Let’s Say Goodbye to Backboards!
By: Dr. Mahmoud Alsomali
Backboards are extrication devices, and a hard surface for performing cardiopulmonary resuscitation. However, they have never been proven to provide spinal protection.
The current practice of immobilizing trauma patients before complete evaluation is to theoretically stabilize the spine is not always necessary, as the likelihood of further damage is small, and may be associated with more harm than benefit.1
Looking into the literature, the first notable study on the implementation of backboards was conducted in the 1960s. Since then, most of the recommendations to support the use of spinal immobilization, such as those by the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons Joint Commission, have been based on tradition and informed opinion (level III evidence), rather than validated, scientific evidence.
A Cochrane review from 2007 noted that there wasn’t a single prospective randomized controlled trials (RCT) on spinal immobilization.2 More recently, the 2013 joint position paper from the National Association of Emergency Medical Services Physicians (NAEMSP) and the American College of Surgeons Committee (ACS) on trauma, stated there is “no proven benefit” to rigid spine immobilization2.
Moreover, in a controversial study done by Hauswald et al, non-immobilized patients in Malaysia had better neurological outcomes than similar injury-matched patients who were immobilized in New Mexico. The authors concluded that blunt spinal injuries immobilization has little to no benefit on patient outcomes.3
Harms caused by Backboards
Backboards are not without risk!
Endotracheal intubation is significantly more difficult in patients with immobilization, with a 41% failure rate,4 partly attributed to reduced view for laryngoscopy due to hard collar, straps and sandbags.5 Immobilization is also associated with significant rate of re-intubation in the emergency department (ED), and unrecognized emergency medicine service (EMS) endotracheal tube malposition or dislodgement.
Straps tightened across the torso have a restrictive effect on respiration, lowering forced vital capacity, forced expiratory volume over 1 second (FEV1), and forced mid-expiratory flow by approximately 15-20%, with older patients having a greater degree of restriction.6 They may lead to injuries to the chest wall and lungs, further interfering with respiratory mechanics.
When using a backboard, the contact pressure in the occipital and sacral region are above the pressures at which tissue necrosis and pressure ulcers develop. Significant hypoxia in sacral tissue of healthy adults starts after 30 minutes on a backboard, which leads to early pressure ulcer development prior to arrival at the hospital.7
This is particularly troubling as another study demonstrated that the average time a patient spends on a backboard is approximately one hour.8
Pain in the lower back and cervical spine due to anatomically incorrect positioning can be caused by a flat backboard.
The process of immobilization has been shown to cause increased pain scores in healthy volunteers, with new pain developing in areas not painful prior to the application of the spine board. In 21 uninjured adults, 55% developed moderate to severe pain after being immobilized for 30 minutes.9 In healthy volunteers, lower back and cervical pain reported to persist for 24 hours after being subject to only one hour of laying on a spine board.9
Due to difficulty in distinguishing between pain caused by trauma and pain caused by the spine board, there is a noticed increase in the number of imaging studies ordered, leading to increased cost of evaluation and ED stay.
Furthermore, unnecessary radiological studies have been correlated with increasing risk for the long-term development of cancer.
Increased Radiation Doses
There is a significant increase in skin entrance dose in the anterior and posterior pelvis in the presence of a backboard; in one study, skin entrance dose increased up to 25% in the anterior pelvis.10 Attempts should be made to minimize backboard use during CT when possible.
The frequency of backboard usage during CT markedly decreased (from 77% to 3%) after instituting a multidisciplinary policy to promptly remove patients from backboards upon arrival to the emergency department after a primary clinical survey.11
Delay in Transport and Definitive Care
Immobilization causes a delay in transport that can be significant enough to increase patient morbidity and mortality. According to the ACS Trauma Committee and the NAEMSP, the use of backboards has been shown to increase mortality by two folds in penetrating injuries. This is probably because it’s time-consuming (five minutes, at least) to place a patient into full immobilization, delaying resuscitation and definitive care.
Indication for Backboards and Cervical Collar Use (table 1)
According to NAEMSP and ACS, the following patients are considered appropriate for the usage of long backboards in the
• Blunt trauma and altered Level of consciousness.
• Spinal pain or tenderness.
• Neurologic complaint.
• Anatomic deformity of spine.
• Drug or alcohol intoxication.
• High-energy mechanism of injury and any of: drug or alcohol, intoxication, inability to communicate, or distracting injury.
This is also corroborated by the American College of Emergency Physicians (ACEP) 2015 guidelines on EMS management of patients with potential spinal injury, stating that “Spinal motion restriction should be considered for patients who meet validated indications such as the NEXUS criteria or Canadian C-Spine rules.” 12
Indication for backboards and collars use
It is not necessary in the following patients:
• Glascow Coma Scale (GCS) of 15
• No spinal tenderness or anatomic abnormality
• No distracting injury
• No intoxication
• Penetrating head, neck or torso trauma without neurological deficit
In addition, spinal precautions can be maintained by application of a rigid cervical collar only without a backboard are appropriate for patients who are ambulatory at scene or have long transport time, and in whom a backboard is not otherwise indicated.13
Take home point
After reviewing the evidence, backboards should not be used unless indicated by clear protocols or guidelines, as the evidence behind their use is minimal and they are not without harm.
More research is needed in this field to continue to minimize the current use, and enrich our practice with evidence. But for now, we need to start saying goodbye to backboards!
1. Morrissey, James F., Elsie R. Kusel, and Karl A. Sporer. “Spinal Motion Restriction: An Educational and Implementation Program to Redefine Prehospital Spinal Assessment and Care." Prehospital Emergency Care 18.3 (2014): 429-32. Web.
2. Kwan, Irene, Frances Bunn, and Ian G. Roberts. “Spinal Immobilisation for Trauma Patients." Cochrane Database of Systematic Reviews Reviews (2001): n. pag. Web.
3. Hauswald, Mark, Grade Ong, Dan Tandberg, and Zaliha Omar. “Out-of-hospital Spinal Immobilization: Its Effect on Neurologic Injury." Academic Emergency Medicine 5.3 (1998): 214-19. Web.
4. Bhandarkar, D. S., T. R. Raju, and L. R. Jenkinson. “Blunt Abdominal Trauma." Postgraduate Medical Journal 74.867 (1998): 53-55. Web.
5. Abram, S., and C. Bulstrode. “Routine Spinal Immobilization in Trauma Patients: What Are the Advantages and Disadvantages?" The Surgeon 8.4 (2010): 218-22. Web.
6. Totten, Vicken Y., and David B. Sugarman. “Respiratory Effects of Spinal Immobilization." Prehospital Emergency Care 3.4 (1999): 347-52. Web.
7. Ham, Wietske, Lisette Schoonhoven, Marieke J. Schuurmans, and Luke P.h. Leenen. “Pressure Ulcers from Spinal Immobilization in Trauma Patients." Journal of Trauma and Acute Care Surgery 76.4 (2014): 1131-141. Web.
8. Cooney, Derek R., Harry Wallus, Michael Asaly, and Susan Wojcik. “Backboard Time for Patients Receiving Spinal Immobilization by Emergency Medical Services." Int J Emerg Med International Journal of Emergency Medicine 6.1 (2013): 17. Web.
9. Chan, Dennis, Richard Goldberg, Arthur Tascone, Stacy Harmon, and Linda Chan. “The Effect of Spinal Immobilization on Healthy Volunteers." Annals of Emergency Medicine 23.1 (1994): 48-51. Web.
10. “This Month in Radiology." Radiology 278.1 (2016): n. pag. Web.
11. Lee, A.y., S. Elojeimy, K.m. Kanal, K.f. Linnau, and M.l. Gunn. “The Effect of Trauma Backboards on Computed Tomography Radiation Dose." Clinical Radiology 71.5 (2016): n. pag. Web.
12. v, Chelsea C. White, Robert M. Domeier, and Michael G. Millin. “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 (2014): 306-14. Web.
13. “EMS Spinal Precautions and the Use of the Long Backboard." Prehospital Emergency Care 17.3 (2013): 392-93. Web.
14. “Backboard and Collar Nightmares." Emergency Medicine Cases. N.p., 2015. Web. 01 July 2016.
15. “Ditch the Spine Board – Emergency Physicians Monthly." Emergency Physicians Monthly. N.p., n.d. Web. 01 July 2016.
16. “Prehospital Spinal Immobilization | EMSWorld.com." EMSWorld.com. N.p., n.d. Web. 01 July 2016.