Plastic Snake Oil – EMS Spinal Immobilization

If you’ve ever stopped to actually think about it, you might notice that EMS is full of things we do simply because they seemed like a good idea at the time. We have providers who blast pure oxygen in the faces of patients where it will not do any good and probably causes harm, have providers who deny pain control to injured patients because they believe they’re preventing some sort of addiction, and even some providers who flood trauma patients with fluid in order to cause a positive Kool-Aid sign. You probably know some providers who do these things, like slapping 15-litres per minute of oxygen on patients with chest pain in spite of the evidence that high-flow o2 on normoxic patients causes constriction of the coronary arteries and may cause more damage than it prevents (1). Heck, you may even know providers out there who still believe in hyperventilating patients with closed head injuries who aren’t in danger of immediate herniation. However if I were to pick a “treatment” modality that I sincerely believe needs to die a quick, quiet death it would be the pseudoscientific voodoo known as “Spinal Motion Restriction.”

Yes, I said “Pseudoscientific Voodoo.” However you may call it “Plastic snake oil” or “Just plain dumb” if you wish.

The cervical collar is one of the mainstays of the process of spinal immobilization, er… I mean “spinal motion restriction” which is something that has never, ever, never, ever, never never ever never been proven to help. (2)

Seriously, the backboard, the c-collar, those gross head block things that never get cleaned? They’re all more useless than faith-healing. You may as well burn incense and chant over trauma patients for all of the good that immobilization has been proven to actually help people. In fact you might wish to seriously consider the whole chanting and incense thing, because at least that hasn’t been proven to cause people harm.

What do I mean?

Pictured: A lot of clapping for Tinkerbell

Pictured: A lot of clapping for Tinkerbell

In 2010, a study was published that showed something rather unsettling. Before this study came out, there were many people who simply thought that spinal immobilization was rather silly, but didn’t stop to consider the fact that the plastic snake oil we strapped around potentially injured people’s necks could actually be causing harm. They figured that c-collars might not be effective, considering the fact that they only actually prevent around 20% of cervical motion (3), but they didn’t expect that they were causing a lot of potential harm.

According to a study published in the Journal of Trauma (4), researchers caused severe unstable cervical injuries in the necks of seven fresh human cadavers. They then applied off-the-shelf rigid plastic cervical collars to them and ran them through a CT scanner both before and after they simulated motion on the cadavers that a patient wearing a c-collar might experience, such as log-rolling, backboarding, and other movements.

The results? Well I’ll just let you read them for yourself:

Intervertebral motion averaged 7.7 mm±6.8 mm in the axial plain and 2.9 mm±2.5 mm in the cranial-caudal direction. The rigid collars appeared to create pivot points where the collar contacts the head in the region under the ear and where the collar contacts the shoulders.” (4)

In case you need a translator that means that c-collars most probably help patients move their necks in the presence of actual injuries. That’s probably bad, but if that’s not enough for you, consider this study that reviewed a very large number of patients with penetrating trauma also published in the Journal of Trauma (5). You should read the study for yourself, but here are the results:

“In total, 45,284 penetrating trauma patients were studied; 4.3% of whom underwent spine immobilization. Overall mortality was 8.1%. Unadjusted mortality was twice as high in spine-immobilized patients (14.7% vs. 7.2%, p < 0.001). The odds ratio of death for spine-immobilized patients was 2.06 (95% CI: 1.35-3.13) compared with nonimmobilized patients. Subset analysis showed consistent trends in all populations. Only 30 (0.01%) patients had incomplete spinal cord injury and underwent operative spine fixation. The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.” (Emphasis is mine)

In the past few years, there has been a big push away from spinal immobilization. Most emergency physicians utilize the NEXUS criteria or the Canadian C-Spine rules in order to remove spinal precautions in the ED (6). While these were created to spare patients from unnecessary dosages of radiation caused by inappropriate imaging of the cervical spine, they have also proven that it is quite possible and safe to rule out spinal injury based upon a physical exam.

If you’re not familiar with the NEXUS criteria, they are simple Yes/No questions that ask the following:

  1. Focal Neurological Deficit Present?
  2. Midline Spinal Tenderness Present?
  3. Altered Level of Consciousness Present?
  4. Intoxication Present?
  5. Distracting injury Present?

According to the overwhelming balance of evidence presented in the NEXUS (National Emergency X-ray Utilization Study) a patient who has no “yes” answers to the above questions can safely have their cervical spine cleared without undergoing x-ray imaging. As of 2004, this criteria had been used tens of thousands of times without a single reported adverse incident (6). I have not heard of any in the time since either.

EMS providers, who should be very interested in the above information, may be asking themselves where the term “significant mechanism of injury” is listed in those five bullet points. The answer is that it isn’t, as the mechanism of injury has never proven to be a reliable indicator of injuries actually suffered by patients. While mechanism can be a valuable tool for predicting the possibility for injuries, it does not mean that injuries not found on physical assessment actually exist.

With the overwhelming balance of evidence turning away from the practice of spinal motion restriction and the scarcity of evidence that exists to support it, the question is not whether EMS providers can safely determine that patients do not need to be placed in spinal precautions, it is whether or not anyone should ever be placed in them at all.

And I believe that they shouldn’t, although the jury is still out on whether or not I can still burn incense in the back of the ambulance to balance out my patient’s chakras. My boss may not like the smell of the incense sticks I use, but the evidence behind the strawberry scented sticks is largely as valid as the evidence for using a backboard, and they let me carry those.

References:

  1. Revisiting the Role of Oxygen Therapy in Cardiac Patients – R. Moradkhan, MD, L. Sinoway, MD – J Am Coll Cardiol. 2010 September 21; 56(13): 1013–1016
  2. Where is the Evidence for Spinal Immobilization – R. Medic – www.RogueMedic.com -August 2013
  3. Restriction of Cervical Spine Motion by Cervical Collars – T. Ducker, MD FACEP – Scientific Exhibit AAONS National Conference 1990
  4. Motion Within the Unstable Cervical Spine During Patient Maneuvering: The Neck Pivot-Shift Phenomenon - Lador et al. – J Trauma, 2011.
  5. Spine Immobilization in Penetrating Trauma: More Harm than Good? – Haut ER et. al – J Trauma. 2010 Jan;68(1):115-20
  6. Clearing the Cervical Spine Without Imaging – J. Lex Jr, MD – Medscape Emergency Medicine “Ask the Experts” August 2010

  • paul

    After almost 30 years in this buisness i can say I wholeheartidly “AGREE” with this article. We have all seen the early days of someone getting full SMR because they slid into second base and tweeked their knee (ya never know, the impact could have shattered a c-2,3,4,5,6 ;P) to now using your head and actually thinking these things through. I have questioned the process over the years but it was always the “standard” or we are protecting ouself from lawsuits. It is time the EMS community as a profession started acting like we know what we are doing and assess our Pt’s properly and treat accordingly. I have seen a lot of people suffer (and yes i mean suffer) from this treatment over the years that is a lot of times unnecessary. Don’t get me wrong, I am not saying it should never be used. I’m just asking people to think it through and understand the when,where and why’s when you do choose to use it.

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  • Casey G

    Very Interesting article, With advancements and education in any field, we will see change, some for better or worse, in this case it seems to prove that cervical spinal immobilization is possibly causing more harm than good, I Will agree that EMS providers use the C-collar too much as sort of catch all safe guard, but do we really need to use it? If we answer no to the NEXUS questions then it should be a safe call to not immobilize the neck. I would like to see where this is going, and if there will be any fall out on medics that have unintentionally caused more harm by following protocols.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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  • Comments
    mr618
    Welcome to the Club
    Well said, Chris. We can't save everybody, but the ones we don't save tend to stick around a lot longer than the ones we do save.
    2014-10-18 14:40:00
    Steel City Medic
    Welcome to the Club
    Particularly appropriate for me this week. Thanks.
    2014-09-23 21:46:00
    DiverMedic
    Welcome to the Club
    Very well done, Chris.
    2014-09-17 22:15:00
    DiverMedic
    My Blogroll
    One of these days you'll figure out where my blog is... :)
    2014-09-17 22:11:00
    emtterri123
    Six Tricks You Can Use Today to Improve Your EMS Narrative Report
    The first and best way to get people reading you to think that you are an idiot is to pepper your writing with spelling and grammatical errors. It makes you look dumb. - Me thinks this should have been restructured as it does not flow and caused me to reread it several times. lol :)
    2014-09-17 08:27:00

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