EDITORIAL: Spinal Motion Restriction Needs to Be Restricted

Dustin Ballard, MD

The best lightning rod for your protection,” Ralph Waldo Emerson once said “is your own spine.” In medicine however, knowing when and where a patient’s spine can protect itself has proven extremely challenging. Take, for example, pre-hospital protocols for spinal immobilization of trauma patients.

For nearly 50 years, the training and culture of our pre-hospital providers has resulted in millions of people being unnecessarily strapped and taped to hard plastic boards. This practice of spinal motion restriction (SMR) remains standard in many localities. And, while in cases of severe spinal trauma such restriction might prevent injury progression, in other situations the use of backboards can be painful and even harmful.

Let’s imagine your run-of-the-mill fender bender. Police and paramedics have been called and the driver has escaped his vehicle and walked away in dismay. When asked by the paramedics, he admits that his neck is a tad sore from whiplash.

Next thing this guy knows, he is pinned to a hard board with a stiff collar around his neck. His head is taped down and there are straps restraining his chest. He has received the full-on SMR treatment, and he will not be freed until sometime after he arrives at the ED.

In this instance, the paramedics have done exactly what they were trained to do. But have they done this patient any good? Almost certainly not; and it’s time we all recognize that there is virtually no evidence to justify SMR.

Full-on SMR began in the late 1960s as the field of EMS was just emerging. At the time, a handful of case-report-level publications recommended its use, and it quickly became standard treatment. Today, some five million patients are bound to backboards in the U.S. each year. Of these, only about 1% actually have any sort of serious spinal injury, and only a miniscule percentage of these might actually benefit from being lashed to a backboard. According to a 2010 study by Haut, et al,¹ analyzing data from the National Trauma Data Bank, the estimate of such an “unstable but incomplete” injury is on the order of 1 in 10,000 patients. Let me repeat that: Only 1 in 10,000 patients with a traumatic event might have an incomplete, unstable spinal injury in the field. So, at best, the full-on SMR has a number needed to treat (NNT) of about 10,000. And that assumes that it can help prevent progression of injury—an assumption that has never been proven.

On the other hand, evidence is accumulating against the use of backboards. We’ve always known they cause pain and anxiety. A significant proportion of healthy patients put on a backboard for an hour will complain of pain when on the board, and some will still have pain after 24 hours. Supine positioning with a backboard can make airway assessment and management difficult, mask neck and upper chest injuries, diminish respiratory function and decrease cerebral perfusion pressure in head-injury patients. Patients may aspirate or, in a struggle to escape, harm themselves or others. The full-on SMR treatment hurts ED throughput too—clogging the works with EMS wall time, staff time, disruption (from clearing patients and disposing of boards), unnecessary x-rays and longer stays. Rather than help, full-on SMR causes pain all around.

Does this sound as silly as a stretcher being called out for a soccer player who takes a flop, dives and rolls after only minimal contact? I think so, especially considering the damage that a backboard can cause a person. (Picture your elderly mother tightly strapped to a hard surface for 30 minutes.)

This is why many EMS jurisdictions are changing the way they use backboards for injured patients. Their revised protocols narrow the criteria for using full SMR to situations where they might truly benefit the patient—such as when there is evidence of a neurologic deficit. Everyone else who fails the State of Maine (the EMS equivalent of the NEXUS criteria) can receive a modified approach—such as a hard or soft cervical collar. The implementation of this type of protocol in Alameda County, California, in mid-2012 resulted in a 58% one-year reduction of backboard use without any adverse effects reported.²

Other EMS jurisdictions, including Marin County, are following suit. In my ED, we are already seeing many more patients arriving with increasingly reasonable (and comfortable) “modified” approaches to SMR. So, when it comes to pre-hospital spine care, less may be more: fewer adverse effects, more comfort.

Elsewhere in medicine, spine care is also evolving. In this issue, Marin Medicine explores some of these new developments. Like a “trick back” itself, knowing when to choose surgery for chronic back pain can be unpredictable. So we begin with a tour d’horizon of back pain and its causes, treatments and outcomes by Drs. Brian Su and Robert Byers. Minimally invasive procedures are gaining ground in many areas. Dr. Rishi Wadhwa tells us about minimally invasive spinal surgery. Vertebroplasty is a promising therapy for patients with painful compression fractures. Dr. Naveen Kumar gives us a back-to-the-basics on this procedure. Finally, the spine is a common cause of chronic pain, and not all reports of pain have the same level of physiological validity. Drs. Anish Shah and Alex Kettner discuss the spine-rattling frustration associated with detecting and managing malingering patients.

In addition to our regular public health and hospital updates—one of which, the Public Health Update, is devoted to the Marin County Opioid Prescribing Guidelines and is placed right in the middle of the magazine to facilitate its being removed and kept for reference—this issue includes a review of the late Oliver Sacks’ autobiography and two out-of-the-office features: a look at the art of M.C. Escher and a physician’s view of Burning Man. Worthwhile  reading, all of it. Enjoy!

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Dr. Ballard is an emergency physician at Kaiser San Rafael and Medical Director for Marin County Emergency Medical Services.

Email: dballard30@gmail.com

References
1. Haut ER, et al, “Spine immobilization in penetrating trauma: more harm than good?” J Trauma, 68:115-121 (2010).
2. Morrissey JF, et al, “Spinal motion restriction: an educational and implementation program to redefine prehospital spinal assessment and care,” Prehospital Emergency Care, 18 (3):429-32 (2014).