Introduction

Spinal immobilization with a backboard and cervical collar for patients with suspected spine injury became common practice in the 1960s. This decision was driven by the increase in automobile accidents as automobiles became more commonplace, and a position paper was published by the American Academy of Orthopedics endorsing its use without evidence that spinal immobilization improved outcomes.[1][2][3][4][5][6][7][8] Spinal immobilization included the use of a cervical collar and a rigid backboard with secured straps. Recent studies assessing the validity of spinal immobilization raised concern for harm instead of better outcomes). In the early 2010s, the common practice moved to spinal motion restriction to replace the common use of spinal immobilization.[1] In 2019, a retrospective observational study from the University of Arizona showed no significant increase in spinal cord injury after the transition from a spinal immobilization protocol to one of spinal motion restriction.[9]

Indications

A joint position paper between the American College of Surgeons Committee on Trauma (ACS-COT), American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP) in 2018 outlined the uniform recommendations for spinal motion restriction in the care of trauma patients.[1] The indications for patients who have experienced blunt trauma are summarized in Table 1. Patients with none of the identified indications should not undergo spinal motion restriction due to the potential for harm by being placed in a cervical collar or backboard.

In the pediatric population, there is no indication based on age alone for the use of spinal motion restriction.[10][11] Young patients can present a challenge to providers due to communication issues. A retrospective review completed by Hale et al. of 2,972 pre-elementary trauma patients showed that CT scans were not necessary for patients less than five years old without clinical findings on the exam. In addition to the criteria listed in table 1, torticollis is considered an indication of spinal motion restriction (particularly cervical collar placement) in pediatric patients.[12]

Issues of Concern

Contraindications

Spinal motion restriction should not be used in the patient with penetrating trauma. In their 2010 publication, Haut et al. reviewed 45,284 patients entered into the National Trauma Data Bank (NTDB). They found that patients with penetrating trauma who underwent spinal immobilization in the field (defined as placement of a cervical collar and/or longboard) had mortality rates twice as high as those who did not.[13] The Eastern Association for the Surgery of Trauma (EAST) performed a systematic review of twenty-four studies in 2018 that showed no benefit to spinal immobilization in either mortality or neurologic recovery, even in those with a direct neck injury.[2]

Complications

The earlier ubiquitous use of the backboard revealed several significant complications, leading to an evidence-based transition from immobilization with a backboard to the current use of spinal motion restriction. The forceful strapping of patients against a rigid backboard is not compatible with the natural curvature of the spine, and such restriction may increase unwanted flexion, extension, and rotation. This effect is more pronounced in populations such as the elderly or those with ankylosing spondylitis who develop marked kyphosis or lordosis.[3] It is preferable to move these patients onto a stretcher and off the backboard as soon as possible. Even when moved to a cot, additional padding with towels or pillows is often required to maintain the patient’s natural alignment and prevent further injury. Similar considerations should be taken with children to prevent excess cervical spine flexion due to high variation in head-to-body size.

In a 2014 systematic review in The Journal of Trauma and Acute Care Surgery, five studies showed an increase in pain scores following immobilization.[4] Patients placed into strict immobilization with a backboard are at higher risk for developing pressure ulcers in as little as thirty minutes.[6] In 2013, a review by Cooney et al. showed that patients spent an average of one hour secured to a backboard after undergoing spinal immobilization in the field.[12] Even without the straps in place, patients should not be left on a hard backboard during transport to the hospital to prevent pain and ulcer development. Spinal motion restriction now allows for neutral alignment on a cot or stretcher, but providers should pay attention to provide padding or support where needed.

When utilizing the backboard as a movement tool from extrication to ambulance, providers should monitor respiratory status closely. Studies have shown significant respiratory restriction in healthy patients who were strapped to a backboard with cervical collars. This restriction was greater in elderly kyphotic patients placed in a cervical collar.[7][8] Patients with significant blunt chest and neck trauma may already have diminished respiratory capacity due to injuries that could worsen with further constriction.

Clinical Significance

Spinal motion restriction is the use of a cervical collar and cot to maintain neutral alignment of the spine during transport of the patient with concern for spinal injury. The goal is to reduce excessive movement of the spine that may worsen existing spinal trauma and neurologic deficit. While backboards may work for the initial extrication and movement of a patient, it is preferable to bring the cot or stretcher to the ambulatory patient and instruct them to lie down. Do not perform a vertical backboard takedown. The backboard requires removal as soon as practical before transport by emergency medical services (EMS) to the hospital. Recent studies suggest that full spinal immobilization does not limit motion during prehospital transportation as much as previously thought. While this was most notable in the non-compliant patient, the increased movement was seen in the compliant patient population.[14]

Not all patients will be able to lie flat on their back on a stretcher. An alert patient with nausea and vomiting may need to have their head of the bed elevated or be rolled on their side to avoid aspiration. If a patient requires intubation, elevating the head of the bed has been demonstrated to improve oxygenation and hemodynamic stability.[15] In the altered patient with head trauma, providers should consider elevating the head of the bed to decrease intracranial pressure. If a patient needs the head of their bed raised, spinal motion restriction requires support through the head, neck, and torso; this is not possible with a patient on a backboard.

While most spinal injuries are due to high force mechanisms, special care is necessary for geriatric patients (age 65 and older) who may present without typical physical exam findings (i.e., midline neck pain) after a ground-level fall (GLF). A 2013 retrospective review of 12,805 geriatric trauma patients found cervical spine fractures in over half of geriatric patients with ground-level falls. Overall, geriatric patients were more likely to sustain upper cervical fractures than non-geriatric patients, and researchers found GLFs to cause both isolated cervical fractures and significant intracranial pathology.[16] Providers should have a high index of suspicion for significant injury in this population even with a low force mechanism.