|| Cervical Spine Stabilization
Tue, 15 Apr 1997 21:03:57 -0700
From: Walter Martins Da Ponte [email@example.com]
The stabilization of a Cspine has
always appeared fairly straight forward until recently - the neurosurgeon
now inform me that backboards serve no other purpose than facilitating
transport and promoting skin breakdown, in other words they no
longer want us to use them unless the patient will be requiring
numerous moves/lifts. I'm curious what the thoughts of the "list"
|| Date: 16 Apr 97 14:26:18
From: Stephen M Stowe, M.D. [102747.3140@CompuServe.COM]
Backboards by themselves are not
very useful. When combined with cervical collars and lateral head
stabliizers such as sandbags the combination reduces c spine movement
by about 70%.. I guess that that is "good but no cigar" as the
carnival pitchman used to say. Vacuum blankets so called Bean
Bags probably work just as well if not better and rarely produce
Stephen M. Stowe, M.D.
|| Date: Wed, 16 Apr 1997 11:27:25
From: Michael D. Harris [firstname.lastname@example.org]
C-spine "protection" seems difficult
to measure. Most out-of-hospital providers do such a poor job at
securing patients to backboards, etc. that their benefit has to
be seriously questioned. On the other hand, how many of us remember
seeing patients who were either A&O and didn't need c-spine precautions
taken or were suffering MST and were packaged so nicely... Clearly
the days of simply placing a patient on a board without adequate
securing AND without having a method to provide for cervical support
are over. Of course I wouldn't advise using the Denver paramedics
approach to c-spine precautions as we have all seen on TV recently
What do they mean about "skin breakdown"?
Aren't most patients on backboards, etc. for brief periods? And
what patients doesn't get moved multiple times (i.e., street to
gurney, gurney to helecopter, helecopter to exam table ....)?
Michael D. Harris
Santa Barbara County
Emergency Medical Services
|| Date: Wed, 16 Apr 1997
From: Brian Frankel [email@example.com]
As a current pre-hospital provider,
I must disagree. While backboards are nice for lifting, they do
serve another purpose. If you have ever ridden in the back of
a moving ambulance, you'll know what I mean. Not only do they
provide support for the patient's spine, they also provide a means
of secure attachment for the patient to limit motion during transport.
There are times when it is necessary to actually turn the patient
onto his/her side, as in the case of head injury when the patient
begins to vomit, etc. Providing care in a rural area of Pennsylvania,
with the roads the way that they are out here, is another example.
So far as skin breakdown, I don't feel that the patients remain
on the board long enough to create a problem. Average transport
times are generally less than 30 minutes for any squad in this
region-truly not enough time to cause such a problem. There are
other options than the rigid, flat boards that are in use today,
however. Some manufacturers produce a contoured board which, while
providing rigid support, minimize "point contact" by supporting
more of the body's soft tissue. Another option is the vacuum splint,
which when evacuated of air, provides excellent support and minimal,
if any, movement, and thereby eliminating skin breakdown. I hope
this helps to see another side of the issue.
Brian Frankel, B.S., M.S.(Public
|| Date: Wed, 16 Apr 97 20:40:11
From: Merlin Curry [firstname.lastname@example.org]
My principle interest in this subject
is to advance the idea that prehospital advanced trauma life support
providers, presented with a moderately traumatic event, can perform
an exam a rule out the need for spinal immobilization. This would
increase patient comfort, increase ease of more detailed exam,
etc. On this thought here are a few references I've found interesting.
Three references to studies regarding
spinal immob all from the Annals of Emergency Medicine:
1. "Prospective Assessment of Clinical
Criteria to Determine the Need for Prehospital Rigid Spinal Immobilization."
Domeier RM, et al. Annals vol 28 no 5 pg 564. This study of 5,000
patients (a rather large group) showed that negative results to
five criteria would all but rule out signifigant injury requiring
full spinal immobilization. The criteria: 1) alteration in mental
status, 2) neurological deficit, 3) midline spinal pain or tenderness,
4) evidence of intoxication, 5) suspected long-bone extremity
2. "Optimal Positioning for Cervical
Immobilization." De Lorenzo RA, et al. Annals vol 28 no 3 pg 301.
This study of 19 healthy adult volunteers conducted with quantitative
MRI was to determine the optimal postion of the head during spinal
immobilization (quote this one to your paramedic friends who really
like to pad in quantity). "Conclusion: In healthy adults, a slight
degree of flexion equivalent to 2 cm of occiput elevation produces
a favorable increase in spinal canal/spinal cord ratio levels
C5 and C6, a region of frequent unstable spine injuries." Get
that? Only 2 cm!
3. Two research forum abstracts
from Annals vol 27 no 1 pg 147. a) "Effects of Neutral Positioning
With and Without Padding on Spinal Immobilization of Healthy Subjects."
Lerner EB, et al. This study showed that pain is frequently reported
by healthy volunteers in response to spinal immobilization, with
or without padding. b) "Duration of Immobilization and Pain Experienced
on Rigid Spine Boards." Cordell WH, et al. This study moves to
showt the deleterious effects of the common practice of prehospital
spinal immobilization. Showing that it is not as harmless as we
all thought. This study showed that spinal immobilization, while
protective, does aggravate and even cause injuries.
|| Date: Thu, 17 Apr 1997
From: Michael D. Harris [email@example.com]
Brian brings up some good points.
However, taping of the head, improper securing of the rest of
the body and failure to provide support to the cervical, lumbar
and occipital areas does little to provide true cervical/spinal
protection or support. Bags on the side of the head can exacerbate
any cervical injuries when a patient is log rolled by causing
lateral weight and thus movement.
Lack of detailed clinical findings/analysis
for pre and post "immobilization" by out-of-hospital personnel
will continue to result in this being a debated issue. Until such
time that the medical community places emphasis on more clearly
documenting outcomes we may not be in a position to decide the
best course of treatment. This of course will be difficult because
few personnel will admit when they may of performed a maneuver
or procedure which result in a negative outcome.