Author: Joslyn Joseph, DO (EM Resident Physician, Morristown Medical Center) and Joshua Bucher, MD (EM Attending Physician/EMS Fellow, Morristown Medical Center) // Edited by: Jennifer Robertson, MD, MSEd and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)
You are the emergency department (ED) attending physician waiting in the trauma bay for emergency medical services (EMS) to bring in a patient. The box report calls in a 33-year-old obese male truck driver who rolled his vehicle on its side. The paramedics report that the patient was ambulatory at the scene and sustained no loss of consciousness (LOC). He did complain of neck pain at the scene and a “standing takedown” was performed by basic life support (BLS) in order to maintain full cervical (C)-spine precautions.
In the ED, the patient complains of nausea and back pain that began during the transport. You see your patient in an adjustable semi-rigid collar with his head taped down to foam head-blocks. There are also several crisscrossed, tangled seatbelts securing him to a rigid backboard. As the paramedics slide the patient over to the ED trauma stretcher, he begins to vomit and choke. As the board is tilted on its edge with the patient’s abdomen squeezed up against the side rail, you suction your patient’s airway while he continues to vomit all over the floor. At this point, you wonder whether full spinal immobilization was even necessary in the first place. Are backboards of any benefit to patients?
Almost a year ago, the American College of Emergency Physicians (ACEP) issued a report entitled “EMS Management of Patients with Potential Spinal Injury”, which addressed the lack of evidentiary support for out-of-hospital management of potential C-spine patients. This paper highlighted the concept that the preventing any forces from acting upon the spinal column during pre-hospital transport via “full spinal immobilization,” is technically impossible.1 Instead, the goal for EMS care of trauma patients with suspected spinal injuries should require “spinal motion restriction,” or minimizing these forces without preventing further harm to the patient.
Several EMS agencies have returned the long backboard (LBB) to its original use – as an adjunct for rapid patient extrication in a rescue scenario. Yet, many agencies are still hesitant to make the change. For both basic and advanced providers with years of experience, it is difficult to move from using “full c-spine precautions” to doing virtually nothing.
Whether you are reading this as a first year resident or a seasoned medical director, it is important to educate the public and provide quality pre-hospital care. In this article, we will address the many myths surrounding the backboard and how to approach them with an evidence-based perspective.
Top 10 Myths About Cervical Spine Injury Management
Myth #1: Backboards can “neutralize” the cervical spine when used properly
As early as 1991, we have known that the LBB is not ideal for aligning the spine in a neutral anatomical position. In a study of 100 healthy college-age volunteers, 98% were put into some degree of cervical extension while lying flat on a backboard. There was also a variance of 0 to 3.75 inches of occipital padding needed to achieve relative neutrality and patient comfort.2 If healthy college students have the ideal spine curvature and yet still require occipital padding on a LBB to achieve proper alignment, then consider the effect of a LBB on an elderly patient. Due to osteoporotic and senile changes of the spine as we age, our natural anterior-posterior spinal curves accentuate. This results in an accentuated cervical lordosis and thoracic kyphosis. In regards to padding from the study above, it can be inferred that the amount of padding required to efficiently restrict spinal motion in these patients is even greater in the elderly. Thus, multiple areas will require additional amounts of padding and even then, a flat LBB is not likely to fully neutralize these extreme curves.
Myth #2: The trauma surgeons will not support removing backboards from our treatment algorithm
The American College of Surgeons (ACS) Trauma Committee and the National Association of EMS Physicians published a paper in 2014 with recommendations that form the basis of ACEP’s White Policy paper in January 2015. This paper can be accessed in the citations seen in this article below.
Myth #3: Use of the LBB is a benign intervention that can only help my patient.
If you only choose to read only one myth to debunk, make it this one. LBBs are not benign. In fact, they can increase the risk of certain disease entities in as little as a 20-minute transport. The adverse effects of the LBB have been well documented for over 10 years. A systematic review of nine experimental trials in healthy volunteers and four clinical trials from 1970-2011 shows that attempting full spinal immobilization with a LBB definitively increased the risk for developing pressure ulcers3. In addition to producing pressure ulcers, the LBB has been associated with decreased respiratory function by producing atelectasis and increasing respiratory effort.4 The LBB is not comfortable, even with the use of occipital padding. The pain that the LBB produces can alter the physical exam, creating high false-positive midline vertebral tenderness5. This false-positive exam has led to countless numbers of unnecessary radiological testing, exposing patients both to unnecessary radiation and costs and depleting ED resources. The LBB, therefore, is hardly a benign intervention.
Myth #4: We should be attempting spinal motion restrictions on all trauma patients
The American College of Surgeons and the American College of Emergency Physicians state that the use of the LBB, as well as any other c-spine immobilization, should not be attempted in the penetrating trauma victim due to providing no measure benefits and increasing the risk of delaying definitive operative management.6 In addition to penetrating trauma patients, ambulatory patients should never be forced onto a LBB. Emergency medical technicians (EMTs) and paramedics have all learned the “standing takedown” at some point. A standing takedown is a three-rescuer procedure involving the tallest rescuer behind the ambulatory, standing patient and the two other rescuers on either side of the patient facing each other. The tallest rescuer applies a c-collar to the patient and maintains in-line stabilization of the head, while another rescuer slides a LBB between the patient and the tall rescuer. The patient is then lowered onto the ground on a LBB while being supported by the rescuers, strapped down onto the board, and then lifted onto a stretcher and into an ambulance. Clearly, this has the potential to go very wrong due to the mechanics of the procedure alone. Additionally, having an uncooperative patient can also make the procedure difficult.
In already ambulatory patients, the standing takedown is completely unnecessary as most have been walking around for a while and clearly do not require immobilization. In fact, the standing takedown has the potential to cause more harm in these patients than any benefit that immobilization could offer.
Myth #5: We extricated the patient with a backboard and therefore, we need to leave the backboard in place until we get to the hospital.
Both the ACS and ACEP policy papers state that LBBs should not be used as therapeutic management. The policies state that patients should be removed from LBBs before transport if no life-threatening emergencies exist. However, if removal of a backboard delays the care of a critical patient, lifesaving measures should be performed first before attempting to remove a LBB. Examples of these measures would include chest decompression, hemorrhage control, airway management or others.
Myth #6: Well, if I am not using the LBB on trauma patients anymore, then I still need to utilize a cervical collar… right?
This question is neither entirely myth nor truth. The answer to this question lies in the mechanism of injury and the clinical scenario. Again, c-collars should not be used in the penetrating trauma patient, as there is no increased risk of c-spine injury unless the patient happens to have been shot or stabbed before falling off a roof or down a flight of stairs. Cervical collars are still appropriate interventions in trauma patients who are high risk for cervical spine injuries and in those trauma patients who are unconscious, altered, or intoxicated.7 Clinical decision rules such as the NEXUS (National Emergency X-Radiography Utilization Study) criteria should still be applied toward any decision whether to image these patients upon ED arrival.
Myth #7: People have come to expect the “board and collar” after an MVC and if I do not use them, then I will be sued.
In the United States, fears of litigation are present with every decision we make. However, drafting your own protocols for spinal motion restriction and training your medics and EMTs on how to apply these techniques can help to overcome these fears. The data speaks for itself, and sources listed in this blog post can assist you in drafting your protocols. If a patient truly insists on a LBB, then document the incident thoroughly. Also, let the patient know that he or she can expect some back pain and a bumpy, uncomfortable ride to the hospital.
Myth #8: Vacuum/inflatable/gel-padded backboards provide better spinal immobilization with increased comfort for our patients.
Neither the vacuum splint nor the inflatable “back raft” has been shown to provide increased comfort and better spinal motion restriction than the rigid LBB. In 2013, a randomized control trial (n=60) determined the speed and ease of application, the degree of spinal motion restriction, and the degree of patient comfort between a vacuum splint and a LBB. A vacuum splint is a long backboard covered in a layer of bean-bag material with the ability to suck out air to conform to the patient and produce a full body splint. Surprisingly enough, the LBB actually outperformed the vacuum splint in all measures. 8 The Back Raft is an inflatable air mattress applied to a LBB for comfort. In a study of 10 volunteers, the amount of tactile pressure in the occiput, scapula, and sacral region was decreased relative to the LBB alone. However, it offered no benefit toward decreasing spinal motion restriction of trauma patients.9
Myth #9: A provider should always be present to “clear” an ED patient off a backboard.
In a busy single coverage ED, finding a provider to quickly clear a patient off a backboard can be challenging. Eighteen out of twenty patients on an LBB will complain of discomfort and back pain that increases over time.5 Log-rolling is a skill that is familiar to all emergency practitioners since 198710. Registered nurse (RN) initiated removal of LBBs in the cooperative patient who can follow commands has been shown to be an effective and safe way of mitigating this issue.11 A protocol for RN removal of LBBs is a good way to help quickly get patients off backboards and mitigate possible LBB induced pain and/or injury. This is a protocol that should be addressed in all EDs.
Myth #10: I need to keep long backboards on my ambulances for extrication of patients.
The use of different extrication devices is dependent on each situation, but there are other safer, more convenient options than the long backboard. A clinical trial of 31 subjects comparing degrees of sagittal, lateral, and axial motion of the C3 and T12 spinous processes during baseline, application of device, secured logroll, and lifting showed both significantly less motion, superior comfort, and increased perceived security. Many newer scoop devices, such as the CombiCarrier II, are lighter, easier to apply, made of plastic, and are less intimidating than the classic aluminum scoop stretchers. These should be used for extrication, not spinal immobilization12. The LBB may be a valid option for short-term extrication of patients to the stretcher only, for a backup method, for a small self-funded volunteer department that cannot afford many scoop devices, or in the case of an MCI (Mass Casualty Incident) where many devices are needed
Top 5 Backboard Clinical Pearls
- The LBB should not be used as a therapeutic intervention. Achieving full spinal immobilization is not possible and its use has been shown to cause patient harm and no benefit. Instead, spinal motion restriction should be practiced.
- LBB use has been shown to cause increased pressure ulcers, decreased respiratory function, increased back pain, and result in a false-positive midline vertebral tenderness. This can result in unnecessary testing, radiation exposure and medical costs.
- Penetrating trauma alone does not increase the risk of cervical spine injury and these patients should never be immobilized.
- Attempting spinal motion restriction should not delay life-saving interventions or delay transport to definitive care.
- Consider RN-directed removal of backboards in the emergency department to avoid complications of prolonged, unnecessary immobilization.
References / Further Reading
- ACEP (Jan 2015) EMS Management of Patients with Potential Spinal Injury. Web.
- Schriger, D. L., Larmon, B., LeGassick, T., & Blinman, T. (1991). Spinal immobilization on a flat backboard: does it result in neutral position of the cervical spine?. Annals of emergency medicine, 20(8), 878-881.
- Ham, W., Schoonhoven, L., Schuurmans, M. J., & Leenen, L. P. (2014). Pressure ulcers from spinal immobilization in trauma patients: a systematic review. Journal of Trauma and Acute Care Surgery, 76(4), 1131-1141.
- Ay, D., Aktaş, C., Yeşilyurt, S., Sarıkaya, S., Çetin, A., & Ozdoğan, E. (2011). Effects of spinal immobilization devices on pulmonary function in healthy volunteer individuals. Ulus Travma Acil Cerrahi Derg, 17(2), 103-107.
- March, J. A., Ausband, S. C., & Brown, L. H. (2002). C HANGES IN P HYSICAL E XAMINATION C AUSED BY U SE OF S PINAL I MMOBILIZATION. Prehospital emergency care, 6(4), 421-424.
- Kang, D. G., & Lehman Jr, R. A. (2011). Spine immobilization: prehospitalization to final destination. Journal of surgical orthopaedic advances, 20(1), 2.
- National Association of EMS Physicians, & American College of Surgeons Committee on Trauma. (2013). EMS spinal precautions and the use of the long backboard.
- Mahshidfar, B., Mofidi, M., Yari, A. R., & Mehrsorosh, S. (2013). Long backboard versus vacuum mattress splint to immobilize whole spine in trauma victims in the field: a randomized clinical trial. Prehospital and disaster medicine, 28(05), 462-465.
- Edlich, R. F., Mason, S. S., Vissers, R. J., Gubler, K. D., Thacker, J. G., Pharr, P., Anderson, M., and Long, W. B. (2011). Revolutionary advances in enhancing patient comfort on patients transported on a backboard. The American journal of emergency medicine, 29(2), 181-186.
- MCGUIRE, R. A., NEVILLE, S., GREEN, B. A., & WATTS, C. (1987). Spinal instability and the log-rolling maneuver. Journal of Trauma and Acute Care Surgery, 27(5), 525-531.
- Bechard, L., & Harding, A. D. (2013). Registered Nurse–Initiated Patient Removal From Backboards in the Emergency Department. Journal of Emergency Nursing, 39(1), 57-58.
- Krell, J. M., McCoy, M. S., Sparto, P. J., Fisher, G. L., Stoy, W. A., & Hostler, D. P. (2006). Comparison of the Ferno Scoop Stretcher with the long backboard for spinal immobilization. Prehospital Emergency Care, 10(1), 46-51.
Comparison Device: CombiCarrier II