Spinal Immobilization: a Twisted Tale

History of Spinal Immobilization

Spinal motion restriction (SMR) using backboards and cervical collars has been a staple of EMS protocols for decades. The long backboard (LBB) is designed to restrict thoracic and lumbar spinal movement and facilitate patient extrication, while cervical collars (C-collars) aim to limit cervical spine motion. The rationale behind SMR is that by immobilizing the spine, the risk of secondary spinal cord injury during extrication, transport, and evaluation of trauma patients is reduced.

SMR practices date back to the 1960s, driven by the belief that trauma victims with cervical spine injuries could suffer neurological damage if moved without stabilization using a rigid cervical collar and long spine board. However, these claims were mainly anecdotal or based on poorly documented case reports.

Despite this, SMR gained traction in 1967 at the annual session of the American Association for the Surgery of Trauma, where backboards and collars were advocated for accident victim extraction. The use of SMR was further endorsed by Dr. Henry Bohlman, an Ohio surgeon, who reported on 300 cervical spine injury cases from 1950 to 1972, noting neurological deterioration in patients who did not receive spinal immobilization.

These early reports led to the establishment of guidelines and the modern practice of prophylactic spinal motion restriction using devices like long spine boards, rigid cervical collars, straps, and tape. Subsequent studies showed a significant increase in trauma patients being admitted with preserved neurological function after the widespread adoption of pre-hospital spinal immobilization. However, these studies often did not account for confounding factors such as advancements in car safety, traffic legislation, and workplace safety measures, which may have contributed to improved outcomes.

Recent reviews have not demonstrated new cases of spinal cord injury during normal patient handling, suggesting that many earlier reports may have been anecdotal. Additionally, the rationale for spinal immobilization is not supported by randomized trials. A Cochrane review found insufficient evidence for spinal immobilization, and the American Association of Neurosurgeons also stated there is no compelling evidence to support current spine motion restriction guidelines. Nonetheless, EMS and ATLS guidelines continue to recommend spinal immobilization for patients with suspected spinal cord or vertebral injury.

This raises the question: Do these measures actually prevent further damage after a spinal injury? Let’s explore what physics and biomechanics have to say about this.

Biomechanics and Physics

For a deeper dive into the matter, I refer you to an excellent article by Dr. Mark Hauswald, (Hauswald, 2013). He argues that the spine is a structure composed of bones and discs held together by reinforcing ligaments and muscles, functioning as energy-absorbing struts. Hauswald suggests that the components of this structure fail at approximately equal levels of force. This means most injuries are either minor (causing no permanent damage) or catastrophic (resulting in multiple permanent insults, including to the spinal cord). Consequently, the majority of trauma patients will not benefit from SMR, either because they will sustain no permanent injury or because the injury is so severe that immobilization offers no benefit.

Additionally, Hauswald discusses the force needed to move the neck (Hauswald, 2013). The neck’s normal range of motion corresponds to the amount of non-destructive force it can tolerate. Beyond this range, injuries occur; within this range, they do not. Moving the neck and spine within this normal range requires minimal energy or force. For example, consider the negligible force needed to position the head of a paralyzed patient before intubation. If uninjured areas of the spine have nearly zero resistance to movement, injured areas cannot have less than zero resistance. In fact, due to tissue edema, muscle spasm, and mechanical impingement, resistance to movement in an injured spine will typically be greater than zero.

Next, consider the physics of spinal motion restriction. SMR has focused on decreasing post-injury motion without accounting for the force required to cause that motion. This approach may not minimize the total energy in the system or the damage to tissue. Instead, we should focus on reducing the energy/work deposited at the injured site, ensuring the total energy of the system is decreased. Therefore, energy generated during prehospital care and early trauma evaluation should be directed away from the injured tissue.

With this understanding, we can conceptualize a different method of spinal care. For example, using a comfortable but firm and high-friction surface for transport, such as an ambulance stretcher. An ambulance stretcher is comfortable in that it reduces the risk of tissue hypoxia (e.g., from pressure ulcers) and high friction means the energy generated during transport is distributed over a large surface area.

In contrast, hard and slippery backboards require multiple straps to secure the patient, causing the energy generated during transport to be absorbed by these straps. These straps attach to areas with different resistances and compressibility (e.g., the skull is less compressible than the thigh), potentially transferring energy to the injured spine. Tightening the straps can reduce energy transfer but at the risk of constricting the patient and causing both global (reduced respiratory effort) and focal (tissue compression) hypoxia. A vacuum board or an ambulance stretcher allows the energy generated during prehospital care to be spread over a greater contoured surface area.

Similarly, one might consider using lateral head supports, such as foam blocks and tape, instead of the standard C-collar. Both provide adequate head and neck motion restriction, but blocks and tape are more comfortable and may offer superior protection against flexion/extension movements. Additionally, as Dr. Hauswald notes, while C-collars reduce visible motion, they transfer force from the mid-cervical spine to the ends, potentially increasing the risk of high- and low-cervical injuries. C-collars have also been shown to increase intracranial pressure, decrease cerebral perfusion pressure, and complicate both intubation and examination, but we’ll explore that more later.

Efficacy of Spinal Immobilization

Next, let’s switch gears and talk about the efficacy of our commonly used SMR implements, like the LBB and the C-collar. How good are these tools in actually restricting spinal motion? Overall, the research looking into the efficacy of these tools is limited with little benefit.

Long Backboard (LBB)

Let’s begin with the long backboard. Its primary purpose is to maintain alignment of the head with the torso to prevent secondary injury.

In a small randomized controlled trial (RCT) from Texas involving healthy volunteers, participants were fitted with C-collars and secured either to an ambulance stretcher or an LBB. They were then driven around a fixed course at low speeds, with measurements taken of head, chest, and hip movement (Wampler et al., 2016). The study revealed that volunteers secured with the LBB experienced significantly more movement at the head, chest, and hip compared to those on the ambulance stretcher.

This increased movement with the LBB can lead to greater torso movement relative to the head, focusing torque on the cervical area, which is detrimental. Even at low speeds and short distances, the difference in movement was notable between the LBB and the ambulance stretcher. From a basic physics perspective, the rigid, flat, smooth surface of the LBB is less effective at minimizing movement compared to the softer, conforming surface of a stretcher mattress.

Another study from Duke University examining spinal immobilization found that a majority of patients on LBBs were improperly or incompletely secured (Peery, Brice, and White, 2007). Out of 50 patients studied, 30% had at least one unattached strap or piece of tape intended to secure their head to the board. Additionally, 88% of patients had over 2 cm of slack between their body and a strap. As discussed earlier regarding physics principles, poorly secured straps allow transport energy to impact the injured spine. Therefore, even when patients are placed on an LBB, proper securing is often inadequate.

Considering the lack of compelling evidence and increasing evidence of harm associated with backboards, the American College of Emergency Physicians (ACEP) has advised against their use as a therapeutic intervention or precautionary measure inside or outside hospitals, or during interfacility transfers.

Given the absence of high-quality evidence demonstrating that backboards prevent spinal injury or improve outcomes, their utility, in my opinion, lies primarily in the extrication of trauma patients from vehicles.

C-Collars

The efficacy of cervical collars in controlling motion has not been rigorously examined in randomized controlled trials (RCTs) involving real trauma patients to date. Cochrane reviews in 2001, 2007, and again in 2015 have consistently shown limited and unconvincing evidence supporting their use.

Moreover, existing data on collars is fragmented and often contradictory. For instance, studies indicate that rigid collars may increase movement in the upper cervical spine (Chin, 2006), while others suggest that both soft and rigid collars offer similar restrictions in the cervical spine range of motion (Miller et al., 2010).

Additionally, collars may not effectively reduce motion in an unstable spine (Horodyski 2011; Lador 2011), and combinations such as collar with a long board versus collar with a vacuum mattress yield differing levels of stability (Hamilton, 1996; Luscombe, 2003). Variations like using sandbags, collars, and tape have been proposed as effective in reducing spine motion (Cline,1985), as have combinations involving boards, collars, and towels (Huerta, 1987; Perry, 1999).

Thus, the evidence remains mixed, weak, and largely untested in actual trauma patients due to practical challenges in conducting such studies, which have primarily been carried out on healthy volunteers in simulated environments.

However, an important retrospective study compared blunt spinal injury patients in New Mexico and Malaysia (Hauswald, 1998). This five-year chart review included 334 patients from New Mexico and 120 from Malaysia. Patients in New Mexico received standard ATLS spinal motion restriction protocols, while those in Malaysia, where the EMS system was less established, often lacked immobilization and were transported by bystanders in cars. Despite higher rates of MVCs among US patients compared to falls among Malaysian patients, the study found that the odds ratio for disability remained higher in New Mexico even after adjusting for other variables. The authors suggested a low probability (2%) of finding such data if spinal immobilization were beneficial overall, implying a 98% probability of harm or no benefit. Notably, neurologic deficit severity was the sole predictor of poor outcomes, with no protective effect observed in isolated cervical-level deficits.

Thus, evidence supporting the effectiveness of long backboards (LBBs) and cervical collars is sparse and inconclusive regarding their intended purpose of restricting spinal motion and preventing adverse spinal outcomes.

However, the primary rationale for spinal immobilization in emergency departments often stems from anecdotal evidence of un-immobilized patients experiencing sudden declines and developing neurological deficits. The effectiveness of collars in preventing such secondary deterioration remains unclear—is this phenomenon a genuine threat or an enduring medical myth?

Spinal Immobilization doesn’t actually prevent secondary neurologic injury

It has been suggested that up to 5% of spinal cord injuries (SCI) result from secondary deterioration during pre-hospital transport or early hospital care due to inappropriate management, such as the lack of spinal motion restriction. However, this claim is flawed for several reasons.

Firstly, detecting neurological decline during prehospital transport is challenging, as serial neurological examinations are not routinely performed. Secondly, extrapolating findings from hospital settings to prehospital conditions can introduce biases and lead to misleading conclusions. Thirdly, many studies reporting secondary decline are historical and reflect different treatment standards, available resources, and systemic prevention strategies (e.g., vehicle safety features), making it difficult to ascertain contributing factors accurately. Lastly, most of these historical reports are case studies with limited evidence-based value.

So, what does the evidence actually say about secondary deterioration in SCI?

A literature review by Oto et al. (2015) found low-quality evidence regarding secondary deterioration. Over a 30-year span, they identified only 41 cases of documented secondary neurological deterioration. Most cases were incidentally mentioned in studies not primarily focused on the topic, often with vague or incomplete details.

Of these 41 cases, 13 worsened before reaching the hospital, while 26 deteriorated after arrival in the Emergency Department (ED). The 13 prehospital cases were primarily documented in a single source—a summary of a 1988 medical dissertation (Toscano, 1988). In many instances, deterioration occurred gradually between examinations rather than abruptly. More than a quarter of cases attributed deterioration to iatrogenic causes, such as halo device placement, patient movement, flexion or extension during radiography, falls near the ED, and incidents involving patients with ankylosing spondylitis forced into neutral positions for collar application. Thus, the case for spontaneous secondary decline weakens with the recognition that only 41 cases were identified over three decades, many progressing gradually and seemingly unaffected by immobilization.

Furthermore, Frankel (1969), who developed the Frankel classification for spinal cord injury, identified only 0.88% of 682 SCI patients showing neurological deterioration upon hospital presentation. Sapkas and Papadakis (2007) followed 67 patients with cervical fractures or dislocations requiring surgical stabilization, finding no cases of neurological deterioration. A multi-center study by Marshall et al. (1987) identified neurological deterioration in 5% of SCI patients, but these instances followed significant movements at fracture sites, such as halo vest application or traction, rather than patient-initiated movements.

From these studies, it becomes evident that spontaneous neurological decline is exceedingly rare and often attributed to excessive iatrogenic movement rather than patient-initiated motion of the spine.

If spontaneous neurological deterioration does occur in patients with incomplete spinal injuries, it is exceptionally uncommon, often due to factors like edema, hematoma progression, inflammation, hypotension, and hypoxia, rather than exacerbation of the initial fracture pattern.

In severe acute cord injuries, impaired spinal cord autoregulation can exacerbate neurological damage, particularly under conditions of hypotension or hypoxia, thereby hindering recovery potential (Todd, Skinner, and Wilson-MacDonald, 2015).

Secondary deterioration in SCI patients is more likely related to the natural progression of the injury or iatrogenic causes rather than spontaneous movement of an unstable spine.

Potential Harms Associated with SMR

Beyond a lack of benefit, the utilization of SMR often results in harm to the patient:

Raised ICP

In head-injured patients, any factor that increases intracranial pressure (ICP) can significantly worsen their clinical outcomes by causing secondary brain injury (Mobbs, 2002). An Australian study conducted in the early 2000s examined patients involved in vehicle, motorbike, or bicycle accidents to assess changes in ICP before and after cervical collar placement (Mobbs, 2002). The study found a median increase in ICP of 32.5% following the application of a cervical collar.

Several other studies have also demonstrated that cervical collar application can elevate ICP, attributed to pain and obstruction of venous outflow caused by the device (Kolb, Summers, and Galli, 1999). Normal ICP ranges from 7 to 15 mmHg in supine adults, with pressures exceeding 20 mmHg considered pathological and pressures over 15 mmHg deemed abnormal.

A notable study from the UK investigated ICP changes in severe traumatic brain injury (TBI) patients and reported a mean increase in ICP of 4.6 mmHg after collar placement (Hunt, Hallworth, and Smith, 2001). Importantly, the rise in mean ICP was more pronounced in patients with baseline ICP levels above 15 mmHg compared to those below this threshold. This suggests that patients with already elevated ICP (>15 mmHg) may be at greater risk of harm from cervical collar-induced increases in ICP. The mechanism is believed to involve compression of neck veins, as there were no changes in cardiorespiratory parameters observed.

Therefore, cervical collar-induced elevations in ICP may pose significant challenges, particularly in patients already predisposed to neurological deterioration due to elevated baseline ICP.

Pressure Ulcers

Pressure ulcers pose significant risks to both patients and healthcare systems. A study from the UK estimated the cost associated with pressure ulcers, ranging from just under $2 for Stage 1 ulcers to up to $40,000 for complicated Stage 4 ulcers (Ham, 2014).

A 2014 systematic review examined the impact of long backboards (LBB) versus soft-layered backboards on tissue interface pressure (TIP) (Ham, 2014). The review identified several studies on this topic, with four noting significantly more discomfort and pain experienced by volunteers on LBBs. Two studies observed a notable increase in pain after only 30 minutes on an LBB. Although most studies involved healthy volunteers and did not extend long enough to develop pressure ulcers, they highlighted that LBBs rapidly decrease tissue perfusion at pressure points, increasing the risk of ulcer formation.

The same systematic review identified three studies examining the effects of cervical collars on TIP. The Aspen collar, commonly used at hospitals like Ottawa Hospital, resulted in the highest overall TIP, while the Miami J collar led to the lowest TIP. Another study found a significant increase in occipital TIP for all collars (Stifneck, Philadelphia, Newport) compared to the Miami J collar. Thus, all types of collars increase pressure and discomfort, with the Miami J collar appearing less detrimental in terms of TIP. Importantly, there is a lack of studies comparing collar immobilization with alternative methods such as blocks and tape.

Missed Injuries

Missed injury in penetrating trauma is a well-documented complication of spinal immobilization. This concern has prompted changes in guidelines and recommendations by the Eastern Association for the Surgery of Trauma (EAST), which now advises against immobilizing patients with penetrating trauma due to associations with increased mortality and lack of evidence supporting any neurologic deficit avoidance.

The EAST’s new recommendation is based on a systematic review and meta-analysis following Cochrane-style methodology. The study analyzed 24 studies on prehospital spinal restriction in penetrating trauma (Velopulos et al., 2018). In the qualitative analysis, none of the studies demonstrated benefits of spine immobilization in terms of mortality or neurologic injury, even among patients with direct neck injuries.

Additionally, the incidence of neurologic injury was consistently low regardless of whether patients underwent spinal restriction, ranging from 2 to 76 per 1000 patients. For instance, one study focusing on patients with firearm injuries to the head and neck identified only one patient who developed transient neurologic symptoms, which occurred late during hospitalization and was unlikely influenced by prehospital care (Schubl et al., 2016).

A large database study highlighted that the number needed to treat to potentially benefit just one penetrating trauma patient was 1032, while the number needed to harm was only 66 (Haut et al., 2010). Moreover, in a qualitative analysis, a study involving 144 patients with gunshot wounds to the neck showed that none of the patients benefited from nonoperative immobilization. Among the 14 patients who underwent surgery for incomplete injury, two deteriorated preoperatively due to bullet compression rather than movement of the head and neck, but both markedly improved after decompression (Beaty et al., 2014).

In the quantitative analysis, spine immobilization did not demonstrate benefits in terms of mortality, neurologic deficit, or potentially reversible neurologic deficit. Regarding mortality, only four studies provided sufficient data for meta-analysis, showing a relative risk of 2.4 (CI 1.07 – 5.41) associated with increased mortality due to spine immobilization (Velopulos et al., 2018). While there was no significant difference in neurologic deficits between immobilization and non-immobilization groups, the point estimate favored non-immobilization (RR 4.16, CI 0.56 – 30.89). Similarly, no difference was observed for potentially reversible deficits, with an RR of 1.19 (CI 0.83-1.79) and minimal heterogeneity across studies.

In conclusion, spinal motion restriction in penetrating trauma is associated with increased mortality and has not been shown to offer any beneficial effect in reducing neurologic deficits.

Who Should We Immobilize?

• Out of an abundance of caution, I recommend immobilizing patients who meet the criteria for Canadian C-Spine rules or NEXUS.
• Patients who are intoxicated or altered and have sustained blunt trauma may benefit from immobilization due to the potential loss of muscle tone and inability to self-splint.
• In cases where patients are extremely agitated, there is a risk that they could exacerbate existing injuries. Therefore, I advocate for sedating these patients and applying a cervical collar to minimize movement and potential harm.

Summary

1. 1. Current Implement Effectiveness: The widely used implements for spinal motion restriction (LBB, collar) are not effective in limiting spinal motion.
   2. Secondary Neurologic Decline: Instances of secondary neurologic decline are rare. When they do occur, they are typically gradual and often result from the natural progression of the injury itself. Abrupt declines can occur due to iatrogenic causes, such as rough handling of patients.
   3. Non-Benign Nature of Spinal Restriction: Spinal restriction is not without risks. It is uncomfortable, increases tissue pressure leading to pressure ulcers, and raises intracranial pressure (ICP), particularly in patients with already elevated ICP. Furthermore, it has been associated with missed injuries and overall harm in cases of penetrating trauma.

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