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" are.

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 decubiti

Stephen M. Stowe, M.D.

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 (oops!).

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

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 Health), EMT-M

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 fracture.

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.

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.