Two things:
- I really appreciate all of the feedback I received to the original article in the comments as well as in personal emails.
- I wanted to comment back on the EMS1 website, but I was told that I needed to open a Facebook account. Yikes! Me, open a Facebook account? At my age?
So, when wily EMS1 Editor Sarah suggested that I consider writing a reprise article, it seemed like a good idea to me. And it appeared to be within my technologic scope of practice.
I am going to try to respond to some of the comments, then provide what I think might be helpful suggestions and finally, offer readers a challenge.
One thing is for sure: Field clearance of the cervical spine is a controversial issue. Believe it or not, I knew that before writing the article. But if there was any doubt, the responses clearly show the passion.
Several readers wondered whether failure to properly apply field clearance principles resulted in worse patient outcomes in our system.
We don’t know the answer. Certainly some patients have had persistent neurologic deficits. But it’s impossible to say what directly contributed to them and what did not.
Indeed, the issue of primary versus secondary spinal cord injury is debated in the literature. The primary injury is, of course, at the time of initial trauma. Secondary injury may occur as a result of poor immobilization and other treatment complications or from later cord swelling or bleeding.
I don’t believe that anyone has been able to elucidate how much secondary injury is a factor in patient outcome, and we don’t know what role non-immobilization plays in worsening secondary injury.
Other readers stressed the findings of Hauswald et al., to which I referred in the first article. Like many who are interested in this topic, they highlighted the trend toward worsening neurologic outcomes in the non-immobilized patients.
When I first read that paper, I, too, was struck by that point. My counter to it now is that the number of immobilized and non-immobilized patients was relatively small. Therefore, I would argue that we probably can not rely on these results as much as we would like to.
Nevertheless, some people have concluded from the Hauswald data and apparently some other studies that we don’t need to immobilize anyone. Further, they opine that immobilization itself causes more secondary cord injury.
Despite this strong sentiment, how many EMS systems have actually done away with spinal immobilization for fears of worsening injury from the procedure itself? I doubt very many.
My response is that the numbers in the Hauswald study, and likely any others, are not yet enough to change our practice. But the questions lead to the challenge I will outline at the end of this article.
In the meantime, here are some points and suggestions based on our experience for providers in those systems that are performing field spinal clearance.
In my first article, we focused mainly on the NEXUS clearance criteria. Recall that NEXUS was originally developed for emergency department use. However, most of the EMS studies involving field clearance have used some variant of NEXUS. A careful review will reveal that the NEXUS criteria do not mention anything about age or mechanism.
The Canadian C-Spine Rule does include these two components. However, I believe that most EMS agencies favor NEXUS variants over the Canadian C-Spine Rule because NEXUS is simpler to use.
Regardless, it’s clear that the elderly are at higher risk for cord injuries even with lower mechanism injuries. EMS providers who are clearing spines need to be aware of this association, especially because it’s not a part of NEXUS.
In addition to the potential problems with properly applying any of the NEXUS criteria, failures can occur when an inadequate extremity neurologic exam is conducted. If a provider glosses over the exam, the results might miss subtle deficits reflecting cord injury.
We can all tell when a patient is quadriplegic or paraplegic. And we will promptly immobilize them (I think). The challenge is to identify the partially-injured spinal cord patient with less obvious findings on exam. I simply do not know how well a careful extremity neurologic assessment is emphasized either during initial EMS training or in refreshers across the country.
I suspect that there is inconsistency, to put it politely. But I do know that it is very important to stress in systems that are clearing potential spine-injured patients. This assessment needs to be done carefully.
My suggestion is to stress the motor exam in the upper and lower extremities by testing all of the major muscle groups (triceps, biceps, shoulders and forearms). In addition, with respect to the upper extremities, assess finger abduction, wrist extension and flexion all against resistance. Ask patients to make the “OK” sign with their fingers, and check their ability touch the thumbs to their fifth fingers. Forearm pronation and supination should be checked. Test upper and lower extremity reflexes.
Finally, evaluate sensation grossly by just asking patients if they can feel your hands. If there is a question about sensation, get a small needle to test pinprick, and use a cotton-tipped applicator to check light-touch sensation.
If all components of this exam appear intact and they meet the rest of the criteria for either the Canadian C-Spine Rule or NEXUS, the patient can be cleared out of immobilization, and the neck does not need to be imaged in the ED.
One other thing that I did not mention in the last article but was mentioned by some readers is the concept of providing additional comfort to patients who are immobilized for whatever reason. I fully agree that this is something we should be doing.
In my opinion, immobilization of the thoracic and lumbar spines is less important than for the cervical spine. This is because the thoracic and lumbar vertebrae have almost no rotatory motion normally and are surrounded by very large protective muscles. So the benefit of a spine board is primarily to assist in better immobilizing the cervical spine because it serves as an anchor for tape and other securing devices.
As a result, reasonable comfort alternatives should be considered. Possibilities include using a vacuum splint device, a scoop, an inflatable mattress on the board, a KED or another commercially available product. Heck, even a foam mattress would help.
Now we come to the challenge part, especially to those who argue we shouldn’t immobilize anyone. While I can’t buy this assertion in its entirety, I do think it’s fair to entertain whether the spine board has any real utility. As a result, I wonder how many readers would be willing to have their systems participate in a study looking at forgoing the spine board.
There is a new office at the National Institute of Health, called the Office of Emergency Care Research The development of this entity, I think, raises the possibility of increased grant funding for both emergency medicine and EMS studies in the future.
I have thought about doing a project like this for years in our local system. But I did not pursue the concept because it was evident that we would never have enough patients to produce meaningful results. However, the intensity of reader response has moved the idea more to the front burner for me.
As I have indicated, we need lots of patients to assess whether the board is necessary to protect against secondary injury to the thoracic and lumbar spinal cord. And to get lots of patients, we need a number of systems.
How many patients? I don’t know yet, but several thousand at a minimum. But, in my mind, this is the best way to answer the question.
I would appreciate hearing from readers in higher-volume systems about whether your system would consider participating. Understand that a carefully constructed research project requires serious work and time commitments -- much of it, if not all, uncompensated. So please do not reply unless you believe you and your key leadership are willing to put in the level of effort required.
If you just want to spout, this is not the initiative for you. This will be a put-up or shut-up project,
Email me directly. If there is enough interest, we may be able to move forward.
Reference
Stiell IG, Wells GA, Vandemheen K, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA 2001;286:1841-8.
