Spinal Immobilization

Terry O’Connor

Indications:

The risk, benefits, and latest evidence regarding the decision to perform spinal immobilization have been reviewed previously here.

For review, we generally recommend a focused spinal assessment in making the decision to perform spinal immobilization. This helps to determine if spinal precautions, such as c-collar, head-blocks and a backboard are necessary for evacuation.  Based on the NEXUS criteria and informed by the Canadian C-Spine rules, the Focused Spinal Assessment is performed in patients who had a mechanism significant for possible spinal injury. When performing a patient assessment, you can consider releasing spinal precautions if your patient meets the following criteria on a re-examination:

1) No altered mental status / GCS 15

2) No thoracic distracting injury

3) No focal neurologic deficit

4) No pain or tenderness along the spine.

For the wilderness setting, a similar guideline has been recently proposed. The treatment algorithm was specifically calibrated so as to minimize risk of exacerbating a potentially unstable spine injury weighed against the risks to rescuers and victim in the austere setting. 

Further research is still warranted to better classify appropriate indications, validate guidelines, and to further assess the risk-benefit ratio for spinal immobilization in the wilderness.

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Cervical Spine Immobilization Technique

 The goals of C-spine immobilization are to minimize movement and maintain a “neutral” alignment. Standard C-spine immobilization is performed with a hard collar in conjunction with a backboard, vacuum mattress, or similar device.  Typically lateral support devices are also employed . The patient’s neck requires manual stabilization in a neutral, in-line position until he or she is fully immobilized. Standard emergency medical services equipment includes lateral support devices (foam or plastic).

In the wilderness setting, these devices can be improvised by rolling clothes, sheets, or blankets and placing them on both sides of head while securing everything in place with tape

Full Spine Immobilization

From a supine (lying) position and after the placement of a cervical collar, the patient is either  logrolled or the slide and transfer technique used to place the patient onto a board or vacuum splint. 

With the log roll technique three people are required to transfer a patient onto a board. The first person is positioned at the head and applies in-line stabilization, the second is at chest level, and the third is at pelvis level. On the command of the person at the head, the patient is rolled onto his or her least-injured side. The board is then slid underneath the patient while the back is evaluated for injuries.

With the lift and slide technique multiple attendants are also required.  One individual maintains manual, in-line stabilization of the head and neck, while other rescuers straddle the victim in preparation for lifting the upper torso, hips, pelvis, and lower extremities. A final assistant is responsible for placement of the spine board. When all participants are ready, the individual stabilizing the head and neck directs the others to raise the patient off the ground to enable the remaining rescuer to slide the spine board under the patient from the foot end. 

Choices for full-body splints include hard backboards, scoop stretchers, and full-body vacuum splints . Full-body hard backboards have been traditionally used. Unfortunately, their size and weight make them undesirable for backcountry use. Secured straps minimize spinal movement during transport.  Hard backboards are uncomfortable.  Since rigid backboards can induce pain, patient agitation, pressure ulcers and respiratory compromise a recent position statement from EMS physicians and trauma surgeons has advocated for limiting their use. 

 

Vacuum splint devices offer certain advantages over rigid hard backboards. They can be applied more quickly, and are significantly more comfortable. Vacuum mattress immobilization of the potentially injured spine is the current recommendation of the International Commission for Mountain Emergency Medicine.