Other ways to “puts handles on a patient”
It may be healthy to take a “trust no one” approach when receiving a patient for transfer to another facility, but taking backward steps to re-apply a rigid backboard cannot be justified with the evidence reviewed here. EMS collars are also not intended for use beyond the pre-hospital and ED setting. The best method may be to stock and apply rehabilitation collars such as the Philadelphia collar (if the crew feels this is absolutely necessary) and using a sheet transfers from hospital gurney to mobile gurney for ambulance or aircraft transport. Find other tools aside from rigid backboards to “put handles on the patient,” especially with intubated or paralyzed patients.

42. SMR Video

43. Thank You! Valley Medical Directors Jim Morrissey, Alameda County EMS
Jerry Schirmer, Laura McElhatten, Mark Jones, Mesa Fire/Medical EMS Division, Charlie Foster, Amy Gaber
MFMD 204-A, CFD E286-C and R286-C
SWA SW208
SFD E601-A, P608

44. Spinal Motion Restriction
Questions?
Modernizing Our Management of Injured Patients
A Valley Medical Directors Collaboration