Page 76 - Journal of Special Operations Medicine - Fall 2016

has no significant prior medical illness. His heart rate protection of a patient with a potential spinal injury
is 90, respiratory rate 12, oxygen saturation is 99%, is one such example. Patient restraint on a backboard
and temperature is 37°C (98.6°F). He has no abnormal leads to conditions that promote formation of pressure
neurological findings, his vital signs are stable, and he sores; these sores can become incredibly painful and very
appears to be uninjured aside from the aforementioned complicated to heal. Contact points can have significant
laceration and right-hand complaint, although he con- pressures above the point at which tissue necrosis oc-
tinues to complain of worsening neck pain. curs and pressure ulcers can develop. Berg et al. showed
3
that otherwise healthy adults had tissue hypoxia and
Having just completed your own assessment of the area pressure sore development after only 30 minutes on a
and its local medical facilities, you know that diagnostic backboard. Furthermore, pain can be induced in areas
4
imaging is hours away. You reach out to higher medical that are not even in contact with the backboard. Due
authority to ask for advice and assistance in organizing to the patient’s position on a flat surface and the axial
the lengthy process of evacuation. skeleton’s innate curvature, supine restraint can cause
pain in the lower back and cervical spine. Lower back
5
and cervical pain has been reported to persist in previ-
History Lesson
ously pain-free, healthy volunteers 24 hours after being
Spinal immobilization of trauma patients with a cervical subjected to only 1 hour on a backboard. This pain in
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collar and a rigid backboard has long been associated areas that were not painful at the time of the accident
with the standard of care for over 50 years. The first leads to difficultly in patient assessment and probably
paper to correlate injury as a result from movement of unnecessary imaging.
an unstable spine in an unprotected patient was in a ret-
rospective study by Geisler et al. in 1966. Despite the When a patient is placed on a backboard, not only are
1
study only discussing two patients who suffered delayed they exposed to contact with a hard surface but also
neurological deficits, the authors went on to conclude often are strapped into place at multiple points across
that the patients “would surely have been protected from the chest, abdomen, and waist. This strapping is aimed
the paraplegic condition had the spinal instability been to secure the patient in place but has its own associated
recognized and precautions taken.” The publication risks and consequences. Studies conducted with healthy,
1
by Geisler et al. prompted the medical community to nonsmoking men show that straps tightened across the
conclude that patients who suffered blunt-force trauma torso have a restrictive effect and can lower forced vital
were at risk of neurological complications from inadver- capacity, forced expiratory volume over 1 second, and
tent manipulation of occult spinal injury and should be forced mid-expiratory flow. Patients with injuries to the
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immobilized on a rigid device to reduce this risk. chest or with lung dysfunction may experience worsen-
ing conditions as a result of typical backboard strapping.
In subsequent years, protocols and medical directives
were developed that instructed providers to approach Simply stated, the goal of spinal precautions is to pre-
the patient and manually immobilize the spine in the vent spinal cord injury in patients with spinal fractures
found position until a cervical collar was placed. Spinal and to prevent worsening of spinal cord injuries, with or
precautions are maintained through extrication onto a without evidence of such an injury. In 1998, Hauswald
backboard, and the patient is immobilized with a cervi- et al. compared neurological outcomes between two
8
cal collar on the backboard until cleared by a physician. 2 patient populations: one based in New Mexico, where
This dogmatic adherence to the use of a cervical collar all studied patients received full spinal immobilization
and backboard is nearly universal for all trauma pa- with a collar and backboard; and the other in Malay-
tients in Canada and the United States. With no obvious sia, where none of the patients received formal spinal
downside and a significant fear of causing further harm precautions. Correcting for age, mechanism, and level
to these already traumatized patients, it was viewed as a of spinal cord injury, the study found that neurological
low-cost intervention that prevented spinal cord injury disability was higher in the New Mexico group. More
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in all patients. Clinical judgment, the presence or ab- recently, Haut et al. compared outcomes of penetrating
sence of symptoms, and the mechanism of injury were trauma patients who underwent spinal immobilization
not part of the front-line decision-making. with those who did not. The odds ratio for death for
9
the immobilized patients was 2.06; in other words, the
risk of death in the studied immobilized patients was
What Is the Harm?
2.06 times higher than that of the nonimmobilized pa-
Protecting a patient from further harm stands at the cen- tients. This risk ratio of immobilization, including back-
ter of competent medical care. It is important, therefore, board use, to nonimmobilization was upheld across all
to periodically review our practices and assess whether types of penetrating trauma. Any potential immobiliza-
our standard practice could be harming patients. The tion benefit was reduced even more when considering

58 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2016