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Spinal Motion Restriction

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Natalie Monas

on 30 September 2014

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Transcript of Spinal Motion Restriction

Spinal Motion Restriction
Objectives
Explore current spinal immobilization techniques
Explore how we got to where we are
Review current research in spinal immobilization
Review our current protocol
Introduce our new protocol

Disclosure
I have developed this presentation based on the information that has been presented by Dr. Jacobsen from Johnson County Med-Act.
Where it all started.......
The seperation of C-Collar and LSB
Cervical collar usage will not change!!

We are not "clearing" the c-spine

The old moto....."If you are going to do it, do it all" will go away



Where we are today......
The new paradigm in trauma management
How do we fix this problem?
Farrington, 1968

First detailed the use of a c-collar and a rigid backboard for use in patient extrication. This was to prevent inadvertent head and neck movement during the extrication.

This spine board was designed to be used as an extrication device!!
What started this dogma?
EMS was established!!
1971

American Academy of Orthopedic Surgeons (AAOS) publishes the first guidelines for EMS.

These guidelines advocate using a backboard and c-collar for trauma patients with S/S of a spinal injury.
Another assumption
Bohlman, 1979

Linked delayed paraplegia, in 100 of 300 hospitalized cervical spine fracture patients, with concern that these injuries were being "under-appreciated"

That must be because EMS messed up!!!

This caused spinal immobilization based solely on MOI


Evidence against LSB
Respiratory compromise on healthy patients. (reduce FVC, FEV1 in healthy patients strapped to a board)

What about injured ones?
Rib Fractures
Pulmonary Contusions

Evidence against LSB
Pressure sores
Evidence shows even short periods on a board can cause tissue hypoxia on contact points. This leads to tissue destruction and pressure sores. People who can't readjust on a board are at an even higher risk.
Evidence against LSB
Hauswald et al. 1998.
Compared outcomes of spinal injury patients in New Mexico with modern EMS and full spinal immobilization and patients in Malaysia where there was no spinal immobilization.
Geisler et al. 1966
Retrospective study of trauma patients with delayed paralysis.

“Failure to recognize the injury and protect the patient from the consequences of his unstable spine.” …regarding an MVC patient with skull fracture in 1955 who had delayed onset of paraplegia T4.

“The importance of proper first-aid (by EMS providers in field) was deduced from the fact that 29 patients [in their review] developed further paralysis through faulty handling.”

Geisler WO, Wynne-Jones M, Jousse AT. Early management of patients with trauma to the spinal cord. Med Serv J of Can. 1966;4:512-23.

Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann Emerg Med. 1988;17:915-8
Walsh M, Grant T, Mickey S. Lung function compromised by spinal immobilization. Correspondence. Ann Emerg Med. 1990;19:615-6

Bohlman HH. Acute fractures and dislocations of the cervical spine. J Bone & Joint Surg. 1979;61A:1119-42.
Riggins RS, Kraus JF. The risk of neurologic damage with fractures of the vertebrae. J Trauma 1977;17:126-133.
Soderstrom CA, Brumback RJ. Early care of the patient with cervical spine injury. Orthopedic Clinics of North America 1986;17:3-13.
Burney RE, Waggoner R, Maynard FM. Stabilization of spinal injury for early transfer. J Trauma 1989;29:1497-1499.

Evidence against LSB
Leonard et al. 2012

Pediatric trauma patients (prospective cohort)
Spinal immobilization was associated with increased pain, radiographic usage, and increased admission.
Pain score (3 vs. 2)
Cervical radiography (56.6% versus 13.4%)
Admitted (41.6% versus 14.4%)
Penetrating trauma
We should NOT be immobilizing penetrating trauma.

There is a clear increase in mortality and is supported by all medical bodies.

AANS, ACS-COT, NAEMSP, NAEMT, ATLS/PHTLS
Harm in penetrating trauma
Rhee T, et al. 2006

57,523 trauma patients
Evaluated by
Blunt assault
Stab wounds
Gunshot wounds
Linares HA, Mawson AR, Suarez E, Biundo JJ. Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics. 1987;10:571-3.
Sheerin F, de Frein R. The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: a trial of three surfaces. J Emerg Nurs. 2007;33:447-50.
Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995;26:31-36.
Berg G, Nyberg S, Harrison P, Baumchen J, Gurss E, Hennes E. Near-infrared spectroscopy measurement of sacral tissue oxygen saturation in healthy volunteers immobilized on rigid spine boards. Prehosp Emerg Care. 2010;14:419-24.

Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5:214-19.

The Odds Ratio for disability was higher for patients in the United States (all with spinal immobilization) after adjustment for the effect of all other independent variables (2.03; 95% CI 1.03-3.99; p = 0.04).
The estimated probability of finding data as extreme as this if immobilization has an overall beneficial effect is only 2%. Thus, there is a 98% probability that immobilization is harmful or of no value.
They repeated analysis using only the subset of patients with isolated cervical level deficits. They again failed to show a protective effect of spinal immobilization (OR 1.52; 95% CI 0.64-3.62; p = 0.34).

Leonard J, Mao J Jaffe D. Potential adverse effects of spinal immobilization in children. Prehosp Emerg Care 2012;16:513-518.

Rhee P, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma. 2006;61:1166-1170

Rates for C-spine Fx:
GSW (1.35%)
Blunt Assault (0.41%)
Stab Wounds (0.12%)

Rates of Spine Cord Inj:
GSW (0.94%)
Blunt Assault (0.14%)
Stab Wound (0.11%)
Surgical stabilization:
GSW (26/158 [15.5%])
Blunt Aslt (6/19 [31.6%])
Stab Wnd (3/11 [27.8])
No patient with penetrating SCI regained significant neurological recovery
American Academy of Neurological Surgeons
"Spinal immobilization in patients with penetrating trauma is not recommended because of increased mortality from delayed resuscitation."
Pre-hospital Trauma Life Support
There is no data to support routine spineinal immobilization in patients with penetrating trauma to the neck or torso.
GSW and spinal trauma
Dubose et al. 2009
4209 patients with GSW's to the head, neck, or torso
327 (7.8%) had spinal column injuries
173/327 had cord injuries
2 (0.6%) required surgery
None had unstable spinal injuries

Do our LSB actually immoblize?
Do scoop stretchers work?
Del Rossi et al. 2010

Scoop stretchers and the
"lift and slide" technique
were able to restrict motion
of the spine as well as the
log-roll technique with the
long board.
What is the best extrication technique?
Shafer et al. 2009. West J Emerg Med. 2009 May; 10(2): 74-78.

Cervical Spine Motion During Extrication. A Pilot Study

They used motion capture video to monitor movement

Occiput
T-spine
Sacrum
Three Points of Contact
Sacrum
Occiput
T-Spine
Del Rossi et al. Are Scoop Stretchers Suitable for use on spine-injured patients? American Journal of Emergency Medicine 2010.

The patient was allowed to exit the vehicle on
their own and lie on a backboard.
The patient was allowed to exit the vehicle on their
own with a C-Collar in place and lie on a backboard.
The patient was extricated head first via standard
technique by two paramedics with a C-Collar alone.
 (Standard technique involves turning the driver so
that the legs are in the passenger’s seat, allowing the driver
to lie back and raising the right hip so a long board
can be placed under the hip. A second paramedic who enters
the front seat passenger’s door helps slide the patient up on to the board.)
The patient was extricated head first via standard technique
by the two paramedics with a C-Collar and a KED.

4 Techniques used
What technique won?
“Ultimately, we documented the least movement of the cervical spine in subjects who had a cervical collar applied and were allowed to simply get out of the car and lie down on a stretcher.”

What are we going to do?
A new protocol has been developed

The new term will be "spinal motion restriction"

We will follow what the Medical Advisory Committee recommended.

We will no longer transport patients on long spine boards.


Here it is!
What will this look like?
What we wont be doing
Questions?
Full transcript