Page 78 - Journal of Special Operations Medicine - Fall 2016

precautions for these patients includes the immediate testing does not reveal any deficits. Given the patient’s
cessation of all movement, with a medical provider pro- lack of significant signs or symptoms of spinal injury,
viding manual stabilization of the head and neck until you remove the collar and have the patient actively ro-
the patient is passively transferred onto a backboard. tate his neck 45° to the left and right. He accomplishes
Even if the patient is awake and fully alert, this process this task without complaint. You instruct the patient to
is common practice for rigidly “protocolized” medicine remain lying down in a position of comfort while you
directed at prehospital providers. These types of elabo- take a moment to communicate your findings to your
rate and regimented maneuvers have never been shown higher medical authority.
to improve outcomes in patients and would result in
said patients ending up on backboards for potentially Speaking with your senior medical contact, you explain
extended periods of time. In fact, the overall utility of a the situation, including that the vehicle “tipped” over
backboard toward the goal of immobilization is ques- at relatively low speed (versus a high-speed rollover)
tionable. Mazolewski and Manix showed that a patient and was driven back, and that the patient was free of
strapped to a backboard still could move in a variety of any neurological findings on examination. Your exam-
directions. 14 ination revealed a minor forehead laceration, a right
thumb injury, no pain during C-spine palpation, and
The movement the medical provider is trying to elimi- the patient was able to rotate his neck without com-
nate often depends on the cooperation of the patient. It plaint. Given this information, your medical officer
is counterintuitive, then, to not use this capability for agrees with you that the likelihood for a significant
self-movement and control to the advantage and en- spinal injury is remote. Urgent evacuation is difficult
hancement of spinal precautions. Engsberg et al. used to achieve and is unwarranted at this time. You are ad-
15
high-speed infrared motion analysis cameras and sensors vised that it is prudent to observe your patient, and that
to detect motion of the cervical spine during different he should avoid any high-risk or high-impact activities
extrication techniques. They found self-extrication with and can depart with the rest of the group in a couple
a cervical collar resulted in the least movement of the days as planned.
spine. Patients with a positive spinal assessment should
15
have a cervical collar applied; then, if able, they can am- Over the next 48 hours you observe your patient as he
bulate to a stable flat surface on their own power or with resumes his normal activity around camp. He complains
assistance, but do not need to be placed on a backboard. of some mild muscular pain and continues to wear a
splint for his thumb injury, but is otherwise doing well.
Once back at home, you hear that the patient underwent
The Case
surgery. You have a moment of apprehension, worried
You confirm no changes from your initial assessment if you missed something. You are relieved to hear that it
and move your patient to where a simple cot is available. was for the repair of the ulnar collateral ligament of his
Wanting to remove the backboard and perform a more right thumb and he is expected to make a full recovery.
thorough examination of your patient, you organize
other members of your group to assist in transferring Case Summary
the patient onto the cot. During the log roll maneuver,
you are able to fully palpate the patient’s spine. You Trauma patients with an unstable cervical spinal injury
note a small area of erythema over C-7; it is not tender represent a very small percentage of blunt trauma pa-
to palpation. The patient states, “No, it doesn’t hurt if tients. The fear of missing one of these injuries and the
you press. It just feels good to be off that board.” resultant neurological impairment has led to a very dog-
matic and rigid approach to universal immobilization
You have the backboard removed and roll the patient on a backboard. This practice may actually be harming
back flat onto the cot. You address the superficial lac- some of our patients. There is sufficient evidence that
eration to the forehead and confirm that he still has allows for the separation of patients into groups based
pain in his right-hand thumb. Physical examination of on who is at extremely low risk for cervical spine injury.
this area reveals edema and ecchymosis surrounding the Using the Canadian C-spine rule or the NEXUS criteria
right thumb and his grip strength is reduced, specifically can help identify those who receive no benefit and would
during “pinch” testing (thumb to forefinger). A more only be exposed to risk. All trauma patients should re-
focused neurological examination reveals an alert and ceive an assessment of their spine based on one of these
oriented patient with a Glasgow Coma Scale score of evidence-supported clinical decision tools. If they fail to
15. He is not experiencing any memory loss or nausea. meet the criteria of the rules or if a neurological deficit is
There is no facial asymmetry and the patient denies any present, a cervical collar should be applied. If the patient
numbness or tingling in his extremities. Strength testing, is awake and able, self-extrication is reasonable. If extri-
aside from grip, is equal throughout and full sensory cation must be assisted, then the backboard is a helpful

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