“First, do no harm.” “Primum non nocere” is a saying that every medical clinician has heard, said, and/or followed. The ethical concept that we should not intentionally do anything that would cause harm is a given for practicing medicine. The prehospital setting is no different, yet we have been taught to use a device that causes harm on a regular basis. This device continues to be used without the support of scientific evidence. What is this device, you ask? I am, of course, referring to the long back board (LBB) used for spinal immobilization. Some of the harmful complications associated with the LBB include the following: Pressure ulcers (as soon as 30 min), increased intracranial pressure, respiratory compromise, undue pain causing unnecessary radiological imaging, delayed treatment, agitation, and anxiety.
In the late 1970’s, the LBB came in to practice to fully immobilize the spine. The hope was to decrease spinal fracture agitation resulting in increased spinal injury. In fear of exacerbating an unknown asymptomatic spinal injury, every patient was eventually placed in a C-collar and secured to a LBB based on mechanism of injury. As the use of the LBB increased, so did the awareness of the above listed complications. An article written in 2011 published by the Journal of Neuroscience stated, “Patients should be removed from the LBB as soon as possible on arriving to the ED.” Fortunately, most emergency departments have adopted this policy.
In my paramedic class, we took an entire day to learn proper immobilization techniques on a LBB. Additionally, a major part of the EMT and paramedic practical tests are about spinal immobilization. The fear of inducing further spinal injury from not using a LBB was drilled into our heads. As more studies are published that show the complications associated with the LBB, EMS agencies and medical directors have started implementing selective spinal immobilization and C-collar protocols. In 2014, the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma published a paper recommending that only those patients with the following circumstances should be left on a LBB:
- Blunt trauma and altered level of consciousness
- Spinal pain or tenderness
- Neurologic complaint
- Anatomic deformity of the spine
- High energy mechanism of injury and:
- Drug or alcohol intoxication
- Inability to communicate
- Distracting injury
Since that publication, there has been more studies that show less lateral movement of the spine when patients are placed in a C-collar and secured to the cot mattress compared to patients placed in a C-collar and secured to a LBB. The cot mattress is basically a padded backboard that is able to provide appropriate spinal movement restriction. Some agencies in the U.S. are switching to spinal precaution protocols and algorithms that encourage the use of LBB only as an extrication device. This is in line with most of Australia where the LBB is prohibited or discouraged as a transportation device.
What exactly is spinal restriction without a LBB, and how is it done? The Emergency Medical Authority Services (EMSA) have put together a training video that explains and shows this better than I can explain it. Please click on the following YouTube link to watch the video:
The State of Michigan has already adopted spinal restriction and spinal precautions protocols limiting the use of LBB. To read their protocols, please click on the following links:
The days of the LBB being used as an immobilization and transport device are numbered. I encourage you to do your own research, if your agency still continues to transport patients placed on a LBB. Be an advocate for change and contact your medical director to encourage spinal precaution techniques and the limited use of the LBB.
Michigan Department of Community Health.(2014) Adult Treatment Protocols, Spinal Injury Assessment. Retreived from: http://www.ocmca.org/wp-content/uploads/2016/08/1-20-Spinal-Injury-Assessment.pdf
Michigan Department of Community Health.(2014) General Precautions, Spinal Precautions. Retrieved from: http://www.ocmca.org/wp-content/uploads/2016/08/5-27-Spinal-Precautions.pdf
Nationa Association of EMS Physicians and American College of Surgeons Committee on Trauma. EMS Spinal Precautions and the use of the Long Backboard. Prehospital Emergency Care. 17(3), 392-393, doi: 10.3109/10903127.2013.773115
Rahman, J. (2015, December 3). Spinal Motion Restriction. Retrieved from: https://www.youtube.com/watch?v=9MzkZ271wdc
Swartz, E.E., Tucker, S.W., Nowak. M., Roberto, J., Hollingworth, A., Decoster, A.,….Mihalik, J.P. (2018). Prehospital Cervical Spine Motion: Immobilization Versus Spine Motion Restriction [Abstract]. Prehospital Emergency Care. 22, doi: 10.1080/10903127.2018.1431341
Underbrink, L., Dalton, A., Leonard, J,. Bourg, B.W., Blackmore, A., Valverde, H.,…..Hopgood, D. (2018). New Immobilization Guidelines Change EMS Critical Thinking in Older Adults with Spine Trauma [Abstract]. Prehospital Emergency Care. 6, 1-8, doi: 10.1080/10903127.2017.1423138
Wampler, D.A., Pineda, C., Polk, J., Kidd, E., Leboeuf, D., Flores, M.,….Cooley, C. (2016). The Long Spine Board Does Not Reduce Lateral Motion During Transport- A Randomized Healthy Volunteer Crossover Trail. The American Journal of Emergency Medicine. 34(4), 717-721, doi:10.1016/j.ajem.2015.12.078
White, C.W., Domeier, R.M., Millin, M.G.,Standards and Clinical Practice Committee, National Association of EMS Physicians. (2014). EMS spinal precautions and the use of the long backboard – resource document to the position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. Prehospital Emergency Care. 18(2):306-14. doi: 10.3109/10903127.2014.884197