Best Practices: Myths and Realities of Spinal Immobilization

Editor's Note: The following column is meant to stimulate critical thinking amongst EMS practitioners. It contains information and opinions that may be foreign to some readers and downright shocking to others.

This piece should be taken for what it is and not be misconstrued as an opportunity to disregard local protocol. Neither the author nor the editor advocates the practice of medicine without standards. The readership is encouraged to talk about the issues contained in this article with department leadership and their medical directors. As always, we welcome your comments.

For each of the numbered statements below, pick the answer that is the best fit from the following list:

a. There is a sound evidence basis for this statement (i.e. there is scientific evidence beyond a reasonable doubt which supports this practice or procedure)
b. Clear scientific support is lacking, but the procedure is considered a "best practice"
c. This is no evidence to support this practice, which is more myth than reality

1. Prehospital spinal immobilization prevents spinal cord injury.
2. Manual cervical stabilization is always required until a cervical collar is applied.
3. Cervical collars alone are inadequate to prevent cervical movement.
4. The standing backboard technique should always be employed when a patient who fits criteria for cervical immobilization is found standing.
5. Rapid extrication has been proven to save more lives than use of the KED.
6. Rapid extrication is now the preferred mode of removal of a patient from a vehicle after a crash of any magnitude.
7. The KED or similar devices have been proven to reduce paraplegia in patients with thoracic or lumbar fractures.
8. A cervical collar is adequate to provide temporary immobilization of a possible cervical spine fracture.
9. Cloth tape is a proven and acceptable method to secure a patient to a backboard.
10. Skin breakdown does not occur after a patient is placed on a backboard.

If you chose answer "a" for any of the above statements, I have good news and bad news for you. The bad news is that you are incorrect. It may come as a shock, but there has never been a randomized prospective trial conducted anywhere in the world and published in a peer-reviewed medical journal to determine if any of the aspects of spinal immobilization actually prevent spinal cord injuries or somehow lessen the morbidity of spinal column injuries. (For more information, see below.) The good news is that we can address many factual discrepancies in this column which may aid in the management of those patients who may have spinal column and/or cord injuries and help to reduce on-scene time.

The ten statements above are presented in no particular order, but represent a broad spectrum of the concerns surrounding spinal immobilization in the field. We will group them into several categories for a brief discussion. What is most interesting about many of these practices is how they developed into de facto industry standards (which is not the same as standards of care) in the absence of any scientific information to support their use. Of course, this information power vacuum itself probably contributed to the development of these practices. Note that the single most divisive issue currently, spinal clearance by EMS providers, is not listed here. This issue is complex and deserves its own discussion, which we will present later this year.

Cochrane Review
The readership is referred to the brief evidence-based emergency medicine report by Baez and Schiebel entitled, "Is Routine Spinal Immobilization an Effective Intervention for Trauma Patients?" which appeared in the Annals of Emergency Medicine in January 2006. The objective of this study was to quantify the effect of different methods of spinal immobilization (including immobilization versus no immobilization) on mortality, neurologic disability, spinal stability and adverse effects in trauma patients.