A review of spinal immobilization techniques

Evaluating prehospital care of patients with potential traumatic spinal cord injury: scoping review

PURPOSE

To gain insight into current research regarding prehospital care (PHC) in patients with potential traumatic spinal cord injury (TSCI) and to disseminate the findings to the research community.

METHODS

In March 2019, we performed a literature search of publications from January 1990 to March 2019 indexed in PubMed, gray literature including professional websites; and reference sections of selected articles for other relevant literature. This review was performed according to Arksey and O'Malley's framework.

RESULTS

There were 42 studies selected based on the inclusion criteria for review; 18 articles regarding immobilization; 12 articles regarding movement, positioning and transport; four for spinal clearance; three for airway protection; and two for the role of PHC providers. There were some articles that covered two topics: one article was regarding movement, positioning and transport and airway protection, and two were regarding spinal clearance and the role of PHC providers.

CONCLUSION

There was no uniform opinion about spinal immobilization of patients with suspected TSCI. The novel lateral trauma position and one of two High Arm IN Endangered Spine (HAINES) methods are preferred methods for unconscious patients. Controlled self-extrication for patients with stable hemodynamic status is recommended. Early and proper identifying of potential TSCI by PHC providers can significantly improve patients' outcomes and can result in avoiding unwanted spinal immobilization. Future prospective studies with a large sample size in real-life settings are needed to provide clear and evidence-based data in PHC of patients with suspected TSCI.

Extrication techniques of entrapped car crash victims: a scoping review

OBJECTIVE

to summarize the extrication techniques of entrapped car crash victims with potential spinal injury.

METHOD

a literature review study, of scoping review type, using the MEDLINE/PubMed, CINAHL, Scopus, Science Direct, Web of Science, Cochrane Library and gray literature data sources, without time frame, with studies that addressed extricating techniques extrication of entrapped car crash victims.

RESULTS

a total of 33 studies were included that enabled identifying and summarizing the different types of extrication and respective devices for extrication of entrapped car crash victims, indicated according to injury assessment and the victim's clinical condition. All pointed to the need for techniques to maintain neutral alignment and prevent spine twists.

CONCLUSION

this study indicated that injury assessment with an emphasis on the victim's clinical condition provides a coherent decision-making regarding the technique and device to be used. However, carrying out other comparative studies between existing techniques may help in the decision-making process more assertively.

Current Topics in the Management of Acute Traumatic Spinal Cord Injury

Acute traumatic spinal cord injury (SCI) affects more than 250,000 people in the USA, with approximately 17,000 new cases each year. It continues to be one of the most significant causes of trauma-related morbidity and mortality. Despite the introduction of primary injury prevention education and vehicle safety devices, such as airbags and passive restraint systems, traumatic SCI continues to have a substantial impact on the healthcare system. Over the last three decades, there have been considerable advancements in the management of patients with traumatic SCI. The advent of spinal instrumentation has improved the surgical treatment of spinal fractures and the ability to manage SCI patients with spinal mechanical instability. There has been a concomitant improvement in the nonsurgical care of these patients with particular focus on care delivered in the pre-hospital, emergency room, and intensive care unit (ICU) settings. This article represents an overview of the critical aspects of contemporary traumatic SCI care and notes areas where further research inquiries are needed. We review the pre-hospital management of a patient with an acute SCI, including triage, immobilization, and transportation. Upon arrival to the definitive treatment facility, we review initial evaluation and management steps, including initial neurological assessment, radiographic assessment, cervical collar clearance protocols, and closed reduction of cervical fracture/dislocation injuries. Finally, we review ICU issues including airway, hemodynamic, and pharmacological management, as well as future directions of care.

Cervical spine trauma evaluation

Cervical spine trauma is a relatively rare but catastrophic event in sports. These critical situations depend on sports medicine personnel understanding every aspect of sideline care to ensure a safe and successful evaluation. This involves thorough preparation, vigilant observation of the sporting event to detect the possible mechanism of injury, and initiation of the appropriate action plan when a potentially catastrophic injury is suspected. Sideline management of cervical spine trauma requires the appropriate primary survey, with spine stabilization if necessary, secondary survey for concomitant injury, and, potentially, initiation of full spine stabilization with a spine board. In this chapter, our primary focus is discussion of the sideline evaluation of cervical spine trauma, and sideline practices designed to stabilize the athlete and minimize risk for further injury.

The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury

The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available literature and a standardised consensus process. The faculty recommends a selective approach to spinal stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal handling should be observed.

Management of acute traumatic spinal cord injuries

Acute traumatic spinal cord injury (SCI) is a devastating disease process affecting tens of thousands of people across the USA each year. Despite the increase in primary prevention measures, such as educational programs, motor vehicle speed limits, automobile running lights, and safety technology that includes automobile passive restraint systems and airbags, SCIs continue to carry substantial permanent morbidity and mortality. Medical measures implemented following the initial injury are designed to limit secondary insult to the spinal cord and to stabilize the spinal column in an attempt to decrease devastating sequelae. This chapter is an overview of the contemporary management of an acute traumatic SCI patient from the time of injury through the stay in the intensive care unit. We discuss initial triage, immobilization, and transportation of the patient by emergency medical services personnel to a definitive treatment facility. Upon arrival at the emergency department, we review initial trauma protocols and the evidence-based recommendations for radiographic evaluation of the patient's vertebral column. Finally, we outline closed cervical spine reduction and various aggressive medical therapies aimed at improving neurologic outcome.

Horizontal Slide Creates Less Cervical Motion When Centering an Injured Patient on a Spine Board

BACKGROUND

A patient with a suspected cervical spine injury may be at risk for secondary neurologic injury when initially placed and repositioned to the center of the spine board.

OBJECTIVES

We sought to determine which centering adjustment best limits cervical spine movement and minimizes the chance for secondary injury.

METHODS

Using five lightly embalmed cadaveric specimens with a created global instability at C5-C6, motion sensors were anchored to the anterior surface of the vertebral bodies. Three repositioning methods were used to center the cadavers on the spine board: horizontal slide, diagonal slide, and V-adjustment. An electromagnetic tracking device measured angular (degrees) and translation (millimeters) motions at the C5-C6 level during each of the three centering adjustments. The dependent variables were angular motion (flexion-extension, axial rotation, lateral flexion) and translational displacement (anteroposterior, axial, and medial-lateral).

RESULTS

The nonuniform condition produced significantly less flexion-extension than the uniform condition (p = 0.048). The horizontal slide adjustment produced less cervical flexion-extension (p = 0.015), lateral bending (p = 0.003), and axial rotation (p = 0.034) than the V-adjustment. Similarly, translation was significantly less with the horizontal adjustment than with the V-adjustment; medial-lateral (p = 0.017), axial (p < 0.001), and anteroposterior (p = 0.006).

CONCLUSIONS

Of the three adjustments, our team found that horizontal slide was also easier to complete than the other methods. The horizontal slide best limited cervical spine motion and may be the most helpful for minimizing secondary injury based on the study findings.

Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature

OBJECTIVES

The objectives were to review published reports of secondary neurologic deterioration in the early stages of care after blunt spinal trauma and describe its nature, context, and associated risk factors.

METHODS

The authors searched the MEDLINE, EMBASE, and CINAHL databases for English-language studies. Cases were included meeting the criteria age 16 years or older, nonpenetrating trauma, and experiencing neurologic deterioration during prehospital or emergency department (ED) care prior to definitive management (e.g., discharge, spinal clearance by computed tomography, admission to an inpatient service, or surgical intervention). Results were qualitatively analyzed for characteristics and themes.

RESULTS

Forty-one qualifying cases were identified from 12 papers. In 30 cases, the new deficits were apparently spontaneous and were not detected until routine reassessment. In 12 cases the authors did attribute deterioration to temporally associated precipitants, seven of which were possibly iatrogenic; these included removal of a cervical collar, placement of a halo device, patient agitation, performance of flexion/extension films, "unintentional manipulation," falling in or near the ED, and forced collar application in patients with ankylosing spondylitis. Thirteen cases occurred during prehospital care, none of them sudden and movement-provoked, and all reported by a single study.

CONCLUSIONS

Published reports of early secondary neurologic deterioration after blunt spinal trauma are exceptionally rare and generally poorly documented. High-risk features may include altered mental status and ankylosing spondylitis. It is unclear how often events are linked with spontaneous patient movement and whether such events are preventable.

Secondary neurological deterioration in traumatic spinal injury: data from medicolegal cases

We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status.

Prehospital use of cervical collars in trauma patients: a critical review

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

Care related and transit neuronal injuries after cervical spine trauma: state of care and practice in Nigeria

Suboptimal care during extraction and transfer after spinal trauma predisposes patients to additional spinal cord injury. This study examines the factors that contribute to care related and transit injuries and suggests steps to improve standard of care in spinal trauma patients in Nigeria. It is a questionnaire-based prospective study of patients admitted with cervical cord injury to two neurosurgical centers in Enugu, Nigeria, between March 2008 and October 2010. Demography, mechanism of injury, mode of extraction from the scene and transportation to first visited hospital, precautions taken during transportation, and treatment received before arriving at the neurosurgical unit were analyzed. There were 53 (77.9%) males, the mean age was 33.9 years, and 23.5% had concomitant head injury. Average delay was 3.5 h between trauma and presentation to initial care and 10.4 days before presentation to definitive care. Only 26.5% presented primarily to tertiary centers with trauma services. About 94.1% were extracted by passersby. None of the patients received cervical spine protection either during extrication or in the course of transportation to initial care, and 35.3% were sitting in a motor vehicle or supported on a motorbike during transport. Of the 43 patients transported lying down, 41.9% were in the back seat of a sedan, and only 11.8% were transported in an ambulance. Neurological dysfunction was first noticed after removal from the scene by 41.2% of patients, while 7.4% noticed it on the way to or during initial care. During subsequent transfer to definitive centers, only 36% had cervical support, although 78% were transported in ambulances. Ignorance of pre-hospital management of cervically injured patients exists in the general population and even among medical personnel and results in preventable injuries. There is need for urgent training, provision of paramedical services, and public enlightenment.

Cervical spine immobilization in sports related injuries: review of current guidelines and a case study of an injured athlete

Cervical spine immobilization is an essential component of the ATLS^® system. Inadequate training in the management of trauma calls and failure of early recognition can have disastrous consequences. Pre-hospital personnel are routinely involved more in the assessment and stabilization of patients in comparison to other health care professionals.

This case study and review highlights the importance of early recognition, assessment and correct stabilization of cervical spine injuries both in the field and during the initial assessment in hospital.

Inadequate assessment, immobilization and lack of standard guidelines on the management of suspected cervical spine trauma can result in secondary injury. Regular assessment and training of pre-hospital and medical personnel is essential to the proper management of these potentially devastating injuries.

Cervical spine alignment during on-field management of potential catastrophic spine injuries

Context:

When cervical spine injuries are suspected, the cervical spine should be immobilized in a neutral position and neck motion controlled in preparation for transport to an emergency facility. Protocols for emergency transport utilizing common devices (cervical collars) and methods (transfer techniques) during these procedures are not entirely evidence based.

Evidence Acquisition:

The medical literature search covered the time period of January 1966 to June 2008 using the following keywords, either alone or in combination: extrication collars, cervical collars, spine orthoses, spinal immobilization, spine board, spinal board, transfer techniques, and back board. Biomedical databases searched included Medline, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL [1982 to 2008]). The reference lists of all trials identified were also searched for additional trials.

Methods:

Only trials that directly compared the efficacy or safety of transfer methods and/or immobilization devices were included. Studies that measured voluntary head movement after the fitting of the cervical orthoses and those that did not evaluate motion across individual spinal segments were not included.

Results:

A lift-and-slide transfer method with a full body immobilization device creates less motion than a log-roll maneuver. Extrication-type cervical immobilization collars are limited in their ability to control neck motion in the injured cadaveric model.

Conclusion:

Allied health professionals responsible for the management of the cervical spine–injured patient should become familiar with and employ a lift-and-slide transfer technique in appropriate situations and should not rely exclusively on extrication-type collars to immobilize the neck.

National athletic trainers' association position statement: preventing sudden death in sports

OBJECTIVE

To present recommendations for the prevention and screening, recognition, and treatment of the most common conditions resulting in sudden death in organized sports.

BACKGROUND

Cardiac conditions, head injuries, neck injuries, exertional heat stroke, exertional sickling, asthma, and other factors (eg, lightning, diabetes) are the most common causes of death in athletes.

RECOMMENDATIONS

These guidelines are intended to provide relevant information on preventing sudden death in sports and to give specific recommendations for certified athletic trainers and others participating in athletic health care.

National athletic trainers' association position statement: acute management of the cervical spine-injured athlete

OBJECTIVE

To provide certified athletic trainers, team physicians, emergency responders, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in the athlete.

BACKGROUND

The relative incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and the timeliness of transfer to a controlled environment for diagnosis and treatment.

RECOMMENDATIONS

Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport, such as football, hockey, or lacrosse; and considerations in the emergency department.

A new external upper airway opening device combined with a cervical collar

Airway problems are the main cause of mortality in otherwise survivable trauma injuries. We developed a novel external airway protector in combination with a cervical collar. The new device simultaneously opens the airway and protects the cervical spine.

MATERIALS AND METHODS

The device called the 'Lubo Collar' has a chin holder that can be attached to a gliding knob on the collar. When the knob is pushed forward, the mandible moves forward, thus imitating the jaw thrust manoeuvre and opens the airway. In order to study the safety and efficacy of this new device, a two-phase clinical trial was conducted. In the safety phase 20 patients were evaluated for adverse reactions immediately, 2h and 24h following application of the device. The efficacy phase evaluated the ability of the device to open and maintain an airway in anaesthetised patients. In this phase, 10 patients who had undergone orthopaedic surgery under general anaesthesia were included. Seven patients had blocked airways following anaesthesia induction. The gliding knob attached to the mandible arc was pushed 1cm forward to open their airways.

RESULTS

No adverse events were recorded. In the seven patients with blocked airways, the external airway/collar device opened and maintained patent airways.

CONCLUSION

The new external non-invasive airway device (Lubo Collar) is safe and effective in opening and maintaining an open airway in an unconscious anaesthetised patient with a blocked airway. These preliminary results may encourage assessment in the field.

Summary of the National Athletic Trainers' Association position statement on the acute management of the cervical spine-injured athlete

The incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and timeliness of transfer to a controlled environment for diagnosis and treatment. The objective of the National Athletic Trainers' Association (NATA) position statement on the acute care of the cervical spine-injured athlete is to provide the certified athletic trainer, team physician, emergency responder, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in an athlete. Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport such as football, hockey, or lacrosse; and imaging considerations in the emergency department.

Acquiring and maintaining competence in the application of extrication cervical collars by a group of first responders

INTRODUCTION

Research on skill acquisition and retention in the prehospital setting has focused primarily on resuscitation and defibrillation. Investigation into other first aid skills is required in order to validate practices and support training regimes. No studies have investigated competency using an extrication cervical collar for cervical spine immobilization.

OBJECTIVE

This study was conducted to confirm that a group of first responders could acquire and maintain competency in the application of an extrication cervical collar over a 12-month period.

METHODS

Participants attended a standardized training session that addressed the theory of application of an extrication cervical collar followed by hands-on practice. The training was presented by the same instructor and covered the nine key elements necessary in order to be deemed competent in extraction cervical collar application. Following the practical session, the competency of the participants was assessed. Participants were requested not to practice the skill during the 12-month period. Following the 12-month period, their skills were re-assessed by the same assessor.

RESULTS

Of the 64 subjects who participated in the study, 100% were competent after the initial first assessment. Forty-one participants (64%) were available for the second assessment (12 months later); of these, 25 (61%) maintained competence.

CONCLUSIONS

Although the sample size was small, this research demonstrates that first responders are able to acquire competence in applying an extrication cervical collar. However, skill retention in the absence of usage or re-training is poor. Larger studies should be conducted to validate these results. In addition, there is a need for research on the clinical practice and outcomes associated with spinal immobilization in the prehospital setting.

The use of extrication devices in crevasse accidents: official statement of the International Commission for Mountain Emergency Medicine and the Terrestrial Rescue Commission of the International Commission for Alpine Rescue intended for physicians, paramedics, and mountain rescuers

Injured patients in crevasses who are suspected of having sustained spinal injuries should ideally be extricated after being immobilized in a horizontal position on a stretcher and having a cervical collar applied. Sometimes, however, horizontal stabilization is not possible, because the crevasse is too narrow, and the patient needs to be stabilized in a vertical position. In such cases an extrication device can be a useful adjunct. The Kendrick Extrication Device stabilizes the position of the body and maintains firm support of the head, neck, and torso. Therefore, the International Commission for Mountain Emergency Medicine supports the use of this device in narrow crevasses, if horizontal evacuation is not possible.

Prehospital spinal immobilization and the backboard quality assessment study

INTRODUCTION

Prehospital spinal immobilization (PSI) for patients with suspected spinal injury has been the universal standard of practice for emergency medical services (EMS) in the United States since the early 1970s. PSI research has faced numerous methodological difficulties, including an inability to evaluate whether the immobilizations being studied were carried out appropriately. The purpose of this study was to assess the quality of spinal immobilization to a long spine board in patients presenting via EMS to an emergency department (ED).

METHODS

All noncritically ill patients presenting to a tertiary care academic trauma center who had been immobilized on a long spine board for EMS transport were approached for enrollment. Each subject was evaluated for the number and location of restraining straps and their degree of tightness.

RESULTS

Of 50 consenting subjects, 15 (30%) had at least one unattached strap or piece of tape that should have attached their head to the board. Of 50 subjects, 44 (88%) were found to have greater than 2 cm of slack between their body and at least one strap. Among those with any straps looser than 2 cm, the average number of loose straps was 3.4.

CONCLUSIONS

This study suggests that many patients are not well immobilized on arrival at the Emergency department.

Evaluation of respiratory function during Reeves stretcher use

OBJECTIVE

We were aware of a small number of cases in our EMS system where patients in respiratory distress had a worsening of their condition after being removed from the home on a Reeves stretcher (RS). We sought to determine if this prehospital lifting device causes additional respiratory effort used in normal subjects by describing changes in heart rate, pulse oximetry, tidal volume, minute ventilation, and respiratory rate.

METHODS

Forty-nine subjects were entered into this study. Data were collected while the subject was supine on the floor in the RS and once while suspended over the floor in the device. A randomized crossover design was used. Ten subjects were excluded because of inadvertent omission of a nose plug during spirometry. Data points were recorded in the final minute of a 3-minute exposure. Three minutes was chosen to simulate a prehospital transport time from the scene to the ambulance. Minute ventilation, tidal volume, heart rate, pulse oximetry, and respiratory rate were recorded for each subject during each phase. Subjects were also asked to rate the difficulty of breathing using the modified Borg scale.

RESULTS

Data were obtained for 39 subjects. The mean respiratory rate while suspended was 9.9 +/- 3.0 breaths per minute compared to 9.1 +/- 2.5 breaths per minutes supine on the floor (p = 0.007). The mean minute ventilation while suspended in a RS was 8.17 +/- 3.25 L/min versus 7.37 +/- 2.37 while lying flat (p = 0.03). There was no difference in tidal volume, heart rate, pulse oximetry, or subjective modified Borg scale ratings.

CONCLUSIONS

Subjects suspended in a RS for 3 minutes had statistically higher respiratory rates and minute ventilation than the same subjects lying flat. Although these modest changes are clinically insignificant in normal subjects, they could present a significant challenge to subjects in respiratory distress.

Comparison of the Ferno Scoop Stretcher with the long backboard for spinal immobilization

OBJECTIVES

Spinal immobilization is essential in reducing risk of further spinal injuries in trauma patients. The authors compared the traditional long backboard (LBB) with the Ferno Scoop Stretcher (FSS) (Model 65-EXL). They hypothesized no difference in movement during application and immobilization between the FSS and the LBB.

METHODS

Thirty-one adult subjects had electromagnetic sensors secured over the nasion (forehead) and the C3 and T12 spinous processes and were placed in a rigid cervical collar, with movement recorded by a goniometer (a motion analysis system). Subjects were tested on both the FSS and the LBB. The sagittal flexion, lateral flexion, and axial rotation were recorded during each of four phases: 1) baseline, 2) application (logroll onto the LBB or placement of the FSS around the patient), 3) secured logroll, and 4) lifting. Comfort and perceived security also were assessed on a visual analog scale.

RESULTS

There was approximately 6-8 degrees greater motion in the sagittal, lateral, and axial planes during the application of the LBB compared with the FSS (both p < 0.001). No difference was found during a secured logroll maneuver. The FSS induced more sagittal flexion during the lift than the LBB (p < 0.001). The FSS demonstrated superior comfort and perceived security.

CONCLUSION

The FSS caused significantly less movement on application and increased comfort levels. Decreased movement using the FSS may reduce the risk of further spinal cord injury.

Caring for the patients with cervical spine injuries: what have we learned?

PURPOSE

Anesthesiologists are often involved in the early management and resuscitation of patients who have sustained cervical spine injuries (CSIs). The most crucial step in managing a patient with suspected CSI is the prevention of further insult to the cervical spine (C-spine). In this review, important factors related to initial management, diagnosis, airway and anesthetic management of patients with CSI are presented.

SOURCE

Medline search was performed to seek out the English-language literature using the following phrases and keywords: spine trauma; cervical spine; airway management after CSI.

PRINCIPAL FINDINGS

Cervical spine injury occurs in up to 3% to 6% of all patients with trauma. The initial management of a patient with potential spine injury requires a high degree of suspicion for CSI so that early stabilization of the spine can be used to prevent further neurological damage. Diagnostic radiology has a critical role to play; however, clinical evaluation is equally important in excluding CSI in a conscious and cooperative patient. Although in-line stabilization reduces the movement at C-spine, traction causes clinically significant distraction and should be avoided.

CONCLUSION

A high level of suspicion and anticipation are the major components of decision making and management in a patient with CSI. Endotracheal intubation using the Bullard laryngoscope may have some advantages over other techniques as it causes less head and C-spine extension than the conventional laryngoscope, and this results in a better view. However, the current opinion is that oral intubation using a Macintosh blade after intravenous induction of anesthesia and muscle relaxation along with inline stabilization is the safest and quickest way to achieve intubation in a patient with suspected CSI. In summation caution, close care and maintenance of spinal immobilization are more important factors in limiting the risk of secondary neurological injury than any particular technique.

The effectiveness of extrication collars tested during the execution of spine-board transfer techniques

BACKGROUND CONTEXT

In the prehospital stages of emergency care, cervical collars are (supposedly) used to aid rescuers in maintaining in-line stabilization of the spinal column as patients with potential or actual injuries are shifted onto a spine board to achieve full spinal immobilization. Unfortunately, not a single study has examined the effectiveness of cervical collars to control motion during the execution of spine-board transfer techniques.

PURPOSE

To evaluate the controlling effect of three cervical collars during the execution of spine-board transfer techniques.

STUDY DESIGN

This was a repeated measures investigation in which a cadaveric model was used to test the effectiveness of the Ambu (Ambu, Inc., Linthicum, MD), Aspen (Aspen Medical Products, Inc., Long Beach, CA) and Miami J (Jerome Medical, Moorestown, NJ) collars during the execution of the log-roll (LR) maneuver and the lift-and-slide (LS) technique.

METHODS

Six medical professionals executed the LR and the LS on five cadavers. An electromagnetic tracking device was used to capture angular movements generated at the C5-C6 vertebral segment during the execution of both transfer techniques. The types of motion that were analyzed in this study were flexion-extension, lateral flexion and axial rotation motion. To test the three cervical collars, an experimental lesion (ie, a complete segmental instability) was created at the aforementioned spinal level of the cadavers and sensors from the electromagnetic tracking device were affixed to the specified vertebrae to record the motion generated at the site of the lesion.

RESULTS

Statistical tests did not reveal a significant interaction between the independent variables of this study (ie, transfer technique and collar type), lending no support to the notion that there may be a combination of collar and transfer technique that could theoretically offer added protection to the patient. Although there was a decrease in the amount of motion generated in every one of the planes of motion as a result of wearing each of the three collars, none of the changes that emerged proved to be significantly different. A significant difference was noted between the LR and LS techniques when the amount of lateral flexion and axial rotation motion generated with each of the procedures were compared. In both cases, execution of the LR maneuver resulted in significantly more motion.

CONCLUSIONS

The data presented here suggest that the collars tested in this study are functionally similar. It is recommended that this study be repeated with a larger sample size.

Comparison of a long spinal board and vacuum mattress for spinal immobilisation

OBJECTIVES

This study was designed to compare the stability and comfort afforded by the long spinal board (backboard) and the vacuum mattress.

METHODS

Nine volunteers wearing standardised clothing and rigid neck collars were secured on to a backboard and vacuum mattress using a standard strapping arrangement. An operating department table was used to tilt the volunteers from 45 degrees head up to 45 degrees head down, and additionally 45 degrees laterally. Movements of the head, sternum, and pubic symphysis (pelvis) from a fixed position were then recorded. The comfort level during the procedure was assessed using a 10 point numerical rating scale (NRS) where 1=no pain and 10=worst pain imaginable.

RESULTS

The mean body movements in the head up position (23.3 v 6.66 mm), head down (40.89 v 8.33mm), and lateral tilt (18.33 v 4.26mm) were significantly greater on the backboard than on the vacuum mattress (p<0.01 for all planes of movement). Using the NRS the vacuum mattress (mean score=1.88) was significantly more comfortable than the backboard (mean score=5.22) (p<0.01).

CONCLUSIONS

In the measured planes the vacuum mattress provides significantly superior stability and comfort than a backboard.

Cervical spine immobilization before admission to the hospital

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

All trauma patients with a cervical spinal column injury or with a mechanism of injury having the potential to cause cervical spine injury should be immobilized at the scene and during transport by using one of several available methods. A combination of a rigid cervical collar and supportive blocks on a backboard with straps is effective in limiting motion of the cervical spine and is recommended. The long-standing practice of attempted cervical spine immobilization using sandbags and tape alone is not recommended.

Maximizing comfort and minimizing ischemia: a comparison of four methods of spinal immobilization

OBJECTIVE

To determine which of four methods of spinal immobilization causes the least ischemic pain.

METHODS

A prospective, nonblinded comparative trial was conducted at a statewide emergency medical services training facility using a convenience sample of emergency medical technician students. After lying motionless for 10 minutes, students evaluated each device using a 10-centimeter visual analog scale. Subjective comfort was used as a measure of ischemia.

RESULTS

Comfort scores were significantly different for all methods (F = 101, p < 0.001). A backboard padded with a gurney mattress and eggcrate foam (the equivalent of a spinal rehabilitation bed) caused the least ischemic pain (9.6 cm, 95% CI, 8.9 to 9.8 cm). A backboard padded with a gurney mattress was the second most comfortable device (7.0 cm, 95%/CI, 6.4 to 7.4 cm). A backboard padded with a folded blanket was the third most comfortable (3.3 cm, 95% CI, 2.6 to 4.9 cm). The backboard alone caused the most pain (0.8 cm, 95% CI, 0.7 to 2.1 cm).

CONCLUSION

Increasing the amount of padding on a backboard decreased the amount of ischemic pain caused by immobilization.

Emergency department evaluation and treatment of the neck and cervical spine injuries

In the United States, nearly 5 million patients per year require spinal immobilization. The emergency physician (EP) must be able to efficiently and effectively manage these patients. To do so, the EP must have an understanding of cervical spine anatomy, spinal immobilization techniques, specific injury patterns, optimal imaging studies, and associated injuries and treatment modalities. This article addresses these important issues and discusses other challenges in the management of cervical spine injuries.