We treat traumatic patients as though they have a spinal injury that could compromise their spinal cord if they have any of the following:
- A substantial mechanism of injury (high speed impacts, landing on head etc)
- Midline point tenderness
- Neurological deficit
- A lowered level of consciousness (are they orientated enough to register spinal pain?)
- Any significant distraction (could they be distracted from spinal pain?)
Treatment typically involves immobilising their spine (C spine in particular), placing a C spine stiff collar, carefully positioning them on a spine board and extracting them to hospital – usually via the ambulance service.
The objective of this process is to minimise the possibility of the patient sustaining a spinal cord injury (SCI) on their way to hospital to undergo a more comprehensive spinal assessment potentially including X-Rays. It is useful to note that around 3-25% of SCI’s occur after the initial trauma – meaning when the patient moves themselves or is moved by others their spinal cord is damaged.
There are, however, downsides to using spine boards. They are often uncomfortable for the patient, they can cause pressure ulcers to develop on pressure points, lying in the supine position can make respirations more difficult for some patients and head injured patients often become more agitated when positioned on a spine board. It also takes a reasonable amount of time to immobilise someone on a spine board – delaying their arrival at hospital.
A study in 2013 out of the USA measured the amount of cervical spine movement when extracting patients from a motor vehicle both on a spine board and with the patient being allowed to remove themselves from the vehicle with a C collar already fitted. Interestingly when the patient removed themselves from the vehicle the amount of bend in their C spine was only 6% compared with up to 20% when the car was cut to pieces and trained paramedics used a spine board to move the patient.
Given these risks, it is important we make informed decisions about whether to use spine boards or not.
The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma stated that, “patients for whom spinal immobilisation has not been deemed necessary include those with all of the following: normal level of consciousness (Glasgow Coma Score [GCS] 15), no spine tenderness or anatomic abnormality, no neurologic findings or complaints, no distracting injury, and no intoxication.”
Our experience, however, is that we have used spine boards to immobilise patients on ski areas or at events, who present with none of the above signs or symptoms but who have turned out to have unstable spinal fractures following a high mechanism of injury.
Overall our take is that spine boards are a useful tool for extracting patients with potential spinal injuries from the outdoor environment to hospital. The ambulance service often will not transport patients on spine boards given the risks mentioned above. However we consider our job to deliver the patient to the road end emergency services as safely and efficiently as possible.
I would not use a spine board for people who do not meet the criteria to be suspected of having a spinal injury, anyone who’s airway, breathing or circulatory system management is compromised by being positioned on a board, anyone who becomes excessively agitated by being on a board (sometimes the patient can put more force into their spine struggling to get a collar off or remove themselves from a board than if they were left to walk around!!) or anyone for whom the pain of being on a spineboard is unbearable.
For everyone else we still firmly advocate the use of spine boards. Pressure sores are less of a concern for us than SCI’s and generally we find most patients have no huge discomfort being on a board for up to an hour at a time. We have positioned hundreds of patients on spine boards, some end up having unstable spinal fractures and some do not but in order to be conservative we will continue to keep using spine boards to extract patients from the outdoor environment until research shows convincingly otherwise.