In wilderness medicine, the traditional response to a potential spinal injury has emphasized immobilizing the patient to prevent further injury. To this end, emergency responders have been trained to use advanced immobilization techniques and equipment, such as rigid cervical collars and spinal boards in conjunction with manual stabilization.
And while nobody educated in emergency medicine would argue against the importance of motion restriction, the priority is shifting as doctors and emergency personnel consider it in the larger context of overall patient health and safety.
Given the importance of the spine in a person’s overall health, the focus on immobilizing patients with suspected spinal injury is no surprise. The spine protects the spinal cord, which functions like a fiber-optic network to carry signals throughout the body to and from the brain. Interruptions in the continuity of the spinal cord can dramatically impact a person’s ability to move and to interpret and interact with the world.
However, over the last few decades, the medical community has acquired a vast body of evidence concerning care for a person with an obvious or potential spinal injury. As a result, recent years have seen a significant shift in thinking on this subject. The conversation regarding the extent to which a spinal injury is impacted by subsequent treatment and transport has evolved into a rather heated debate that’s beginning to reflect evidence-based medicine as it drifts away from deeply entrenched dogma and cults of personality.
This post introduces the components and direction of this conversation and the impact it is having on the practice of wilderness medicine.
The Language of Spinal Care in The Backcountry
Although protocols for responding to potential spinal injuries are evolving, the language has remained fairly consistent. Terms such as spinal immobilization, spinal motion restriction, spinal cord protection, spinal care, spinal splinting, spinal clearance versus cervical spine stabilization, selective spinal immobilization, and spinal precautions are still used to communicate ideas and actions regarding the benefits of any given response to injury of the spinal area.
Understanding the Three Key Concerns Driving the Debate
The debate over the prioritization of immobilizing a patient with a possible spinal injury comes down to the following three primary concerns:
- Harm done at time of injury
- Harm done during movement post injury
- Harm done post injury due to inflammation and swelling
Concern over causing serious harm to the spine post injury is what has driven the traditional emphasis on immobilization, almost to the exclusion of other factors — some posing an even bigger threat to the patient’s life and quality of life.
Findings from recent studies have increased our understanding of the risks. Based on these studies, we now know that:
- Harm done at time of injury normally results in obvious and immediate death or disability.
- Harm done during post injury movement has been overstated. Evidence suggests that little to no further injury is likely if a mechanism of force similar to the one that caused the initial injury is avoided.
- Harm done post injury due to inflammation and swelling is not strongly related to reasonable post injury movement and may or may not be inevitable to some degree.
So, What Has Changed?
The primary change in care for patients with obvious or potential spinal injury centers around the fact that responders must perform a risk-to-benefit analysis when deciding whether and how to move the patient. Responders are well-advised to consider not only the risk of moving the patient, but the risk of not moving the patient — risks posed by potentially more life-threatening problems or by having the patient spend more time in the environment prior to and during evacuation to a higher level of medical care.
For example, I was involved in a wilderness Emergency Medical Services (EMS) response in which a patient fell from a waterfall and remained in the water because bystanders and initial responders prioritized keeping the patient still over moving the injured party out of the water. They remained committed to this course of action even though hypothermia poses a greater life threat than moving a patient with a possible spinal injury.
Also under reconsideration are the tools used for what has historically been referred to as “spinal immobilization.” No evidence whatsoever supports the notion that improvised cervical collars are helpful in preventing further injury post incident. Some evidence even suggests that they may be harmful.
Long boards used for “immobilization” are now widely considered counterproductive for that task, and certain state EMS protocols clearly assert that they are to be solely used for transferring patient from ground to stretcher and never for transport to the hospital.
Comparing the Traditional Approach to the More Nuanced Modern Approach
Another example: A lead climber has fallen about 30 feet after her weight removed two anchors placed in cracks to shorten a fall. She struck a ledge during the fall causing deformities to both ankles. The fall ended on the ground where the patient came to rest. She remained alert and oriented during and after the fall and complained secondarily of neck pain. Her helmet reflected a strike against the rock during the fall that was shown by significant denting to the modern “soft” shell.
An outdated response to this situation would be to make attempts to perform full spinal immobilization to this patient including improvised collar, backboard, and headblocks, and potentially request helicopter evacuation.
The more modern approach would be to perform a thorough focused spinal exam and make very specific decisions about whether she had the ability to walk out or whether additional resources would be needed to provide assistance.
Following the Evidence
No one involved in rational discussion about the future of spinal care is suggesting that motion restriction is unimportant. However, experts in the field are beginning to recognize that complex decisions often need to be made in the field and that we must adapt our reactions in the field to the best evidence available instead of following decades of potentially ill-informed opinions that prescribe an overly cautious response.
We continue to learn more as the discussion spreads throughout the world of wilderness medicine, EMS, and hospital care. Our hope is that this new insight provides better outcomes for those experiencing trauma in the wilderness setting.
When it comes to spinal assessment and treatment, let’s take a fresh, objective look — one guided by the tenets of evidence-based medicine.
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About the Author: Todd Mullenix is the Director of Wilderness Medicine Education at The National Center for Outdoor & Adventure Education in Wilmington, North Carolina.
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