Spinal precautions

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Spinal precautions
Cervical Collar Emergency.jpg
A person with a hard cervical collar on a long board

Spinal precautions, also known as spinal immobilization and spinal motion restriction, are efforts to prevent movement of the bones of the spine in those with a risk of a spine injury. [1] This is done as an effort to prevent injury to the spinal cord [1] in unstable spinal fractures. [2] About 0.5-3% of people with blunt trauma will have a spine injury, [3] [4] with 42-50% of injuries due to motor vehicle accidents, 27-43% from falls or work injuries, and the rest due to sports injuries (9%) or assault (11%). [4] [5] [6] The majority of spinal cord injuries are to the cervical spine (neck, 52%), followed by the thoracic (upper back) and lumbar (lower back) spine. [4] Cervical spinal cord injuries can result in tetraplegia or paraplegia, depending on severity. [6] Of spine injuries, only 0.01% [7] are unstable and require intervention (either surgery or a spinal orthosis). [8]

Contents

Some authors argue that use of spinal precautions is controversial because benefit is unclear and there are significant drawbacks including pressure ulcers, increased pain, and delayed transport times. [9] [7] [10] Spinal boards can also be uncomfortable. [11]

Indications

Spinal precautions are first initiated by emergency medical services in the prehospital setting. [9] There are multiple decision rules used by different EMS departments to determine which patients should be immobilized. [3] [4] [7]

Due to concerns of side effects the National Association of EMS Physicians and the American College of Surgeons recommend its use only in those at high risk. [7] This includes: those with blunt trauma who have a decreased level of consciousness, pain or tenderness in the spine, those with numbness or weakness believed to be due to a spinal injury, and those with a significant trauma mechanism that are intoxicated or have other major injuries. [7] These recommendations are also endorsed by the Consortium for Spinal Cord Medicine. [12] Immobilization is also recommended in those with a definite spinal cord injury. [13]

Spinal motion stabilization is not supported for penetrating trauma to the back including that caused by gun shot wounds. [9] [14]

Prehospital

Methods

Spinal precautions generally include long spine boards, cervical collars, head blocks, and straps with the goal of immobilizing or reducing movement throughout the entirety of the spine. [4] [7] [12] They also include methods to reduce spinal movement while moving a patient, such as logrolling. [7] Measures to reduce intracranial pressure, such as lowering the feet of the bed while keeping it flat, are also sometimes used. [7]

If a longboard is used, cushioning it is useful to decrease discomfort due to pressure. [15] A vacuum mattress and scoop board typically results in lower pressures. [15]

Contraindications

Spinal precautions should not be used in patients who are at low risk of spinal injury. [7] If intubation is required the cervical collar should be removed and neck stabilization provided by a trained staff member holding the patient's head. [3] [13] Whenever possible, intubation methods that decrease spinal motion should be used such as awake fiberoptic intubation. [6]

In those with penetrating neck or head trauma spinal immobilization may increase the risk of death. [14] [10]

Controversy

There is little high quality evidence for spinal motion stabilization of the neck before arrival at a hospital. [12] [10] [16] Multiple studies have demonstrated that current methods used to immobilize the spine in the field do not improve patient outcomes. [9] Additionally, because spinal cord injury is rare, it is estimated that if everyone at risk for spine injury was placed on spinal precautions, approximately 50-100 people would be put on precautions for every one person who actually had an injury. [4] The benefit of spinal precautions is also questioned because the initial forces that lead to spine injury tend to be massive, while forces experienced during transport are subsequently minor. [7] Thus, there is skepticism that movement during transport could cause a new or worsened spinal cord injury if an initial high-impact injury, such as a car crash, did not. [7]

Spinal precautions including a cervical collar and rigid board have been shown to delay time to intubation, increase risk of aspiration, raise intracranial pressure and cause pain, agitation, and pressure ulcers. [4] [12] [17] A systematic review found cervical collar related skin ulcers from the devices in 7 to 38%. [18]

There are no high-quality randomized trials supporting the practice of spinal cord immobilization in the field. [12] However, secondary injury (i.e. injury to the spinal cord during transport after an initial trauma), is suspected to be the cause of up to 1/4 of spinal cord injuries. [12] Because of the devastating consequences of spinal cord injury and the theoretical benefit of spinal precautions in preventing secondary injury to the spinal cord, the use of spinal precautions is still recommended in high-risk patients by major societies. [12]

Clearance

Due to their side-effects, backboards should be removed as soon as possible, even before imaging. [6] [7] It is also recommended to remove cervical collars as soon as possible. [6] If patients require ongoing cervical spine precautions, they should be switched to an adjustable cervical collar such as a Miami J collar [6] or halo-gravity traction device for long-term immobilization. [12]

Cervical Spine Clearance

The Canadian C-spine rule for those with a normal Glasgow coma scale and who are otherwise stable The Canadian C-spine rule for those with a normal Glasgow coma scale and who are otherwise stable.png
The Canadian C-spine rule for those with a normal Glasgow coma scale and who are otherwise stable

There are two main algorithms, the Canadian C-spine rule and NEXUS, which are used to decide who requires cervical spine imaging via CT scan [6] after blunt trauma, and who can be cleared without imaging. [4] The Canadian C-spine rule appears to have greater sensitivity and specificity (i.e. fewer false positives and false negatives). [19] However, following either rule is reasonable.

If the chosen decision rule (NEXUS or Canadian C-spine) is negative, or if cervical spine imaging is negative, the cervical collar can be removed if the patient does not have significant midline tenderness and can move the neck 45 degrees to both sides. [6] If a patient cannot do both, the collar should be replaced and additional imaging or follow-up should be pursued depending on facility guidelines. [6]

CT scan demonstrating one thoracic vertebra Image of trabecular bone of the spine by Quantitative computed tomography.jpg
CT scan demonstrating one thoracic vertebra

Thoracic and Lumbar Spine Clearance

Unfortunately, the NEXUS and Canadian C-Spine rules do not apply to suspected thoracic or lumbar injury; indeed, there are currently no validated guidelines for who requires imaging in this setting. [4] [6] Instead, imaging should be obtained according to physician gestalt. [6] High-risk features include tenderness in the center spine, new numbness or weakness, or spinal fracture of another area; imaging of the thoracic and lumbar spine should be pursued in patients with these findings. [6] [12] If a patient's cervical spine has been cleared, but they have a thoracic or lumbar spine injury, the cervical collar can be removed but they must maintain thoracolumbar immobilization using a firm padded bed and careful maneuvers for transfers and repositioning. [12]

If a patient has new numbness or weakness but without evidence of a spinal fracture on CT-scan, they may have spinal cord injury without radiographic abnormality (SCIWORA), and may require MRI to confirm the diagnosis. [12] Spinal precautions should be maintained while pursuing further imaging. [12]

Postoperative

Fracture of the cervical spine (left red arrow showing vertebral body fracture) treated with open reduction and internal fixation (ORIF) (hardware seen on the right) Teardrop fracture.jpg
Fracture of the cervical spine (left red arrow showing vertebral body fracture) treated with open reduction and internal fixation (ORIF) (hardware seen on the right)

Patients with spinal cord injury due to trauma tend to have other life-threatening traumatic injuries or complications of spinal cord injury such as neurogenic shock [12] that take precedence to repair of the spine. [6] Thus, spinal motion restriction should be maintained while other medical interventions are begun. [6] Neurological outcomes may be better with early spine repair when possible, [20] however the evidence is low-quality. [12]

In all patients with spinal cord injury, high-quality skin care to prevent pressure ulcers is essential. [12] This includes adequate cushioning, frequent repositioning of the patient, keeping the skin dry and clean, and ensuring adequate nutrition. [12]

After surgery for an unstable spinal fracture, methods to reduce movement of the spine vary depending on the severity of injury and method of repair. [8] Surgeons strongly recommend to avoid smoking, as it slows healing. [21] There is also debate that NSAID medications such as aspirin, ibuprofen, and naproxen may delay bone repair after spinal fusion or grafting, however there is some evidence that short-term use around the time of surgery is not associated with worse outcomes. [21] Finally, patients should avoid activities that cause movement to the spine, including bending, lifting more than 5-10 pounds, or twisting the spine for 4-12 weeks after surgery. [22] Patients can learn special ways to get out of bed and do other activities during this time. [20] Other activities that should be avoided until a provider permits them include soaking in water like a bathtub or hottub, sports (running, horseback riding, etc.), and chores (vacuuming, sweeping, opening windows/jars etc.). [22]

Methods

Depiction of the halo traction device. Halo Brace.png
Depiction of the halo traction device.

There are multiple devices that can be used in addition to avoiding maneuvers or activities that move the spine. [8] [20] Long-term cervical spine immobilization in patients with cervical spine fracture who did not undergo surgery can be performed using a long-term cervical collar (Miami J, [6] [8] Philadelphia, [8] or Aspen [8] ) or halo traction device. [8] [12] When using a traction device such as the halo to hold the spine in place while it heals, this is called closed reduction, as opposed to a surgery which is termed open reduction with internal fixation (ORIF). [20] In general, the halo traction device is preferred for unstable fracture, while the cervical collars are used for neck sprain, stable fracture, or after surgical fixation. [8] Soft cervical collars do not restrict head movement and are more so used for comfort. [8] The sternal occipital mandibular immobilizer (SOMI) can also be used to provide support for cervical spine sprain, stable fracture, or postoperative support. [8]

For thoracic and lumbar spine, support can be provided using custom-fit, hard-shell back braces, most commonly after surgery. [8]

A patient in the LA County Medical Center intensive care unit with a Halo orthosis in place. (July 2004) US Navy 040723-N-8977L-008 Navy Hospital Corpsmen and Medical Officers assess the treatment and prognosis of a patient with a gunshot wound.jpg
A patient in the LA County Medical Center intensive care unit with a Halo orthosis in place. (July 2004)

These devices are used while the spine is healing and are not needed permanently. [8]

History

Spinal precautions including prehospital use of a backboard and cervical collar were first introduced in the United States in the 1960s. [7] Before the widespread use of spinal precautions in the 1970s, 55% of patients referred to spinal cord injury centers had complete spinal cord injury. [12] In the 1980s, spinal immobilization was initially used routinely for people who had experienced physical trauma, with little evidence to support its use. [23] However, the majority of patients in the 1980s had incomplete spinal cord injury, indicating an improvement in outcomes from the 1970s to the 1980s. [12]

The widespread use of routine spinal precautions drew criticism and prompted studies investigating the ability of EMS providers to selectively determine who required spinal precautions in the field in the late 1990s and early 2000s. [12] These studies led to the 2008 recommendation by the Consortium of Spinal Cord Medicine to only immobilize high-risk patients. [12]

Related Research Articles

<span class="mw-page-title-main">Tetraplegia</span> Paralysis of all four limbs and torso

Tetraplegia, also known as quadriplegia, is defined as the dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord. A loss of motor function can present as either weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk, and pelvis. The paralysis may be flaccid or spastic. A loss of sensory function can present as an impairment or complete inability to sense light touch, pressure, heat, pinprick/pain, and proprioception. In these types of spinal cord injury, it is common to have a loss of both sensation and motor control.

<span class="mw-page-title-main">Lumbar spinal stenosis</span> Narrowing of the lower spinal canal

Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case it is known as cervical spinal stenosis or thoracic spinal stenosis. Lumbar spinal stenosis can cause pain in the low back or buttocks, abnormal sensations, and the absence of sensation (numbness) in the legs, thighs, feet, or buttocks, or loss of bladder and bowel control.

<span class="mw-page-title-main">Clearing the cervical spine</span> Process of determining the existence of a cervical spine injury

Clearing the cervical spine is the process by which medical professionals determine whether cervical spine injuries exist, mainly regarding cervical fracture. It is generally performed in cases of major trauma. This process can take place in the emergency department or in the field by appropriately trained EMS personnel.

<span class="mw-page-title-main">Spinal board</span> Device used in pre-hospital trauma care

A spinal board, is a patient handling device used primarily in pre-hospital trauma care. It is designed to provide rigid support during movement of a person with suspected spinal or limb injuries. They are most commonly used by ambulance staff, as well as lifeguards and ski patrollers. Historically, backboards were also used in an attempt to "improve the posture" of young people, especially girls.

<span class="mw-page-title-main">Vehicle extrication</span> Process of removing a person trapped in a vehicle

Vehicle extrication is the process of removing a patient from a vehicle which has been involved in a motor vehicle collision. Patients who have not already exited a crashed vehicle may be medically or physically trapped, and may be pinned by wreckage, or unable to exit the vehicle because a door will not open.

<span class="mw-page-title-main">Spinal cord injury</span> Injury to the main nerve bundle in the back of humans

A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. It is a destructive neurological and pathological state that causes major motor, sensory and autonomic dysfunctions.

Myelopathy describes any neurologic deficit related to the spinal cord. The most common form of myelopathy in humans, cervical spondylotic myelopathy (CSM), also called degenerative cervical myelopathy, results from narrowing of the spinal canal ultimately causing compression of the spinal cord. When due to trauma, myelopathy is known as (acute) spinal cord injury. When inflammatory, it is known as myelitis. Disease that is vascular in nature is known as vascular myelopathy.

<span class="mw-page-title-main">Cervical collar</span> Medical device used to support a neck

A cervical collar, also known as a neck brace, is a medical device used to support and immobilize a person's neck. It is also applied by emergency personnel to those who have had traumatic head or neck injuries, although they should not be routinely used in prehospital care. They can also be used to treat chronic medical conditions.

<span class="mw-page-title-main">Scoop stretcher</span> Device used for moving injured people

The scoop stretcher is a device used specifically for moving injured people. It is ideal for carrying casualties with possible spinal injuries.

<span class="mw-page-title-main">Cervical fracture</span> Medical condition

A cervical fracture, commonly called a broken neck, is a fracture of any of the seven cervical vertebrae in the neck. Examples of common causes in humans are traffic collisions and diving into shallow water. Abnormal movement of neck bones or pieces of bone can cause a spinal cord injury, resulting in loss of sensation, paralysis, or usually death soon thereafter, primarily via compromising neurological supply to the respiratory muscles and innervation to the heart.

<span class="mw-page-title-main">Cauda equina syndrome</span> Nerve damage at the end of the spinal cord

Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Signs and symptoms include low back pain, pain that radiates down the leg, numbness around the anus, and loss of bowel or bladder control. Onset may be rapid or gradual.

<span class="mw-page-title-main">Spinal fusion</span> Immobilization or ankylosis of two or more vertebrae by fusion of the vertebral bodies

Spinal fusion, also called spondylodesis or spondylosyndesis, is a surgery performed by orthopaedic surgeons or neurosurgeons that joins two or more vertebrae. This procedure can be performed at any level in the spine and prevents any movement between the fused vertebrae. There are many types of spinal fusion and each technique involves using bone grafting—either from the patient (autograft), donor (allograft), or artificial bone substitutes—to help the bones heal together. Additional hardware is often used to hold the bones in place while the graft fuses the two vertebrae together. The placement of hardware can be guided by fluoroscopy, navigation systems, or robotics.

<span class="mw-page-title-main">Spinal disc herniation</span> Injury to the intervertebral disc

A spinal disc herniation is an injury to the intervertebral disc between two spinal vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatments may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including good posture.

<span class="mw-page-title-main">Radiculopathy</span> Medical condition

Radiculopathy, also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly. Radiculopathy can result in pain, weakness, altered sensation (paresthesia) or difficulty controlling specific muscles. Pinched nerves arise when surrounding bone or tissue, such as cartilage, muscles or tendons, put pressure on the nerve and disrupt its function.

<span class="mw-page-title-main">Central cord syndrome</span> Human spinal cord disorder

Central cord syndrome (CCS) is the most common form of cervical spinal cord injury (SCI). It is characterized by loss of power and sensation in arms and hands. It usually results from trauma which causes damage to the neck, leading to major injury to the central corticospinal tract of the spinal cord. CCS most frequently occurs among older persons with cervical spondylosis, however, it also may occur in younger individuals.

Grady straps are a specific strapping configuration used in full body spinal immobilization.

<span class="mw-page-title-main">Spinal fracture</span> Medical condition

A spinal fracture, also called a vertebral fracture or a broken back, is a fracture affecting the vertebrae of the spinal column. Most types of spinal fracture confer a significant risk of spinal cord injury. After the immediate trauma, there is a risk of spinal cord injury if the fracture is unstable, that is, likely to change alignment without internal or external fixation.

<span class="mw-page-title-main">Spinal stenosis</span> Disease of the bony spine that results in narrowing of the spinal canal

Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in onset and improve with leaning forward. Severe symptoms may include loss of bladder control, loss of bowel control, or sexual dysfunction.

Spinal cord injury without radiographic abnormality (SCIWORA) is symptoms of a spinal cord injury (SCI) with no evidence of injury to the spinal column on X-rays or CT scan. Symptoms may include numbness, weakness, abnormal reflexes, or loss of bladder or bowel control. Neck or back pain is also common. Symptoms may be brief or persistent. Some do not develop symptoms until a few days after the injury.

<span class="mw-page-title-main">Bizhan Aarabi</span> Iranian-American neurosurgeon

Bizhan Aarabi is an Iranian-American neurosurgeon, researcher, author, and academic. He is a professor of neurosurgery at University of Maryland and the Director of Neurotrauma at the R Adams Cowley Shock Trauma Center.

References

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  2. ↑ Vaccaro, A. R.; Silber, J. S. (2001-12-15). "Post-traumatic spinal deformity". Spine. 26 (24 Suppl): S111–118. doi:10.1097/00007632-200112151-00019. ISSN   0362-2436. PMID   11805617.
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  11. ↑ National Association of EMS Physicians; American College of Surgeons Committee on Trauma (2012). "EMS Spinal Precautions and the Use of the Long Backboard Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma" (PDF). American College of Surgeons. Retrieved November 27, 2024.
  12. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Consortium for Spinal Cord Medicine (2008). "Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals". The Journal of Spinal Cord Medicine. 31 (4): 403–479. doi:10.1043/1079-0268-31.4.408 (inactive 2024-11-14). ISSN   1079-0268. PMC   2582434 . PMID   18959359.{{cite journal}}: CS1 maint: DOI inactive as of November 2024 (link)
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  16. ↑ Sundstrøm, T; Asbjørnsen, H; Habiba, S; Sunde, GA; Wester, K (15 March 2014). "Prehospital use of cervical collars in trauma patients: a critical review". Journal of Neurotrauma. 31 (6): 531–40. doi:10.1089/neu.2013.3094. PMC   3949434 . PMID   23962031.
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  23. ↑ Oteir, AO; Smith, K; Jennings, PA; Stoelwinder, JU (August 2014). "The prehospital management of suspected spinal cord injury: an update". Prehospital and Disaster Medicine. 29 (4): 399–402. doi:10.1017/s1049023x14000752. PMID   25046238. S2CID   19574297.
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