Ep. 30 - Rethinking Spinal Immobilization: EMS Evidence Update

Reevaluating Spinal Motion Restriction: Evidence Update

In this episode of Wilderness Medicine Updates, host Dr. Patrick Fink delves into the evolving guidelines and practices concerning spinal motion restriction. Drawing from historical dogma and modern research, Patrick explores the inefficacies and potential harms of traditional spinal immobilization tools like rigid spine boards and cervical collars. Instead, he advocates for more flexible, evidence-based approaches such as using well-padded surfaces and coaching patients to minimize their own motion. Key points from a comprehensive literature review by the National Association of EMS Physicians and other authoritative bodies are discussed, highlighting the shift from immobilization to motion restriction and its practical implications. Listeners are urged to stay updated with current evidence and consult medical directors before altering their practices.

Links

Ep. 14 - Spinal Immobilization Guidelines Update

2018 ACEP/NAEMSP Sminal Motion Restriction Position Statement

Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries - A NAEMSP Comprehensive Review and Analysis of the Literature

Chapters

00:00 Introduction to Wilderness Medicine Updates

00:42 Historical Perspective on Spinal Immobilization

01:44 Transition to Spinal Motion Restriction

03:30 Review of Recent Literature

05:40 Key Findings on Spinal Motion and Neurological Outcomes

09:30 Effectiveness of Backboards and Cervical Collars

12:10 Potential Harms of Immobilization Tools

16:38 Practical Recommendations and Future Directions

21:48 Conclusion and Final Thoughts

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Transcript

Patrick Fink: 0:01

Hello and welcome back to Wilderness Medicine Updates. I'm your host, Patrick Fink. Today I'm gonna dive a little bit more into the idea of spinal motion restriction. A few episodes back, there was an episode about the updated guidelines on spinal motion restriction. Make sure to dive into that if you haven't before, but why am I talking about this more? The reason that I'm talking about this more is that as I sit here in my office, I have a few EMS textbooks behind me from when I trained as a basic life support provider, an EMT basic to, you know, have those skills as a ski patroller back in the year 2011 or so, a long, long time ago, and back at that time, treatment of traumatic victims. I had a heavy emphasis on immobilization of the cervical spine. It was like get on scene BSI seen as safe shoot trauma victim. Okay, I'm gonna go to the head and I'm gonna hold the head. I'm gonna stabilize the cervical spine, and then we're gonna definitely put on a cervical collar and we're gonna put that patient on a hard backboard with the spider straps and they're gonna stay strapped to this plastic thing because the dogma was that movement. Of the spine after initial injury could cause neurological disability. If we weren't careful, we could paralyze that patient. Well, the world has been changing. One of the changes that I've promoted as a medical director for ski patrol is a movement away from this older idea of spinal immobilization, the rigid spine board, and the hard cervical collar to other forms of spinal motion restriction, which is one of the new terms of art. And those. Tactics can include coaching a patient to remain, still using a vacuum mattress as a mobilization, using a flat and well padded toboggan or a gurney as Im mobilizing surfaces and other means of securing the head while we trans transport the patient. The reason that I was transitioning to this spinal motion restriction is largely based on this great joint position statement that came out from the National Association of EMS Physicians, American College of Surgeons Committee on Trauma, and the American College of Emergency Physicians, so the EMS people, the trauma surgeons, and the ER docs. And this came out in 2018. Old news kind of, but it hasn't really percolated this brilliantly concise and legible document highlights that there are a wider variety of tactics that can be employed to reduce unwanted motion to the injured spine. And it also highlights that a lot of the tactics we do employ, like a hard collar, don't really immobilize the spine at best. They just. Reduce motion, and that's why we switched to the spinal motion restriction or reduction terminology away from spinal immobilization. But I'm always on the lookout for new or better information to inform what we do. I wanna deliver the highest quality care that we can based on the best evidence. So I was quite happy to come across an article in the Wilderness Medicine magazine that was written by Seth Hawkins, who's a well-known EMS and wilderness physician, who is quite literally the chief author on the wilderness EMS textbook about the history of spinal immobilization in the evolving literature on the subject. And that led to. Finding the article, which is linked in the show notes, which is called Pre-Hospital Trauma Compendium, Pre-Hospital Management of Spinal Cord Injuries, A-N-E-M-S-P, comprehensive Review and Analysis of the Literature. That's a chunky name, but basically the National Association of EMS physicians are doing these comprehensive reviews on pre-hospital management of trauma, and they went to the literature and tried to find everything that they could. All the available evidence about the pre-hospital management of spinal cord injuries so that they could answer a few select questions and say, what does the evidence actually say on this point? They did a huge literature search, and we're gonna talk through their primary questions and what they found. I've distilled their questions a little bit to make them a little bit more understandable, a little bit less wordy, so forgive me there, but we've got some great material to move through here and we're gonna bust some dog mouth. These folks screened 3,944 articles and reviewed 769 full manuscripts, and ultimately found 115 papers that they used to fully inform their review of these questions. So this is the best available evidence current 2025 publication date. That I think, you know, timestamp now January, 2026 is potentially the best information that we have to inform how we immobilize patients. So the idea here is we're looking for evidence for, is there supporting evidence that suggests that if we don't handle trauma patients well, we can cause neurological injury. If we do handle them well, can we reduce rates of neurological injury? And are there problems or side effects or adverse effects of the tactics that we are using to try to immobilize the spine? So the first question that they asked is, what are the causes of delayed neurological injury in trauma patients with a focus on movement? Hypoxia, low oxygen or hypoperfusion. Low blood pressure so you have a trauma patient. They've been injured. Will moving them subsequent hypoxia or subsequent hypoperfusion result in delayed neurological injury? Well, here's the punchline right up front, which is that they did not find any quality evidence showing that movement of a PA trauma patient with spinal injuries results in worse neurological outcomes. I will say that again. There are no papers that show a connection between handling trauma patients with spinal injuries and worsening their outcomes, the dogma that we've been relying on my entire medical career. Came from two very crummy case reports in the early 20th century. I'm talking like the 1930s, where some surgeons had a list of cases and said, Hey, we think that the outcomes that these patients had were due to their pre-hospital handling. But there was very poor description of these cases. There were a bunch of confounding factors, like it was just very low quality evidence. And this stuff got incorporated actually into these early textbooks, emergency care and transportation of the sick and injured. That's the one sitting on the floor behind me back in the seventies, used this to create the dogma that we still use today. So there's not actually evidence that moving a patient can is gonna harm them or result in a worse. Neurological outcome down the line. In contrast, there is evidence that low blood pressure after an initial injury can worsen the neurological outcome. And the studies that they reviewed there were a lot more rigorous. For example, one showed that a 10 millimeter mercury increase in pre-hospital mean arterial pressure led to a 79% increase in the odds of a patient having improved neurological outcome and the benefit. Was seen at an inflection point of around a mean arterial pressure of 85. Additionally, another study showed that in patients with fewer pre-hospital hypotensive events, they saw neurologic better neurological recovery. At one year, they didn't find any significant evidence pertaining to hypoxia, so movement. Not a big influencer of delayed neurological injury in trauma patients, but hypotension may be. It may be that defending a mean arterial pressure of 85 millimeters, mercury is actually much more important. So that's like the big dogma out of the way. But let's just say hypothetically that we are still worried about moving trauma patients. We wanna protect, protect them from unnecessary movement. Do backboards and cervical collars prevent neurological injury or reduce spinal motion as they are intended? In short, probably not. The one paper that they identified that showed a benefit to spinal immobilization, failed to control for a lot of other variables and had multiple methodologic flaws. If anything, it may support the use of cervical collars. In a specific subgroup of patients, those with a cervical cord injury and a high trauma severity score of an ISS score of greater than nine. So sick, sick trauma patients with a suspicion for cervical spine injury. Perhaps in this one study, however, it's also confounded this one study by the. Hypertension issue, it's not controlled for. So the effect could be all about hypertension. On the other hand, quite a number of other higher quality studies were identified that show either no change to neurological deficits when using cervical colors and spine boards, or worsened neurological deficits. After immobilization, nine studies showed increased movement of the spinal column after immobilization. Six of them showed no effect, and 11 showed a reduction in spinal movement with immobilization. So there is a, there's a mix of them there, but there is really no clear, clear benefit. It's essentially 50 50 leaning slightly towards no effect or worse movement, and quite a few studies. F. Quite a few studies showed no effect on neurological deficits when immobilization was withheld. So in systems that moved away from cervical collars or rigid spine boards, they found no increase in delayed neurological injury in those patients. Even the ones who were then later found to have a cervical spine injury. So the cervical collar, the backboard probably aren't actually reducing motion in the way that we hope them to be. There's some evidence that they might actually increase neurological deficits, and then when you take them away, there's no negative impact to the patients. It's getting harder and harder to think that these are things that we really should be using. Now their third question is, does using a backboard or a cervical color harm patients and their focus here was on pressure ulcers, respiratory problems, increased intracranial pressure, or direct harm to the nervous system. They identified quite a few studies that showed that even brief use of a spine board or cco, just a CCO alone, were associated with the development of pressure injuries. And that's not just in the elderly, but the, that is our big at-risk population. And unfortunately sad for me because I like them a lot. This might also apply to vacuum mattresses. So immobilizing people, even for a short period of time, starts to accumulate a risk of pressure injury that's, I think, intuitive and something that we want to minimize as much as possible. Sea collars. We're also found to make it more challenging for patients to breathe, and there was a study that demonstrated that it can lead to respiratory obstruction in unconscious patients. Unfortunately, again, using a vacuum mattress doesn't seem to prevent those issues. How about intracranial pressure? Can you catch onto a theme here? Intracranial pressure was found to be elevated in patients with CCO use. This is a problem with anyone who has bleeding or swelling in the brain or reduced blood pressure due to poly system trauma, and we're just trying to circulate blood to the brain because that blood flow to the brain is basically your mean arterial pressure. The perfusing pressure. Minus the intracranial pressure. So let's say you have a low blood pressure. If we increase the intracranial pressure, the amount of blood flow that the brain gets is actually reduced. So putting on a cervical collar, likely obstructs venous outflow, blood returning from the brain, creates a traffic jam, and subsequently increased intracranial pressure and reduced blood flow to the brain. Not ideal in people with intracranial injury. Lastly, and not surprisingly, CCOs and backboards increase pain and discomfort in patients. And when those patients arrive in the hospital, they are more likely to receive radiologic studies like X-rays and CT scans than patients who arrive without immobilization in place. I think we, we could say that in an ideal world, there would be equal rates of imaging, which were based on. Clinical signs and symptoms, patient history and mechanism, but just seeing that cervical collar on the patient and the backboard, I can relate to you as an emergency physician. It feels like you are taking a risk if you choose to clear that patient's cervical spine without radiology. Lastly, and just briefly, they looked at whether there are other factors that could influence the usefulness of backboards and cervical collars, like effect on patient anxiety. You know, age and anatomy affects environmental conditions. Uh, just a couple short points here. Sea collars, particularly distort anatomy in pediatric patients because they have humongous heads and small bodies. You know, kids are shaped like lawn darts and have, you know, very flexible cervical spine. So when you clamp it, it puts them in a compromised anatomical position. Unclear the clinical significance of that. Older people tend to spend more time in cervical collars once they're on. Probably because of that reason that I just talked about when, when we see an older person in a cervical collar, we feel more reluctant about clinically clearing that spine in the emergency department without radiology. So it's staying on longer in older folks, and they are the ones who are at greater risk of developing swallowing difficulties or respiratory problems from having those cervical collars on. So what can we take away from this? I think we can actually take away that the 2018 joint policy statement that I talked about upfront is probably a bit too aggressive in recommending spinal motion restriction. There just isn't good evidence that. Movement of the patient after injury can be harmful to them or that spinal immobilization is able to reduce those harms. On the other hand, there's good evidence that hard spine boards, cervical collars, and even vacuum mattresses can cause harm to patients. Now the literature review here is all based on retrospective, looking back and observational data. There's no prospective clinical trials really informing our practice here, but it may still be strong enough evidence to change our practice. I thought initially that this opened the door to a clinical trial. That could be the end of backboards and cervical collars, but there's an interesting letter to the editor and response from the authors on this. Review where they actually say, yes. We don't think you can do a randomized controlled trial of cervical collars, but it's not because of risk to patients from withholding it. We think that there's actually just an abundance of evidence that these things are harmful. There's a paucity of evidence that they're helpful, and so it's probably unethical to subject people to it. Which is a fascinating stance to take. The National Association of EMS Physicians, the College of Surgeons on Trauma and, and American College of Emergency Physicians have not updated their position statements on this yet. So we're at essentially the bleeding edge of the evidence currently. So what can we use for touchstones for now? What can we actually take to the bank? I think it is reasonable practice to minimize movement of the spine in cases where a spinal injury may be present. But we need to think more broadly about motion minimizing tactics to include well padded surfaces like toboggans or gurneys or beds, litters, and coaching patients to minimize their own motion. We should take those old extraction tools, the long spine boards, the scoops, and think of them as extrication tools. They're patient spatulas as someone put it to me recently. They remain useful to us in certain contexts. For example, in the ski patrol context, the toboggan ride is essentially an extrication from the mountain environment. It's a very motion rich environment. We sometimes need to move unconscious or uncooperative patients around in a challenging, slippery soft surface called snow. Securing them on a spine board for the relatively brief transport to a base clinic or an ambulance is a reasonable thing to do. But once we get to that clinic or ambulance, we should try to remove them from the board or the vacuum mattress and onto a soft surface To minimize harm to the patients, we should definitely start paying more attention to blood pressure in our trauma patients. And we need to minimize hypotension in patients where there might be a suspected spinal injury. That means monitoring on a regular basis. It means patient positioning and it means potentially considering fluid boluses uses use of blood pressure supporting medications or if you're in the right context. Blood products, sadly for me because I do love them. Vacuum mattresses shouldn't be thought of as safer spinal immobilization because they're accompanied by many of the same issues, such as pressure ulceration or um, respiratory compromise. However. They're definitely more comfortable than a hard spine board and should be used in place of them whenever it's reasonable. If you're using it as an extrication tool, it's definitely better than a hard plastic board that, and they remain excellent tools for splinting. The whole body in the position of comfort or however is found in a patient who has multiple traumatic injuries and needs to be moved. So I'm not throwing these out with the hard plastic spine boards. I'm still enthusiastic about the use of the vacuum mattress and in contrast to long spine boards, there is not quite as robust a bevy of evidence to suggest harms from these. So I am definitely keeping them in our toolkit and I think they're super useful in polytrauma patients. And finally, moving forward, we're gonna need to be able to continually reexamine our practices as far as spinal motion restriction goes. And we need to be prepared to change those in the future as more and better evidence becomes available and as society guidelines align with the evidence. So I hope that this was useful if you. Haven't taken the march through the spinal immobilization stuff before. Definitely look back at the older episode that I did and you know, for the Interested reader, this literature review is very well written and very entertaining. Particularly the recounting of the history of the dogma of where spinal immobilization came from, those early case reports and how that came to be. I just enshrined in the EMS textbook that then became the predominant source of information training. EMTs and paramedics across the country, it's freely available. So go ahead and grab a copy of that PDF if you're, if you're feeling nerdy. Otherwise, thank you for listening to Wilderness Medicine Updates. Share this show with someone who would appreciate it. Share it with a fellow Ski Patroller SAR member. EMT. Medic, firefighter, fellow nurse, even maybe your local ER physician who may not be so hip to this stuff. I know that we are starting to look at a system level about could we possibly maybe start minimizing the use of cervical collars and have a liberal policy about removing them when the patient arrives to the emergency department. I'd encourage you, of course, to speak with your medical directors before making any change to your own practices if you're in a structured context, because while it is important to try to practice at the leading edge of the evidence and. The evidence that supports the best possible care of our patients. You also shouldn't be practicing outside of your protocols. You want the system to evolve with you so that you are protected as you protect your patients. I. If you have questions, comments, feel free to reach out. I love hearing from you at Wilderness Medicine updates@gmail.com. In response to listener questions, I'm trying to bring new episodes online, find guests, authorities to answer your questions. You can look forward to more of that coming soon. Or if you just want to give a shout out, I'll shout you out on this little radio station of ours. So thanks again for listening. Until next time, I'm your host, Patrick Fink. Stay fit, stay focused, and have fun.