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The Use of Backboards for Spinal Immobilization

Take Home Points:

  • The use of backboards have been the main method for spinal immobilization of potential spinal cord injuries.
  • Unfortunately, there has never been a study that demonstrated the efficacy of the backboard in preventing spinal cord injury.
  • Furthermore, there is evidence that their use can lead to pressure ulcers, agitation, respiratory compromise, and spinal pain that generates unnecessary additional imaging.
  • In response, the National Association of EMS Physicians (NAEMSP) and the American College of Surgeons (ACS) Committee on Trauma released a joint position paper on the judicious use of spinal immobilization and outlined the small subset of patients in whom spinal immobilization with a backboard may be considered and when it should be avoided (as outlined below).

Summary:

Immobilization of potentially unstable spinal injuries is a mainstay of prehospital care. For the last 40 years, the rigid long backboard has been the tool of choice for this task. Despite having been originally designed as a tool for extrication, the backboard was readily adopted as the best way to secure a patient during (a potentially long) transport to protect the injured spine.

In spite of its ubiquity, there has never been a study that demonstrated the efficacy of the backboard in preventing spinal cord injury. In addition, there is a growing body of evidence that backboards may cause significant morbidity, leading to the development of pressure ulcer, respiratory compromise, agitation, and pain. Backboards have been shown to cause spinal pain necessitating imaging studies and prolonging emergency department stays.

In 2013, in response to this evidence, the National Association of EMS Physicians (NAEMSP) and the American College of Surgeons (ACS) Committee on Trauma released a joint position paper on the judicious use of spinal immobilization. The paper outlines a small subset of patients in whom spinal immobilization with a backboard may be considered, and a much larger group of patients in whom it is inappropriate. Adoption of these guidelines would lead to a significant reduction in the use of backboards and therefor a reduction in backboard-related morbidity.

  • The guidelines state that patients who may be appropriate for backboard immobilization include those with:
    • Signs of neurologic compromise
    • Evidence of spinal injury
    • A high risk injury with an inability to properly evaluate the patient (i.e. intoxicated, altered mental status, presence of distracting injuries)
  • Patient with none of these risk factors do not require backboard immobilization.
  • Similarly, patients with penetrating trauma and no signs of neurologic injury do not require backboards.
  • Because the risk for decubitus ulcers increases with prolonged immobilization, patients should be removed from backboards promptly on ED arrival, and patients with long transport times (including interfacility transports) should not be secured with backboards.
  • Techniques other than rigid immobilization can be used to protect a potentially injured spine. These techniques include using a cervical collar, appropriately securing a patient to the stretcher, minimizing patient movement, and maintaining appropriate in-line stabilization when patient movement is necessary.


Editor(s):

  • Dylan S. Kellogg, MD
  • Anthony J. Busti, MD, PharmD, FNLA, FAHA

Date Last Reviewed:  September 2015

Supporting Guidelines

  • 2013 National Association of EMS Physicians and American College of Surgeons Committee on Trauma

    • Appropriate patients to be immobilized with a backboard may include those with:
      • Blunt trauma and altered level of consciousness
      • Spinal pain or tenderness
      • Neurologic complaint (e.g., numbness or motor weakness)
      • Anatomic deformity of the spine
      • High-energy mechanism of injury and any of the following:
        • Drug or alcohol intoxication
        • Inability to communicate
        • Distracting injury
    • Patients for whom immobilization on a backboard is not necessary include those with all of the following:
      • Normal level of consciousness (GCS 15)
      • No spine tenderness or anatomic abnormality
      • No neurologic findings or complaints
      • No distracting injury
      • No intoxication
    • Patients with penetrating trauma to the head, neck or torso and no evidence of spinal injury should not be immobilized on a backboard
    • Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for:
      • Patients who are found to be ambulatory at the scene
      • Patients who must be transported for a protracted time, particularly prior to interfacility transfer
      • Patients for whom a backboard is not otherwise indicated
    • Whether or not a backboard is used, attention to spinal precautions among at-risk patients is paramount. These include application of a cervical collar, adequate securing to a stretcher, minimal movement / transfers, and maintenance of inline stabilization during any necessary movement / transfers.
    • Education of field EMS personnel should include evaluation of the risk of spinal injury in the context of options to provide spinal precautions.
    • Protocols or plans to promote judicious use of long backboards during prehospital care should engage as many stakeholders in the trauma / EMS system as possible
    • Patients should be removed from backboards as soon as practical in an emergency department.

    Reference: 

    • National Association of EMS Physicians and American College of Surgeons Committee on Trauma. 2013. Position Statement: EMS Spinal Precautions and the Use of the Long Backboard. Prehospital Emergency Care 2013;17:392-393.  PubMed
    • White CC 4th, Domeier RM, Millin MG, Standards and Clinical Practice Committee, National Association of EMS Physicians. 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. Prehosp Emerg Care 2014;18(2):306-14.  PubMed

Original Report

  • Geisler WO, et al. Early management of patients with trauma to the spinal cord. Med Serv J Can. 1966;4:15-523. PubMed

Key Studies

  • March J, et al. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care. 2002;6(4):421-424. PubMed
  • Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehospital Emergency Care. 1999;3:4:347-352. PubMed

Systematic Reviews

  • Ham W, et al. Pressure ulcers from spinal immobilization in trauma patients: a systematic review. 2014 Apr;76(4):1131-41. PubMed
  • Kwan I, et al. Spinal immobilisation for trauma patients (Review). Cochrane Database of Systematic Reviews 2001(2): CD002803. PubMed

Related Articles

  • Peery CA, Brice J, White WD. Prehospital spinal immobilization and the backboard quality assessment study. Prehospital Emerg Care 2007;11;3:293-297. PubMed
  • Schriger DL, Larmon B, LaGassick T, Blinman T. Spinal immobilization on a flat backboard: does it result in neutral position of the cervical spine? Ann Emerg Med 1991;20(8):878-881. PubMed

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