Overview of EMS Long Spine Board Immobilization
Blunt traumatic injuries, or injuries from a sudden, hard impact, are the major cause of spinal cord injuries in the United States. Every year, there are around 54 cases per million people, making up about 3% of all hospital admissions due to such accidents. Despite only being a small percentage of these injuries, spinal cord injuries are a significant cause of serious health complications and death.
In 1971, to manage and prevent further damage from such injuries, the American Academy of Orthopedic Surgeons suggested the use of a cervical collar (a brace to support the neck) and a long spine board (a rigid board to immobilize the spine) for patients with suspected spinal injuries. This practice, mostly based on expert agreement rather than hard evidence, has since become the standard emergency care for these injuries. It is recommended in various medical guidelines, including emergency and trauma management guidelines.
However, there have been questions raised about the effectiveness of this approach. A global study compared patients who were treated this way to those who were not. The study found that those who did not have this treatment often had fewer spinal cord injuries that caused disability. However, it’s important to mention that these two groups of patients did not have injuries of the same severity. Another study, which used healthy young volunteers, found that a long spine board allowed for more sideways movement of the spine than a regular stretcher mattress.
In 2019, another study looked at if there was any change in the number of spinal cord injuries after an emergency medical service protocol was introduced that only used these strict movement precautions for patients who had major risk factors or abnormal examination results. The study found no difference.
There are currently no high-level, controlled studies to either support or disprove the use of these movement restrictions. Future studies of this nature are unlikely, as they would involve a substantial risk of permanent paralysis, which is against current ethical guidelines.
Because of these findings, newer guidelines now suggest limiting the use of a long spine board to only those patients who have either a high risk of injury or show concerning symptoms. It is also recommended to limit the time a patient is immobilized in this way as much as possible.
Anatomy and Physiology of EMS Long Spine Board Immobilization
The spinal column, also known as your backbone, is the main support for your body. It consists of 33 individual bones stacked one on top of another, called vertebrae. The spinal cord, which is a bundle of nerves that sends signals to other parts of your body, runs through the center of these vertebrae. The spinal column is split into five sections: The neck (cervical spine), the chest (thoracic spine), the lower back (lumbar spine), the hips (sacral spine), and the tailbone (coccyx).
Each vertebra has many parts, but we can broadly separate them into two sections: the front (anterior) and the back (posterior). The front part includes the large rounded body of the vertebra, which is surrounded by a strong band of tissue called the anterior longitudinal ligament at the front and the posterior longitudinal ligament at the back. The back part of the vertebra includes the bony projections called spinous and transverse processes, the vertebral arch, and several ligaments.
In between each vertebra, there are disc-like structures filled with fluid, surrounded by a tough ring of tissue. These discs essentially act like shock absorbers for your spine.
There are many ways doctors can describe spinal fractures, but one of the most commonly used methods is from a three-column model proposed by a doctor named Francis Denis in 1983. According to Denis, the spine can be divided into three columns:
The front column includes the front part of the vertebrae, and its surrounding ligaments.
The middle column includes the back part of the vertebral body and its surrounding ligaments.
The back column includes the posterior ligament complex, the arch of the back part of the vertebra, and the spinous and transverse processes.
According to this model, if two or more of these columns are injured, it means the fracture is unstable and there’s a risk of injuring the spinal cord. Restricting movement after an injury like this can help to prevent further damage by keeping any fragments from unstable fractures from causing additional injury during the rescue, transport, and initial evaluation of the patient.
Why do People Need EMS Long Spine Board Immobilization
Whether someone needs to keep their spine from moving (called spinal motion restriction) depends on the local emergency medical service director’s rules. These instructions might be a little different depending on where you are, but they usually include guidelines from the NEXUS C-Spine Rule or the Canadian C-Spine Rule. A joint statement from major medical groups like the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians, has some signs to look for. These include:
- Confusion, drunkenness, or a score less than 15 on a test called the Glasgow Coma Scale
- Tenderness or pain along the middle of your spine
- Neurological symptoms like weakness or numbness
- A visible deformity of the spine
- Other injuries or situations that might distract you (like fractures, burns, distress, language barrier, etc.)
The same medical groups have also given advice about when children who’ve suffered a blunt trauma (a forceful hit or impact) should have their spines kept from moving. They said that a child’s age or communication ability shouldn’t affect this decision. The indications for children include:
- Complains about neck pain
- Has a condition called torticollis, where the neck is twisted or tilted
- Shows neurological symptoms or signals
- Acts differently, such as scoring less than 15 on the Glasgow Coma Scale, showing signs of being intoxicated, or showing other signs like being easily upset, having trouble breathing, being very sleepy, etc.
- Was involved in a major car crash, a hard-hitting dive, or has a serious torso injury
When a Person Should Avoid EMS Long Spine Board Immobilization
Patient’s who’ve experienced a trauma to the head, neck, or body, but aren’t showing signs of neurological issues (like problems with movement, speech, or thought) or pain, may not need immediate immobilization. This is called a relative contraindication.
Research published in the Eastern Association for the Surgery of Trauma and The Journal of Trauma, found that patients with this type of trauma, who had their spines immobilized, were twice as likely to pass away compared to those who were not immobilized.
Spinal immobilization is a process where the medical team restricts your movement to protect your spine, typically using a backboard and neck collar. However, this process can take between 2 to 5 minutes. This not only delays the patient’s transport for more specialized care, but it also postpones other treatments that could be done before reaching the hospital, as two people need to be involved in this procedure.
Equipment used for EMS Long Spine Board Immobilization
To restrict movement in your spine after a suspected injury, medical professionals may use a device called a spine board, along with a special neck brace known as a cervical collar. There are two types of spine boards – long and short – that are used depending on the situation.
The longer spine boards were originally used along with a cervical collar to keep the spine still. This is because moving the spine incorrectly could potentially worsen a spinal cord injury. These long boards are also inexpensive and handy for carrying patients who are unconscious, limiting unwanted movement, and dealing with uneven surfaces.
Shorter spine boards, on the other hand, are especially useful in tight or enclosed spaces, like car accidents. Their smaller size lets them support the mid-back and neck region before the patient is transferred onto the longer board. A well-known type of short board is the Kendrick Extrication Device, which is slightly flexible and broadens out to cover the sides and head as well.
Cervical collars, the neck braces mentioned earlier, comes in two styles: soft or hard. For situations involving trauma, the hard collars are preferred for better neck restriction. These collars mainly have a back part that leans on the large muscles at the top of your back for support, and a front part that props up your jaw and relies on your breastbone and collarbones for further support. It’s important to note that these collars alone don’t provide enough neck immobilization. They often need to be used with other side-support structures, such as Velcro foam pads found on longer spine boards.
How is EMS Long Spine Board Immobilization performed
Spinal motion restriction is a method to keep your spine as still as possible, particularly in case of an injury. ‘Supine log-roll technique’ is a common way to achieve this. This procedure asks for ideally five people, but it can be done with four people as well, if needed.
If you have a team of Five:
Before the procedure starts, the patient should cross their arms over their chest. Then, one person should be chosen as the team leader. This person goes to the head of the patient and uses their hands to hold onto the patient’s shoulders from the back, while their thumbs should be at the front, with their forearms pressed against the sides of the patient’s head. This limits the patient’s head movement and secures the neck. If a neck brace is available, it should be positioned around the patient’s neck at this time. Please make sure the patient’s head is not lifted off the ground while doing so. If you don’t have a neck brace, continue stabilizing the patient’s head in the same manner throughout the procedure.
Next, the team’s second member should stand next to the patient’s chest, and the third member should be at the hips. The fourth member should take their place at the legs and their hands should be on the far side of the patient. The fifth person has the task of sliding a long, rigid board under the patient when they are rolled on their side.
All four members then roll the patient, on a command from the first member (usually on a count of three), so that the fifth member can slip the board under the patient. Then, on another command from the first member, the patient is rolled again onto the board.
The patient is then aligned and secured with straps over their chest, followed by their lower belly and upper legs. The head is then secured using rolled towels or a commercially available device and then taped onto the board.
If you have a Team of Four:
Follow the same procedure as above, with a minor difference related to hand positioning. The second team member should stand at the patient’s chest and place one hand on the far shoulder and the other on the far hip. The third team member, standing at the legs, should place one hand on the far hip and the other on the far leg. It’s better if the arms of the team members cross over each other at the hip. The remaining steps are the same as above, with the fourth member sliding the long spine board under the patient.
Possible Complications of EMS Long Spine Board Immobilization
If someone has to lie on a long backboard for a long time or has their neck motion reduced, they might get something known as pressure injuries, also known as bed sores. These sores happen when the body is kept in one position for too long. They usually start to show up over bony parts of the body and start causing damage to the skin and tissue under the skin. In the early stages, the skin might still look intact, but as time goes on, it can turn into an open sore.
A study with healthy volunteers has shown that this harm to their tissue might start in just about 30 minutes. On average, most people have to remain still on a long backboard for about 54 to 77 minutes. If we break this period into sections, around 21 minutes of the total time is spent in the Emergency Department after being transported there. Knowing this, it’s important for people providing care to try to reduce the amount of time someone needs to be kept still on a long backboard or with a neck collar to prevent pressure injuries.
Being strapped to a long backboard can affect breathing as well. In several studies, it was shown that chest straps can reduce lung function. Even in healthy young people, these straps led to a decrease in the capacity for forced breathing and the volume of breath that can be exhaled forcefully. For children, results showed a 20% decrease in baseline lung capacity. For both rigid boards and vacuum mattresses, they were found to restrict breathing by 17% on average in healthy people. Such restrictions can be more severe for people who already have lung disease and for children and older adults, so extra care should be taken when immobilizing them.
Long backboards can cause pain too. This is the most common problem and it can start in as little as 30 minutes. The most common types of pain experienced are headaches, back pain, and jaw pain. It’s clear that the time spent immobile on a long backboard should be kept to a minimum to reduce the likelihood of pain.
What Else Should I Know About EMS Long Spine Board Immobilization?
Blunt force trauma, or severe impact to the body, can cause injuries to the backbone and the spinal cord housed within, leading to serious health consequences and even death. In the 1960s and 1970s, a method called ‘spinal motion restriction’ was used to manage these injuries. The main goal of spinal motion restriction was to reduce or prevent additional spinal injuries that could lead to neurological complications, like nerve damage or paralysis.
However, despite being widely used, there’s not a lot of scientific research of high quality that supports the effectiveness of restricting spinal motion in improving outcomes for patients with spinal injuries. In fact, there have been recent studies suggesting that this practice can sometimes cause complications.
For these reasons, the latest guidelines recommend using spinal motion restriction wisely and specifically for certain groups of patients. Therefore, it’s important for healthcare providers to fully understand these guidelines, as well as the possible risks, so they can make the best decisions for their patients and aim to better overall health outcomes.
