Changing Attitudes Toward Spinal Immobilization in Emergency Medicine

Date: July 21, 2023 Reference: McDonald et al. Patterns of change in prehospital spinal motion restriction: a retrospective database review. AEM July 2023 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: A 42-year-old is struck in the face by a slowly moving I-beam at work. He has a brief loss of consciousness (LOC) and then awakens and is ambulatory on scene. Emergency Medical Services (EMS) is called and on arrival the patient is walking but has obvious facial trauma and is complaining of some neck pain. He has midline neck tenderness but no limb numbness or paresthesia. As an EMS crew member, you are tasked with deciding what method of spinal motion restriction to use. Background: We have covered head injuries including concussions multiple times on the SGEM. This has included looking at the Canadian CT Head Rules/Tools (SGEM#106, SGEM#266, and SGEM#272). We have also covered concussions (SGEM#112, SGEM#331, and SGEM#362). Another core element of emergency department (ED) and pre-hospital care is the assessment for potential spinal injuries [1,2].  Patient care and positioning has evolved over time, previously routine spinal immobilization (SI) was with a cervical spine collar, placement on a long, rigid backboard, and straps or head blocks. Over time this has evolved to spinal motion restriction (SMR) with more variable use of cervical collars, patient positioning, and accessories such as head rolls and tape [3-4]. This has evolved due to recognition of some of the adverse effects of immobilization as well as limitations to its benefits. The role of the cervical collar itself varies by jurisdiction and it is not entirely clear which devices and procedures are most effective at reducing potentially harmful spinal motion [5-11]. Existing research on SMR confirms decreases in the use of long backboards and increases in collar-only treatment [12-14].  Some of this research has observed substantial under-treatment among patients who met criteria for precautions, as well as some patients with confirmed injuries who received no treatment from EMS [15-16]. Other studies have observed no increase in the diagnosis of cervical spine injuries, however, variable practice and the possibility of patients not receiving appropriate treatment remains a concern [17-18]. In order for standards for acute management of spinal injuries to progress, we must optimize patient protection and limit harm [19]. Clinical Question: How has the rate of pre-hospital spinal immobilization/spinal motion restriction changed from 2009 to 2020? Reference: McDonald et al. Patterns of change in prehospital spinal motion restriction: a retrospective database review. AEM July 2023 Population: EMS patients with traumatic injuries Excluded: None Intervention: Spinal immobilization/spinal motion restriction Comparison: This is a retrospective review and includes several changes over time, thus the comparison is the change in rate over time of SMR Important Changes Were: In 2009, selective spinal immobilization using NEXUS criteria was implemented. In July 2012, changing documentation required paramedics to record the indications for SI/SMR in all cases. In November 2014, cases of isolated penetrating trauma were exempted from SMR. In April 2016, treatment guidelines were revised to allow for collar-only treatment in low-risk scenarios (patient ambulatory prior to paramedic arrival) Outcome: Primary Outcome: Rate of spinal immobilization/spinal motion restriction Secondary Outcomes: Rates of splinting and wound care as proxy measures of the incidence of trauma care over time. Patient and practice-related factors associated with potential changes over time. Patient related factors include age, sex,