Spinal Immobilisation: A Literature Review A review of the literature regarding spinal immobilisation has been undertaken using databases for PubMed, MEDLINE, CINAHL, OVID and Cochrane EBM. Reviews were electronically searched using the subject headings “spinal injuries”, “spinal immobilisation” and “management of spinal injuries”. The results generated by the search were limited to English language articles and reviewed for relevance to the topic.
The aim of this literature review is to compare and contrast the views on spinal immobilisation and to achieve a better knowledge of evidence based practice.
According to Chiles and Cooper (1996) spinal injury should always be suspected in patients with severe systemic trauma, patients with minor trauma who report spinal pain or have sensory or motor symptoms, and patients with an impaired level of consciousness after trauma. According to Caroline (2008) the primary goal of spinal immobilisation is to prevent further injuries. Good initial and acute management is crucial no matter the degree of damage (Sheerin and Gillick, 2004). The purpose of immobilisation in suspected spinal trauma is to maintain a neutral position and avoid displacement and secondary neurological injury (Vickery, 2001).
Means of immobilisation include holding the head in the midline, log rolling the person, the use of backboards and special mattresses, cervical collars, sandbags and straps (Kwan, Bunn & Roberts 2009). The Advanced Life Support Group supports the use of the long spinal board (backboard) for spinal immobilisation, despite knowledge of pressure problems and poor immobilisation in some patient groups. The spinal board was originally developed as an extrication device using its smooth surface to allow a person to be slid out of a vehicle.
However, it is difficult to remove the patient from the board in the field and therefore the patient is most commonly transported to the A & E department on the spinal board (Cooke, 1998). There is considerable variation in the best technique for pre-hospital cervical spine immobilisation (Vickery, 2001). Some have advised the use 1 to 1. 5 inches of padding under the head as standard, others have advised that judgement on the use of padding be based on visual inspection (Butman, McSwain & McConnell, 1986). Conversely, several rauma texts recommend placing the patient directly against the spinal board (McSwain, 1989). In the United Kingdom, the vacuum mattress is predominately used by mountain rescue teams as it is believed to provide better overall protection of an injured casualty and is perceived to be safer and easier to transport over the terrain encountered in these situations (Herzenberg, Hensinger and Dederick, 1989). In a recent study by Luscombe and Williams (2002), it was shown that the vacuum mattress prevents significantly more movement in the longitudinal and lateral planes when subjected to a gradual tilt.
Perceived comfort levels are significantly better with the vacuum mattress that with the backboard. Chan, Goldburg & Mason (1996) reviewed the use of the long spinal board and its association with pressure injury, unsatisfactory immobilisation and positioning, and the pain that it can cause (Chan, Goldburg & Tascone, 1994). A study by Lovell and Evans (1994) indicated that while a casualty resides on a backboard it may possibly lead to pressure sores in those who have sustained injury to the spinal cord. The amount of time casualties remain on backboards can exacerbate the problems of pain and pressure.
Ambulance journeys and waits in accident and emergency may be lengthy and there may be long distances involved in getting to hospital (Lerner & Moscati, 2000). In addition to pressure injury and poor immobilisation, the backboard may be the cause of pain even in otherwise healthy patients, leading to unnecessary investigations, radiographs and potential ambiguity regarding the cause of pain (Chan, Goldburgh & Mason, 1996). The evidence suggests that the backboard itself is not ideal and far from a gold standard.
This has led to the suggestion that the backboard should not be the preferred surface for the transfer of patients with spinal injuries (Main & Lovell, 1996). According to Vickery (2001) however, the spinal board is considered to be the gold standard for spinal immobilisation during the pre-hospital phase of trauma management. For some patients, effective spinal immobilisation is beneficial and can also be vital in preventing the devastating effects of cord damage however it has been suggested that for many the excessive use of this preventative measure may not be prudent or necessary.
It has been estimated that over 50% of trauma patients with no complaint of neck or back pain were transported with full spinal immobilisation (McHugh & Taylor 1998). Inappropriate spinal immobilisation may lead to patients experiencing unnecessary pain, skin ulceration, aspiration and respiratory compromise, which in turn may lead to further unnecessary procedures, a longer hospital stay which then incurs increasing costs to the National Health Service (Kwan, Bunn & Roberts, 2001).
Shooman & Rushambuza (2009) report that immobilisation is a crucial part of the management of a trauma patient. They believe that if the mechanism of injury is uncertain, the patient should remain immobilised until further imaging even if there are no symptoms of spinal instability after log rolling. However, in a recent study by Pandie, Shepherd & Lamont (2010) they concluded that on its own, standard immobilisation techniques appear to be inadequate to maintain the cervical spine in the neutral position.
One argument for keeping the patient on a spinal board is that it facilitates an urgent turn should vomiting occur (Vickery 2001). Spinal immobilisation is used throughout the world however the clinical benefits of pre-hospital spinal immobilisation have been put under scrutiny. It has been argued that spinal cord damage is done at the time of impact and that subsequent movement is generally not sufficient to cause further damage (Hauswald, Ong, Tandberg & Omar 1998).
In contrast, in-line stabilisation of the neck, also termed ‘neutral alignment’, is usually enhanced by using immobilisation blocks and straps that fix the patient’s head and neck to a spinal board. In-line head and neck immobilisation is important during the transfer period to hospital and remains an important part of the care of the patient (Sheerin, 2005). Butler and Bates (2001), disagree with this and suggest that cervical collars are of no additional benefit to patients already immobilised using a long spine board with straps.
In a recent report it was found that many patients brought to A & E automatically had a cervical collar applied ‘as a precaution’. This usually means that the victim has been involved in an accident that could possible cause a cervical injury, although the patient shows no signs or symptoms of such an injury (Sexton, 1999). Immobilisation in suspected spinal trauma must be initiated at the scene of an accident and continued until unstable spinal injuries are ruled out.
Adequacy of spinal immobilisation must be reviewed during the primary survey in the A & E department (Vickery, 2001). Once the patient has reached A & E, the spinal board should be removed as soon as possible once the patient is laterally transferred from the ambulance trolley onto an A & E or resuscitation trolley (Vickery, 2001). The early removal of spinal boards and cervical collars is advocated by spinal units (Sexton, 1999). Complications associated with prolonged use of the spinal board include pressure ulcer development, pain and discomfort (Vickery, 2001).
Vickery (2001) also suggests a partial solution would be recommended that the backboard should be removed as soon as possible after arrival in the A & E department, ideally after the primary survey and resuscitation phases. Hickey (2003) agrees with this, it is vital that following initial assessment, the patient is removed from the spinal board. Porter and Allison (2003) support this by suggesting that the patient should be then transferred and nursed on an emergency trolley with head immobilisation and straps applied.
This in turn should minimise the risk of pressure ulcer formation which is prevalent in patients with spinal cord injury (Sheerin and Gillick, 2004). Vickery (2001) also suggests that where a spinal injury is suspected, prompt and safe removal of the spinal board is mandatory, these are patients that are at the greatest risk of developing pressure sores. Vickery (2001) continues to say that spinal board immobilisation on the board may be inadequate ending with tragic consequences.
Observational studies in the US have shown that immobilisation by rigid collars may cause airway difficulties, increased intracranial pressure (Davies, Deakin & Wilson, 1996), increased risk of aspiration (Butman, 1996), and skin ulceration (Hewitt, 1994). Caroline (2008) also suggests that complete spinal immobilisation is painful, especially over pressure points and can also be a cause of airway constriction which in turn creates an increased risk of aspiration. It has been reported that many trauma patients do not suffer from spinal instability and will not benefit from spinal immobilisation (Orledge, 1998).
The value of routine pre-hospital spinal immobilisations are questionable due to any benefits of immobilisation being outweighed by the risks (Kwan, Bunn & Roberts, 2009). Kwan, Bunn & Roberts (2009) have already indicated that inappropriate immobilisation is contributing to the increasing budget of the NHS. Dimond (2001) agrees and claims that litigation claims are increasing against the NHS. Society is becoming less tolerant of mistakes or inadequate service and litigation claims are now becoming an accepted part of daily life (Vukmir, 2004).
In contrast, a study in the USA has indicated that due to the fear of litigation, over five million patients receive spinal immobilisation every year (Orledge & Pepe 1998). In this current media inclined era, media attention for high profile claims against the NHS organisations is at a high. Although most of the evidence in literature is regarding claims against hospital specialities, there have been few claims written about claims against the ambulance service (Hulbert, Riddle & Longstaff 1996).
However, there may be few documented claims against the ambulance service there have been a significant number of claims settled by ambulance trusts (Vukmir, 2004). In conclusion, there are many different points of views by many authors on the subject of spinal immobilisation. Many argue that the need to immobilise suspected head, neck and spinal trauma is a priority due to the potential life threatening incident. This way of thinking has been supported by many of the authors.
Others however have stated that each incident needs to be individualised as the necessity of using spinal immobilisation is increasingly being inappropriately used. Methods of spinal immobilisation are also highly debatable, calling the clinical professional to use their own training and judgements when deciding how to transfer each individual patient. It was highlighted by many authors that it was necessary for patients to be removed from the spinal board as soon as possible when being cared for within the hospital setting as this reduces the possibilities of further trauma and pressure sores.
It became quite clear when conducting this research that many health professionals are now very aware of the potential to become a target for the all too common blame culture that is so prevalent in today’s society. The fear of litigation may be the cause for the higher usage of spinal immobilisation although there is limited research at this time but within the next few years we may in fact see a rise in claims against the Ambulance Service.
There is evidence that inappropriate and prolonged use of spinal immobilisation can be very detrimental to the patient’s welfare, there is a vast amount of research to suggest the need to use spinal immobilisation in most head, neck and spinal trauma. Effective and appropriate use of spinal immobilisation is best practice in all situations and should be used wisely and competently by a trained professional.