Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Where is the Evidence FOR Spinal Immobilization?

 
Some things are bad ideas, even if they once appeared to be good ideas.

MAST/PASG (Medical Anti-Shock Trousers/Pneumatic Anti-Shock Garment), an amp of Bicarb (NaHCO3) for cardiac arrest or even for acidosis, withholding morphine for severe pain, because slowing the patients respirations from 60+ to 20 would indicate dangerous respiratory depression, Lights and Sirens for everything, because you can’t be too safe.

What about spinal immobilization?

It once seemed like a good idea.

Then dangerous people started claiming that You can’t be too safe! (Of course you can. Reasonable people can give plenty of examples, but that is not the point here.)

Since strapping curved spines to flat boards was such a good idea, we began to inflict it on everyone who might have hit something at some time, or might know someone who once witnessed something hitting something else. You can’t be too safe!
 


 

The NAEMSP position paper on spinal immobilization makes it clear that the largest group of EMS medical directors do not support using back boards on most of the patients we put on back boards.

This seems to be just as much a standard of care as any other.
 

Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for:

  • Patients who are found to be ambulatory at the scene
  • Patients who must be transported for a protracted time, particularly prior to interfacility transfer
  • Patients for whom a backboard is not otherwise indicated[1]

 

A collar and no back board!
 

But WAIT!

What does the NAEMSP base this radical change on?

Dr. Bryan Bledsoe describes the research.
 

However, medicine in the 21st century calls for evidence-based practice. We must provide care that has been demonstrated in unbiased ways to improve patient outcomes. Such is the case with prehospital spinal immobilization.[2]

 

For example, here are two bits of evidence for spinal immobilization.
 

A Canadian study found spinal immobilization techniques during simulated vehicle motion to be generally ineffective.4 A 1998 Tennessee-based study examined the commonly used Aspen cervical collar and concluded “full cervical immobilization is a myth.”5 [2]

 

If that is the evidence for spinal immobilization, I don’t want to see the evidence against spinal immobilization.

Here is just one example.
 

Spinal immobilization also restricts respirations. In one study of 39 healthy volunteers, it restricted respirations by an average of 15%, and this was more pronounced at the extremes of age.12 [2]

 

Is there something else we should consider about strapping people to boards?

Kelly Grayson and Gene Gandy describe an example of a rollover patient, who was up and walking around, but was strapped to a board by EMS, transported to the hospital, and later found to have an unstable cervical fracture.
 

“Thank God we immobilized her,” the medic breathes in relief. “She’d have been a quad for sure,” her partner agrees.

The truth is, the crew of Medic 4 has no way of knowing that their attempt to immobilize their patient’s spine contributed in any way to her favorable outcome.[3]

 

Why do we assume that we know we improved the outcome for patients?

Because we do not understand what we are doing.
 

At best, the studies show no evidence of further harm from spinal immobilization. That’s far from a ringing endorsement for the efficacy of one of our most long-held practices.[3]

 

In other words, the EMS immobilization could have made things worse, but there is no reason to believe that the back board provided any benefit.
 

Given the devastating long-term effects of spinal cord injury, it may be tempting to say, “If it only helps one patient, it’s worth it.” That presumes we are doing no harm to the many thousands of patients who do not benefit from immobilization. But are we?[3]

 

That also presumes that we doing no harm to the patients with unstable spinal fractures.

There is no evidence to show that we are helping patients with unstable spinal fractures.
 

When it comes to prehospital c-spine clearance, agencies that refuse to adopt the practice are now one generation behind the treatment curve. The debate now is not whether EMTs can effectively determine which patients do not require immobilization in the field, it is whether we should immobilize at all.[3]

 

There are other articles to read questioning whether back boards help any patients.[4],[5],[6]

A podcast may be more to your liking.
 

At First Few Moments, Kyle David Bates, Russell Stine, Bob Lutz, Dr. Laurie Romig, Kelly Grayson and I discuss the lack of evidence of any benefit from spinal immobilization and the evidence of harm in A Change of the Dogma: If it helps only one? Episode 36.

Footnotes:

[1] EMS spinal precautions and the use of the long backboard.
[No authors listed]
Prehosp Emerg Care. 2013 Jul-Sep;17(3):392-3. doi: 10.3109/10903127.2013.773115. Epub 2013 Mar 4.
PMID: 23458580 [PubMed – in process]

Free Full Text in PDF Download format from NAEMSP.

[2] The Evidence Against Backboards – What does the spinal science say?
Bryan E. Bledsoe, DO, FACEP, FAAEM
August 1, 2013
EMS World
Article

[3] Does Spinal Immobilization Help Patients? – Who needs c-spine clearance?
Steven “Kelly” Grayson, NREMT-P, CCEMT-P AND William E. “Gene” Gandy, JD, LP
August 1, 2013
EMS World
Article

[4] In order to protect the c-spine, should we stop helping?
Mill Hill Ave Command
Saturday, December 15, 2012
Article

[5] Why We Need to Rethink C-Spine Immobilization
By Karl A. Sporer, MD, FACEP, FACP
Created: November 1, 2012
EMS World
Article

[6] Another Nail in the Board
StreetWatch: Notes of a Paramedic
January 17, 2013
Peter Canning
Article

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Comments

  1. Not that my point here is the most critical argument against spinal immobilization, and it’s also somewhat obvious when you think about it, but it just crossed my mind (I spent a couple years as a volunteer EMT with a New England FD before moving):

    You know what we WEREN’T doing when 2 or 3 of us were busy getting backboards, doing standing take-downs for ambulatory patients, putting head blocks together, etc.?

    We weren’t reassessing vital signs, we weren’t fully listening while getting SAMPLE histories, we weren’t efficiently allocating manpower to other possible patients, and so on. So, in addition to – at BEST – making patients moderately uncomfortable unnecessarily, we simply weren’t focusing all our efforts and attention on things that could actually be beneficial.

  2. Thank you for putting in the time to research all the vital points brought up here. Maybe one day EMS will not be back boarding so many patients that don’t truly need it. I will do my part to try to clear my patient’s from the board if at all possible.

Trackbacks

  1. […] The cervical collar is one of the mainstays of the process of spinal immobilization, er… I mean “spinal motion restriction” which is something that has never, ever, never, ever, never never ever never been proven to help. (2) […]

  2. […] **RougeMedic did a post on the original position statement, which goes into details a little more than I do here.  I also borrowed his picture… […]

  3. […] More importantly, resources on how to deliver the service are scarce. There is the textbook Special Events Medical Services by the American Academy of Orthopaedic Surgeouns (AAOS). While I’m not quite sure why the AAOS is putting out a book that, from my perspective, would have been better coming from the American College of Emergency Physicians (ACEP) or National Association of EMS Physicians (NAEMSP). Having an understanding of what the Emergency Medical Services is capable of in order to develop quality Event Medical Services from both operational and clinical viewpoints is important. While I don’t think AAOS has that understanding, they were the ones who published it. While it has some good information, in my opinion it falls short in a number of areas, including making certain assumptions that in practice do not hold true… sort of like strapping someone with a curved spine to a long flat board for a transport to prevent spinal injury. We know (now) how effective that was… which is it wasn’t. […]

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