The C-Spine Immobilization Controversy

C-spine immobilization is not a benign procedure.

It’s not something that’s always worth doing “just in case.” It’s not risk free, comfortable or even practical. And, now, recent research from the Washington University School of Medicine suggests that it may not even do such a good job of keeping the patient’s head still.

Does anyone else agree that we’ve seen enough bad news about c-spine now that we can stop the massive overuse that plagues our industry? Can we start evaluating people and deciding who does and doesn’t meet criteria for spinal immobilization. Please?

      

Consider that c-spine:

  1. Increases aspiration risk
  2. Makes airway management more difficult
  3. Increases intracranial pressure
  4. Increases the incidence of pressure sores
  5. Is expensive.
  6. Increases combativeness in drunk patients
  7. Is time consuming to put people in.
  8. Is difficult to remove without lumbar movement.
  9. Frequently fails to achieve a neutral alignment.

        

And now, this latest research suggests that we’re also causing quite a bit of movement when we c-spine using our most common in-the-car methods. (Something most EMS providers have been painfully aware of for a long time.)

The study used an infrared video motion capture system to analyze cervical movement during for different extraction scenarios. The patient was allowed to self extricate without any immobilization. Then the patient self extricated with a cervical collar in place. Third, the patient was removed by two medics head first. And finally the driver was removed head first with a KED.

Most field providers can already guess which technique moved the spine the least. We’ve known it for a long time. The patient who had the c-collar placed and then was allowed to extricate themselves and lay down on the board had the least amount of cervical movement.

Smart research like this is exactly what we need to final overhaul this flawed treatment modality.

    

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Comments

  1. When I taught paramedic classes, I would do a rant on this. I would take an informal poll on how many of my students have ever taken a neck fracture into the ER. It is usually not many. Then I ask how many of those fractures did not have any sort of mechanism of injury that would clue you in to the injury. Right there is where everyone tells the crazy stories of extensive trauma. Then I say, “Okay, has anyone in here ever had a neck fracture that they didn’t expect?” Only once have I had a student tell me yes. And after pursuing that student for more explanation I found that the patient was c/o pain. So there was still a reason to suspect something.

    Then, after I have set the stage for conversation I say, “Okay then, how many people have you inconvenienced over the years by making them lay on a hard-ass backboard for over an hour? How many patient’s have you had to dump on their side with vomiting? How many pregnant patients have you strapped to a board? How many little ol’ ladies from nursing homes have you hurt? Do the people we help justify the people we hurt with this procedure?”

    Then the whole liability argument comes up. And the class as a whole always admits that the only reason we do it is liability. And we all know that liability is the basis for much of the medical care we do. I know what is going to have to happen. People are going to have to start suing over damages done from strapping people down to a backboard. If the liability pendulum starts to swing the other way these protocols will change so fast your head will spin. And then you really will have a neck injury worth collaring.

  2. Called to 24 y.o. Female pt, post fall off horse, LOC< 1min. On scene, pt dorsal GCS 15, VSS stable and in good humour! C/O pain 9/10 Right Clavicle (closed # obvious) and possible rib #. A Ferno/Patriot collar that I attempted to place after a secondary head to toe survey was just causing too much pain. I tried a soft collar pad but took a clinical decision to not C-Spine collar at that stage but use bystanders to scoop stretcher and load. Manual head and spine alignment at all times, nil neck pain and nil abnormalities detected- spine visualisation and palpation. Should I have C- Spined or even Kendrick’d? I could have. In this case, a high degree of suspicion and using moderate clinical experience, I think I did the right thing. As Ambulance/EMT professionals- we are on a constant learning curve. Both Evidence based and on the road practice outcomes are essential! Thanks for the excellent articles!

  3. In reply to Buckman I quote “Then I say, “Okay, has anyone in here ever had a neck fracture that they didn’t expect?” Only once have I had a student tell me yes.” I have actually had a person that had been in a car wreck had no pain anywhere and had not even a scratch on him. Upon palpation of the neck there was no deformities or pain noted. We ended up flying him out of our hospital with a C 2 or C 3 fracture.

    So maybe we do not need to look into when or when not to use c-spine immobilization, but more importantly take into account C-Collar size and care in move the pt….

  4. Buckman I agree about the liability pendulum. When do we become concerned about eh drunk teenager who aspirated straped to the board, the elderly female with sepsis from her pressure sores, the failed nasal intubation.

    The “just do it on everyone” crowed fails to recognized that c-spine is not a benign procedure.

  5. Austrailian it sounds like this patient was appropriate to immobilze and you did immobilize. I think his is another common c-spine error. We learn standard immobilization with all the bells and whistles and then we think we can’t adapt that technique to fit the circumstances. You can.

    If the patient has sever kyphosis, you cant force them to a flat board, Use a bunch of pillows and tape the head to the pram … or use someone to manually hold the head still.

    Broken clavicle? Forget the collar! The pain you cause them is going to create far more movement that the lack of a collar will.

    Combative head injury … sedate them. The end goal is to create as little mvement as possible. Sometimes forgoing some of the equipment IS the best immobilization.

    Good job using your head instead of blindly following the protocol.

  6. Tony, thanks for being willing to put yourself out there and take a contrarian stance on the subject. I’m glad you came along and said something people are thinking.

    The patient you are describing is called an outlier. Someone whos presentation lies on the far outer end of the clinical spectrum. I can’t say if I would have ruled the patient in for c-spine or not. I’d have needed to be there. Maybe, maybe not.

    But if there was no significant mechanism, no underlying bone degenerative etiology, no pain on palp or movemment, no neurological deficits, no distracting injurys and no intoxication / sedation / ALOC. Then I don’t think it was a bad decision to not c-spine.

    To say that the end result … the presence of a very unusual c-spine fracture, makes the lack of immobilization wrong is called hindsight bias. http://en.wikipedia.org/wiki/Hindsight_bias .

    If the event was not predictable .. it isn’t justification to start puting everyone in c-spine and just being real careful when we do it. Research says cervical fractures are predictable. When a clearance protocol is used we find them over 98% of the time.

    C-spine is not a benign procedure. If we can minimize its use … we should.

  7. Unfortunately, the “just c-spine everyone” crowd doesn’t come entirely just from the liability aspect, although it could be said that this is an extension of that.

    EMT training, and a percentage of paramedic programs just don’t teach the proper assessment skills needed to completely rule out a cervical fracture. While there are good protocols in place for “clearing” a cervical, thorascic, and lumbar spine, can the skills of the average EMT be trusted to rule out a condition that risks permanent paralysis or even death?

    I “clear” spines on a regular basis using a systematic, detailed physical assessment that includes as thorough of a neuro and ortho exam as I am able to perform.

    I’d say that the answer lies between increasing our proficiency in examining the spine for injury and improving our equipment used for the procedure. Do we have to use the long board and uncomfortable collar or is there something better?

  8. Michael Endres says:

    “Other limitations include the use of a mock automobile and our choice of subjects. We involved only healthy, cooperative, EMS-educated personnel, whose depth of medical knowledge was another drawback.” (Washington University School of Medicine)

    I found this study very limited in its diagnostic conclusion regarding the given circumstances and condition mentioned above. Don’t get me wrong, I also found it is a start at least and I am glad somebody did it. Evidence based medicine is a good thing and I highly believe it is the way to go. But it is always a question of what you really want to prove with your study or if you are just simply looking at the facts. I don’t think that you can compare a fit, healthly and medically knowledged person with the avarage injuried, unstable, emtionally distressed and unaware patient you normally would have in such an incident. Especially here in Australia exists quite a confusion in the ambulance services regarding this topic. The trend here is rather away from full immobilisation then we used to do years ago, based on studies like this one. But I think much more research has to be done before final conclusions can be made…..what about cultural and anatomical deferences, various injury patterns, weather conditions (temperature?), education level etc.? “One size fits all” is always dissatisfying and you can’t compare apples to oranges. Want we need is prehospital data with real patients….any ideas?

    Keep up the good work!

  9. Michael Endres says:

    Sorry for the horrible typos (deferences/differences, Want/What etc)! Next time I will use my laptop again instead of my iphone and get some more sleep after night shift….promised! ;-)

  10. Immobilisation is such a argumentative subject, to do or not to do and in my opinion , contrary to Michael E’s statement above, i believe its not my job to rule it spinal damage but to assume from the mechanism, symptoms, etc that it may be present. How many paramedics / emt’s have treated a burly guy who doesnt tell the whole truth about the symptoms that they have and not all spinally injured patients are going to have apparent symptoms.

    I treated a patient a few weeks ago whos motorbike front tyre slipped on gravel on a bend, bystanders said it was a slow slide. Patient got up and pushed his bike back to the side of the road and awaited help. On arrival he was sitting on the kerb. He complained of pain to his shoulder only which was dislocated. Pt was fully immobilised because of a distracting injury although didnt complain of pain any where else and had no neuro deficit. At A/E the Dr removed all immobilisation after handover. 2 days later a crew transported the pt to a spinal care facility with a C6 and C7 fracture.

    You can never take enough care and you can never 100% rule out a spinal injury in the field.

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