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Spine Injury for the Prehospital Provider

Kevin Collopy BA, FP-C, CCEMT-P, NR-P, CMTE

Introduction

Spinal cord injuries are often permanent and debilitating. Despite the best medical care, these patients have poor chance of returning to independent life. Long-term management is also extremely expensive. The lifetime medical expense for a 25-year-old patient who experiences complete quadriplegia is more than $4 million.1 These figures emphasize the importance of pre-injury education and prevention. Measures that help prevent spinal cord injury include seat belt use campaigns, safe driving courses, firearm awareness courses, and safety education programs in sports.

Epidemiology

Every year, 12,000 people in the U.S. experience spinal cord injury (SCI), a sudden and debilitating injury that can devastate their lifestyle and livelihood.1 Spinal cord injuries range from simple contusions to complete cord transection. Presently more than 200,000 persons in the U.S. are living with limitations following a spinal cord injury.2 Traditionally, Caucasian males between age 16 and 30 have been the most commonly injured age group in the U.S. However, since 2005, individuals experiencing SCI had an average age of 42.2 years with 80% of the injuries occurring to males.1

The vast majority of spinal cord injuries occur in the cervical spine region. These injuries occur at a rate of 4.06 per 100,000 person-years, compared to rates of 0.34 per 100,000 person years for thoracic injuries and 0.75 per 100,000 person years for lumbar injuries.3 The fewest injuries occur in the thoracic region because the vertebrae are stabilized and protected by the chest wall.

Nearly half (42%) of all spinal cord injuries occur during motor vehicle collisions. Other common causes of SCI are falls (26.7%), acts of violence (15%), and sporting injuries (7.6%). Other mechanisms of injury include diving accidents, motorcycle collisions, and surgical complications. Nearly 20% of these injuries result in complete tetraplegia which is the paralysis of all four extremities. Incomplete tetraplegia occurs in 31.6% of spinal cord injuries, complete paraplegia occurs in 24.6% of cases, while incomplete paraplegia occurred in 18.6%. The remaining patients are discharged from hospitals with minimal deficits.1

Anatomy & Physiology

Picturing the spinal column anatomy allows visualization of why most injures occur in the cervical spine. The head sits on top of the smallest and most fragile vertebrae. These vertebrae lack the protection and support found in the thoracic and sacral spinal regions.

Each vertebra has two distinct parts: The body and spinal processes. The vertebral body makes up most of the mass of the vertebra and provides strength and stability. It is located on the anterior spine. When the posterior aspect of the spine is palpated, what is actually being felt is a spinous process. Three spinous processes are found on the lateral and posterior aspects of the vertebral body and are connected by bony articular processes. Together the spinous processes make a canal with the vertebral body inside of which the spinal cord travels the length of the column.

The spinal canal itself is divided into four regions: cervical, thoracic, lumbar, and sacral. Located in the neck are the seven vertebrae of the cervical spine and are named C1–7. Of note, C1 is also known as the atlas, and C2 is also known as the axis.

There are 12 thoracic vertebrae numbered T1–12. Each of these vertebrae have ribs attached which serves to increase their strength and stability.

The lower back is comprised of the five lumbar vertebrae, numbered L1–5. These vertebrae support the most weight and thus the vertebral body is the largest of all the vertebrae.

The lowest vertebrae in the spinal column are the five sacral. In addition, humans have four fused coccyx vertebrae.

Traveling from the base of the brain, the spinal cord exits the skull at the foramen magnum and travels inside of the lumen of the each vertebra until it terminates at approximately the L1–L2 junction. Spinal roots traveling beyond this point are collectively known as the cauda equina. In total, the adult spinal cord is roughly 18 inches long and less than an inch in diameter. Consecutive 31 pairs of nerve roots exit the spinal cord at each vertebra and are known as spinal nerves. Each spinal nerve has both motor and sensory nerves for a specific region of the body. Specific motor regions are known as myotomes; sensory regions are known as dermatomes.

Although it is not important to understand the function of each individual section of the spinal cord, it is important to understand that motor and sensory nerves travel along different sections of the spinal cord. Thus when incomplete spinal cord injuries occur, it is possible for only sensory or motor nerves to be impaired.

Pathophysiology

A good understanding of how the spinal column and cord can become injured can make it fairly easy to predict injury patterns and locations. The mechanism of injury also helps indicate when injury to the spinal column or cord injury is suspected-or when both are.

Mechanism of injury: Sudden forces of any sort—including direction changes, speed shifts, or blunt and penetrating impacts—that cause the head and the body to move, twist, flex, or extend in exaggerated or abnormal directions can fracture the spinal column and injure the spinal cord. The following few simple principles can help paramedics evaluate a mechanism of injury in a patient with potential spinal cord injury:

  • An object in motion will stay in its current motion unless acted on by another force with enough energy to cause a shift in the first object’s motion or direction.
  • The head is positioned on top of the spinal column and generally moves in the opposite direction of any force applied to the spinal column.
  • The greater the force, the greater the injury potential.

The absence of neurological deficit does not rule out a spinal cord injury.4

A skilled paramedic can immediately recognize a situation in which the mechanism of injury has clear potential for spinal cord injury.  These are called obvious mechanisms of injury. Such an incident often involves direct trauma to the head or torso, as well as large, sudden accelerations, decelerations, or high-velocity penetrating forces. Examples of obvious mechanisms of injury include are updated by the Centers for Disease Control and Prevention with their Guidelines for the Field Triage of Injured Patients. Updated criteria may be viewed at www.cdc.gov/fieldtriage. They currently include the following:

  • A motor vehicle crash in which the patient’s head stars the windshield.
  • A patient ejected from a moving vehicle.
  • A pedestrian struck by a vehicle and knocked to the ground.
  • A motorcycle crash at a high speed.
  • A fall greater than three times the patient’s height. In the case of an infant, this could be as small as a fall from a high chair or table.5

Based on the above information, injuries isolated to one specific body region, without an obvious mechanism of injury may not require a spine assessment or immobilization.

Quite often, patients provide a vague story or are unsure of the events that have led to their injury. Alternatively, the patient may know what has occurred but it is unclear whether the mechanism could have caused an injury to the spinal column or cord. When the mechanism is more subtle, more thorough assessments and interviews of the patient, bystanders, and other first responders are required.

The following are the two types of trauma to the spinal region:

Direct trauma: Impacts against the spinal column and/or the spinal cord are considered direct trauma. Depending on the amount of energy exchanged, an impact that strikes only the spinal column can transfer energy through the column to the spinal cord, causing the cord to swell and become impaired. Impacts passing through the spinal column may actually lacerate, puncture, or transect the spinal cord. Examples of direct trauma to the spine include gunshot wounds, stabbing wounds, and blunt force trauma, such as in an assault with a tire iron. During blunt trauma, spinal column injury can cause bone fragments to lacerate the spinal cord; cord compression can occur as a result of swelling as well.

Indirect trauma: Forces other than those that directly impact the spinal column or cord can result in spinal cord injury as well. Indirect traumas result in hyper-or exaggerated-movements, which can result in vertebrae fractures or dislocations, herniated spinal disks, or bruise, tear, or stretch the spinal cord. Other indirect traumas can transmit energy from the point of impact through the body ultimately affecting the spinal cord.

Axial loading: Also known as vertical compression, axial loading occurs when a force is significant enough to compress vertebrae together. The compression forces may result in squeezing of intravertebral disks, causing herniation or rupture, or bursting fractures of the vertebrae. Axial loading injuries can occur chronically when someone repeatedly lifts heavy loads or acutely such as in a fall where the patient lands on their head.

One of the most common acute axial loading injuries occurs when a patient falls from a significant height and lands on their feet bringing their lower body to a sudden stop. The patient’s upper body continues to move downward resulting in compression of the lower thoracic and upper lumbar vertebrae. This also occurs in diving accidents when the patient’s head strikes the bottom of water body and their body continues movement into their neck and head compressing the cervical spine. Starring a windshield with one’s head during a motor vehicle crash is yet another example of axial loading.

The spinal column, and thus cord, can normally be flexed and extended forwards and backwards. Each section of the spinal column has a unique natural range of motion with the cervical spine having the most range of motion, and the sacral spine the least. Some lateral extension is present in all spine sections as well. Abnormal flexion and extension can cause muscle and soft tissue injuries.

Hyperflexion and hyperextension: Extreme flexion or extension is termed hyperflexion and hyperextension. Either of these can rupture the tendons and ligaments, which form the spine’s stabilization system. Hyper movements also have the potential to stretch the spinal cord resulting in impaired function, tearing, swelling, or bruising.

Abnormal twisting beyond the spinal column’s normal rotation range can cause serious damage to both the spinal column and cord. Rotational forces most easily affect the cervical spine particularly when the head is twisted during a direct force trauma; however rotational forces can also affect the lower spinal regions as well. Sport injuries are common sources of twisting spinal cord injuries. Athletes wearing cleats in contact sports can plant themselves just as another athlete hits them causing their torso to twist awkwardly.

Distraction: Also known as stretching forces, distraction is the exact opposite of compression force. Distraction occurs when the body is pulled, or stretched in opposite directions. Often distraction occurs when the body is in motion and is suddenly jerked to a stop such as in bungee jumping, or in a hanging. The sudden stop results in the stretching of the spinal cord, column, and the support tendons and ligaments. Not surprisingly, the cervical spine, with the weakest support structure, is most vulnerable to distraction injuries.

Carefully evaluate what has occurred to determine which forces were involved. Understanding the forces and mechanisms involved help predict the injuries patient’s experience.

Types of Spinal Cord Injury

The great variety in mechanisms for spine injury can damage the spinal column or cord independently, or it can damage the two together. A careful and complete spine assessment reveals whether the injury affects the column, cord, or both. Anytime evidence suggests an injury, spine stabilization is indicated.

Spinal cord injuries are generally more complicated than column injuries. Only a small percentage of cord injuries actually transect, or cut completely across, the cord. By understanding the mechanism, a knowledgeable paramedic may predict which types of cord injuries may be present. There are specific symptoms for spinal cord injury including numbness and tingling down a dermatome line. It is important to be able to suspect when symptoms are the result of primary cord injury such as a penetration, or when the cord injury may be the result of swelling. It is important to look for evidence suggesting the presence of a primary or a secondary cord injury.

Primary cord injuries: Trauma directly insulting the spinal cord causes a primary cord injury; the energy force directly impacted the cord. Primary cord injuries result in immediate impairment of cord function by disrupting, distracting, or transecting the spinal cord. Most often, a spinal column injury also results.1 Primary injuries include tearing/shearing during a hanging, laceration, puncture from a knife or bone fragment, and compression from a crush injury. Symptoms of spinal cord injury appear immediately in a primary cord injury—however, those symptoms are specific to the region of cord injury.

Secondary cord injuries: Primary cord injuries often have limited damage with only subtle symptoms. Over time, even in as short a time period as an EMS transport, the symptoms can begin to worsen. These worsening symptoms are not the result of poor EMS care, but rather from a secondary cord injury; typically caused by bleeding, swelling, and ischemia. Whenever tissue is damaged, its natural response is to swell—a phenomenon the spinal cord is not immune to. As swelling worsens it begins to squeeze the cord against the inside of the spinal column and function deteriorates. Injured blood vessels can bleed into the spinal canal increasing the pressure inside of the canal and leading to ischemia to the cord regions perfused by the injured vessel.

Cord concussion: There are many types of spinal cord injuries. One type, which is similar to brain concussions, is the spinal cord concussion. This results in a temporary neurological deficit that resolves on its own over time and is usually a result of blunt force trauma. Following the blunt trauma, the cord becomes “stunned” for a brief period and then resumes normal function. No structural damage occurs; however, swelling can develop later.

Cord contusion: Another type of spinal cord injury that is not permanent is the cord contusion. These are areas of soft tissue swelling. In the spinal cord, symptoms are present for a more extended period, and evidence of spinal cord bruising can be found. A cord contusion indicates some bleeding is occurring in the spinal cord and suggests the mechanism of injury was more significant. Over time the symptoms will completely resolve as the cord heals. It is not expected that a paramedic distinguish a cord concussion and cord contusion during prehospital care.

Cord compression: This occurs when either a primary or a secondary cord injury decreases the spinal column’s foramen, resulting in a squeezing of the spinal cord. Crushed vertebrae and intravertebral disks can lead to direct compression. An example of a secondary cord injury is compression as a result of swelling developing from soft tissue injury. Regardless of the mechanism, cord compression can lead to cord ischemia. Left untreated, ischemia can lead to necrosis and non-repairable cord damage.

Lacerations: Bone fragments and knife wounds are examples of puncture wounds that can lacerate the spinal cord. The spinal cord is affected in three ways from a laceration. Nerve bundle separation is the most obvious effect from a laceration; however the laceration and can also lead to significant bleeding and swelling within the spinal foramen. Significant amounts of bleeding can occur from even small spinal cord lacerations.

Complete cord transection: Any time a mechanism causes a complete cut across the spinal cord, the injury is termed a complete cord transection. A cord transection eliminates the body’s ability to send or receive signals distal of the injury site; this is a permanent injury that is not repairable and often results in paralysis. When a transection occurs above T-1, or the first thoracic vertebrae, the patent experiences quadriplegia, which is the paralysis of all four extremities. Transections that occur below T-1 cause paraplegia. Patients with paraplegia can have full use of their upper extremities but are unable to use their lower extremities. The specific site of the transection determines the amount, if any, movement or sensation the patient might retain. Patients with paraplegia typically retain use of the muscles aiding breathing—but not always. Table 1, below, summarizes the expected function level following cord transection.6

Table 1: Anticipated Function Level following Spinal Cord Transection

Transection Location Extremity Movement Respiratory System Function Communication and Other Functions
C-1 through C-3 Complete paralysis of limbs and body; limited head/neck movement No chest wall muscle or diaphragm use; patients require long term ventilator use Patient may be able to speak; is completely dependent upon others for assistance with all daily functions
C-4 through C-5 Full head and neck movement present, limited shoulder movement, no use of hands, wrists, forearms, or lower extremities Capable of diaphragmatic breathing, no cough reflex present, needs assistance clearing the airway May speak with a voice recognition computer. Requires assistance completing daily functions
C-5 Full use of head, neck and shoulders. Can flex elbows but not extend them. No finger or wrist movement Capable of diaphragmatic breathing, no cough reflex present, needs assistance clearing the airway May speak with a voice recognition computer. Requires assistance completing daily functions
C-6 Full use of head, neck, and shoulders, can flex elbows, extend wrists, cannot move fingers Capable of diaphragmatic breathing, no cough reflex present, needs assistance clearing the airway Passive grip strength possible with some objects. Can speak but still needs aid with regular daily functions
C-7 As above, but gains use of thumbs and some fingers as well Can spend time breathing without the aid of a ventilator for brief periods Some control over bowel and bladder use; is independent with use of upper extremities 
T-1 through T-4 Full use of upper extremities, some chest wall muscle use Able to breathe with chest wall muscles, no abdominal muscle aid in breathing Able to clean and feed independently; communicates freely
T-5 through T-9 Full upper body use above injury, strength is dependent on the injury site, legs remain paralyzed Able to breathe without assistance but has limited endurance Relatively independent
T-10 through L-1 Limited paralysis of lower body and lower extremities Normal respiratory system Often lives without any assistance
L-2 through S-5 Full upper body control and function. Some control over hips, knees, feet. Use increases as injury site lowers Normal respiratory system Lives independently

Source: Rehab Team Site. Miami/Jackson Memorial Medical Center. c1998; [cited 11 Oct 2015]. Overview: Goals and functional outcomes. Available from: http://calder.med.miami.edu/providers/PHYSICAL/goals.html.

Incomplete cord transection: Spinal cord injuries do not always result in complete cord lacerations. Often, only part of the spinal cord is cut, or transected during a spine injury. This injury, called an incomplete cord transection, results in some nerve bundles remaining intact while others are severed. Only part of the spinal cord is affected by an incomplete cord transection, which leaves the potential for some neurological recovery following injury. The following three types of incomplete cord transection are of note for EMS providers.

Anterior cord syndrome: Transection or infarction of the anterior portion of the spinal cord causes anterior cord syndrome. Typically, anterior cord syndrome occurs when the anterior spinal artery is obstructed or interrupted resulting in anterior cord ischemia and then infarction. Below the infarction site limited paralysis develops as well as impaired pain and temperature sensation. Patients often maintain a sense of touch, vibration, and proprioception, which is the ability to detect the location of body parts relative to the rest of the body.7

Central cord syndrome: The most common cause of this presented to EMS providers is traumatic injury, such as hyperextension of the neck. Central cord syndrome resulting from trauma most often occurs in the cervical spine and results in destruction of the motor nerves found in cord’s center.  Classic symptoms are an initial presentation of complete quadriplegia followed by a rapid return of lower extremity function. The return of lower extremity use develops over several minutes, followed later by the return of upper extremity function, and a decrease in bladder function. Patients may also complain about burning sensations in their extremities.8

Brown-Séquard Syndrome: Penetrating trauma and spinal disk herniation can both cause this syndrome, which compresses and impairs one side of the spinal cord, essentially creating a hemicordectomy, which causes loss of motor control, propioception, and vibration sensation on the same side of the body as the spinal cord is injured. The patient may also experience loss of pain control and sensation control on the opposite (contralateral) side of the body.9

A careful and complete spine assessment should be completed when time allows. Incorporating a spine assessment into the routine physical exam may result in aspects of the spine assessment being overlooked. To avoid missing any component of the spine assessment, complete it at a separate time with the intention of specifically evaluating the spinal column and spinal cord. Approach a spine assessment with the mentality that you are looking for a reason to immobilize a patient: You’re looking for an injury. An accurate spine assessment identifies the presence or absence of injury to the spinal column and/or cord. If both are absent, full spine stabilization may not be indicated in some protocols, and there is no need to transport the patient on a longboard.

Use caution and take appropriate time because inaccurate and rushed spine assessments can lead to ruling out a spine injury when one is actually present. The spine assessment not only identifies when a spine injury is present but also identifies the injury extent.

There are three components to the detailed spine assessment: determine reliability, a clear history, and a clear physical exam.8 All three components must be evaluated and have the appropriate findings to rule out spine injury. Completion takes time; rushing through a spine assessment can result in missing a spine injury and failure to immobilize patients who have spine injuries.

An accurate spine assessment requires a completely reliable patient. Reliable patients are completely awake and oriented times 4 (person, place, time, events). The patient must also be cooperative and calm. Intoxication can mask injuries so sobriety is required. Finally, a reliable patient is free from distracting injuries. Distracting injuries are ones that keep the patient’s attention and focus when you are trying to engage the patient in the spine assessment. This can be somewhat subjective; however, if the patient keeps returning the conversation to an injury, or cannot carry on a conversation because they another injury’s pain is so great, then that injury is distracting their attention and prevents the patient from being reliable. Distracting injuries may include: dislocated ankles, impaled objects, open fractures, severe abdominal pain, and respiratory distress. Restrict spinal movement and manage all of the patient’s distracting injuries before attempting a spine assessment; often proper injury management can increase a patient’s comfort to the point where the patient may become reliable. This is especially true for musculoskeletal injuries, which are often very painful prior to management. Repositioning muscular skeletal injuries into their anatomical position, providing padding, and a quality splint often substantially decreases the patient’s pain level.

Completing an accurate spine history requires the patient’s focus and undivided attention. Ask them two questions: “Do you have any numbness, tingling, or sensations of electrical activity anywhere in your body?” and “Do you have any pain on your spine?” Try to differentiate discomfort along the ribs and muscles of the back from the spine. Many patients have chronic lower back discomfort in their muscles though they do not have bone pain. When assessing for spine pain, it may be helpful to ask the patient to close their eyes and visualize their spine. Have the patient mentally walk their mind down each vertebra and ask if it hurts may help the patient separate spine from muscle pain. Pain in any vertebra suggests a spinal column injury. Suspect a spinal cord injury whenever the patient identifies numbness, tingling, or electrical sensations shooting through their body. Any evidence of column or cord injury here indicates full spine immobilization is required. Even when evidence in their history suggests a spine injury continue the spine assessment so you can fully identify the injury’s severity.

The final component to the complete spine assessment is the physical spine exam. A potential spinal injury indicates having several responders assist in log-rolling the patient can potentially limit spinal movement. To evaluate the spine itself, roll the patient onto their side, exposing the entire back and neck (the entire spine), and slowly palpating each vertebra from C-1 to L-5 in an attempt to illicit tenderness. To assess for tenderness press firmly on the posterior spinus process for each vertebra, tenderness on any bone suggests that there may be a fracture. Although it may be reasonable to assess the spinal column first, it can be done at any point throughout the exam. For example, should a patient have paresthesis, it is reasonable to assess the column last and move the patient only one.

Please note that the motor and sensory exam completed during a spine assessment is dynamically different from an evaluation of circulation, sensation, and movement (CSM). A CSM check evaluates the integrity of the neurovascular bundle in an extremity and the motor and sensory exam evaluates the body’s ability to send and receive signals between the distal aspect of an extremity and the spinal cord itself. Do not confuse these two assessments.

A distal motor and sensory exam evaluates the patient’s extremities for bilateral equality of strength and sensory skills. Perform full spine immobilization whenever a patient demonstrates inequality between strength or sensory function.

Motor strength in the upper extremities can be performed with either wrist extension or finger abduction against moderate resistance. Both the wrist and fingers are innervated by the upper extremity’s most distal dermatome. To test wrist extension, stabilize the lower arm firmly (usually against the ground), and apply moderate pressure with one hand against the posterior aspect of the patient’s hand. Then, ask the patient to extend their hand upwards against your pressure. Repeat this on both sides. Alternatively, test the patient’s finger abduction strength when the patient cannot extend their wrist for a non-spine injury related reason (e.g. splinted extremity). Have the spread their fingers apart and ask them to resist your attempt to squeeze their index and ring finger together. The resistance should be identical in each hand.

Test lower extremity motor strength with the extension and flexion of either the patient’s ankle or great toe. Bear in mind that this is different from the upper extremity motor test, which only evaluates extension. Apply pressure against both feet simultaneously and ask the patient to pull their feet towards their head. Immediately place your hands on the inferior aspect of the feet and ask the patient to push down as if pressing the gas pedal. Both legs normally have equal strength. Abnormal weakness on one side suggests spinal cord injury. Use the same flexion and extension process with only the great toe whenever an injury or illness prevents the patient from moving their ankle normally.

The final portion of the spine assessment is a sensory skill examination. Successful completion requires the patient distinguish between light/soft touch and sharp (pain) at the distal end of each extremity. Evaluating pain sensation tests the free nerve endings in the skin, and light touch evaluates the Meissner Corpuscle. Good tools must be used to accurately test these nerve endings, cotton balls or Kling are great objects capable of triggering a light touch sensation, and a safety needle or pointed tweezers effectively trigger pain sensors. Pressure sensors are not being tested, only pain and light touch nerve endings. To be sure the patient can effectively distinguish the two objects selected test them on the patient’s forehead; the skin of the forehead is nearly always unaffected by a spine injury. While testing an extremity, keep it out of sight of the patient, but do not hold it with your hand or arm as this will trigger other nerves in the patient’s extremity. In the hands, press one of the two objects at a time along the top and lateral aspects asking the patient to state if the patient feels pain or light touch. Randomly alternate between the two objects  several times on each hand before moving on to the lower extremities. In the lower extremities, complete the sensory exam along the anteriolateral surface of the foot and along the lateral aspect of the ankle. If a patient cannot distinguish between light and touch and sharp sensation multiple times in an extremity, or cannot distinguish the two apart at all, suspect a spinal cord injury and perform complete spine immobilization.

A reliable patient with a clear history and a clear physical examination does not need immobilization. Performing unnecessary immobilizations causes discomfort for the patient. Any impaired motor or sensory skill, or the presence of numbness, tingling, or electrical sensations suggests the patient has a spinal cord injury. Pain or tenderness along the spine indicates the column itself is injured. Carefully document your assessment findings justifying why you did or did not perform spine immobilization. Identify when you suspect a spinal column or cord injury, and when you suspect both.

Whenever motor weakness is appreciated in an extremity use a strength scale endorsed by the American Spinal Injury Association to rate the patient’s motor skills. (See Table 2, below.) As the score lowers cord injury worsens.

Table 2: Motor Strength in Spinal Cord Injury

Strength Score Motor Activity
0 No contractions or movement
1 Minimal movement noted
2 Limited movement with no resistance; no movement against resistance or gravity
3 Active movement against gravity but not resistance
4 Active movement against some resistance
5 Active movement against full resistance

Source: Medscape.com [Internet] Gondim FA. Spinal cord trauma and related diseases. [24 Jan 2008; 20 May 2009]. Available from: http://emedicine.medscape.com/article/1149070-overview.

Treatment

Once a cord injury mechanism is recognized, the EMS provider must provide manual stabilization to the spine’s three weight centers—the head, shoulders, and hips. Movement of any of the weight centers causes spinal cord movement as well; spinal cord injury is an immediate life threat that must be properly managed during the initial assessment.

Spine stabilization requires control over the entire spinal column and cord. To do so properly, it is essential to control the three weight centers that affect spine movement: the head, shoulders, and hips.

Historically, EMS providers immediately used a cervical collar and long board to immobilize any patient with an obvious mechanism of injury. However, recent literature has caused some agencies to rethink this approach.

For example, the recommendations in the 2011 Journal of Trauma article, “Prehospital Spine Immobilization for Penetrating Trauma—Review and Recommendations from the Prehospital Trauma Life Support Executive Committee,” provided a review of the clinical evidence that immobilization of patients experiencing penetrating trauma do not require immobilization and discouraged the immobilization of these patients.10 This position was further supported by the 2013 position paper jointly released by the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma titled “EMS spinal precautions and the use of the long backboard,” which provided consensus opinion that the benefit of spine immobilization via backboard is unproven and suggested that immobilization be limited to patients with one of the following complaints or presentations:

  • Blunt trauma and altered mental status;
  • Spine column pain or tenderness;
  • Neurologic complaints suggestive of SCI (e.g., numbness);
  • Anatomic spine deformity, and
  • High energy mechanisms with patient intoxication, inability to communicate, or distracting injury.11

Several agencies in different regions of the country have changed their spinal immobilization protocols. Examples include Alameda County (Calif.) and Johnson County EMS (Kansas). In addition, the North Carolina Office of EMS has endorsed a state-wide selective spine immobilization protocol.12

Immobilization

In recent years, the frequent use of backboards and current EMS cervical immobilization devices has come under scrutiny. The National Association of EMS Physicians (NAEMSP) and the American College of Emergency Physicians (ACEP) is challenging routine use of these devices and recommending that spine immobilization be limited because current strategies lack evidence.13

Current immobilization fails to properly immobilize the head in 42% of patients and the body in up to 88% of patients.14 In addition, immobilization causes tissue hypoxia, which places patients at risk for pressure ulcers.15 It also increases spine pain and the potential for developing pressure sores.

In 2013, the joint position paper between the NAEMSP and the American College of Surgeons Committee on Trauma recommended that spinal immobilization is not necessary when patients meet the following criteria:

  • Normal level of consciousness (Glasgow Coma Scale =15);
  • No spinal column tenderness or abnormality;
  • No distracting injury, and
  • No intoxication.

This position paper also advised that patients with penetrating trauma without evidence of spinal cord injury do not need immobilization and that immobilizing these patients may worsen outcomes.16

Rather than attempting spine immobilization, which is nearly impossible, focus on spinal motion restriction with the goal of eliminating all unnecessary motion of the spine. In this approach, the best patient care strategy may be to apply a cervical immobilization device and then keep the patient supine on the stretcher without a long backboard. Patients supine on a mattress are likely to be more comfortable and less likely to develop pressure sores. This strategy may be particularly helpful when a patient is found ambulatory on the scene of a traumatic injury, when there is an extended transport (greater than 30 minutes), or when immobilization is being performed purely because of “protocol requirements.”

Both the American College of Emergency Physicians and the NAEMSP support the use of an evidence-based and validated spine assessment, such as the NEXUS criteria or Canadian C-Spine Rule, to rule out spine injury.17 The specifics of these examinations need to be established by local medical direction

Conclusion

Spinal cord injuries are catastrophic patient injuries which result in serious morbidity and can create the need for a lifetime of intensive medical care. When prehospital providers manage patients with the mechanism for a spinal cord injury it is important to take the time to perform a thorough spine assessment to determine whether or not patients require spinal motion restriction. Only 0.01% of penetrating trauma and less than 5% of blunt force trauma patients experience spinal cord injury.18 When spinal motion restriction is deemed necessary the use of a long backboard for immobilization is unproven. On scene time can be reduced and patient care improved by placing a patient supine on a soft mattress with a cervical collar rather than by using a backboard. Spinal motion restriction means elimination of unnecessary spine movement by controlling the 3 weight centers that move the spine: the head, shoulders, and hips; by controlling the weight centers the spine remains stable.

A thorough spine assessment helps to avoid the unnecessary use of the long backboard. By avoiding unnecessary immobilizations, there is also a decreased risk for patients developing pressure ulcers and backboard associated neck pain. Limit the use of a backboard to times when it is needed for extrication and for stabilization of the major trauma patient with an altered mental status or those with known evidence of spinal cord injury.

References

  1. University of Alabama at Birmingham [Internet]. Birmingham, Ala: National Institute on Disability, Independent Living, and Rehabilitation Research; [updated 2015 Feb; cited Feb 2013]. The National SCI Statistical Center, Spinal Cord Injury Facts and Figures at a Glance. [about 2 screens]. Available from: http://www.uab.edu/nscisc
  2. Centers for Disease Control and Prevention [Internet]. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention; [updated 2015 March 27.] Injury Prevention & Control: Traumatic Brain Injury. Available from: http://www.cdc.gov/TraumaticBrainInjury/scifacts.html
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  5. Centers for Disease Control and Prevention [Internet]. Centers for Disease Control and Prevention, Guidelines for the Field Triage of Injured Patients Recommendations of the National Expert Panel on Field Triage, 2011. MMWR [Internet]. 2012 Jan 13. Available from: http://www.cdc.gov/mmwr/pdf/rr/rr6101.pdf
  6. Medscape. Chin, L S, Dawodu ST, Mesfin FB. Kopell, BH, editor. WebMD LLC: c1994-2016 [updated 2015 Jul 7.] Spinal cord injuries. Available from: http://emedicine.medscape.com/article/793582-overview
  7. Rehab Team Site. Miami/Jackson Memorial Medical Center. c1998; [cited 11 Oct 2015]. Overview: Goals and functional outcomes. Available from: http://calder.med.miami.edu/providers/PHYSICAL/goals.html
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  16. National Association of EMS Physicians and American College of Surgeons Committee on Trauma. EMS spinal precautions and the use of the long backboard. Prehosp Emerg Care. 2013 Jul-Sep;17(3):392-3. doi: 10.3109/10903127.2013.773115. Epub 2013 Mar 4.
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Published: May 4, 2016
Revised: January 5, 2017