Improving the technique of spine protection is a passion of mine. I thought that the quote, “There is certainly near-universal agreement that the benefit of C-spine immobilization outweighs the risk in the majority of injured patients,” was very unfortunate. (“Ditch the Cervical Collar? No, Just Design a Better One,” EMN 2010;32:1.) Because experts will agree that there is no scientific evidence that C-spine immobilization prevents a secondary injury, the benefit is hypothetical. What we are doing with C-spine immobilization is deciding on a hypothetical benefit versus known adverse consequences. There is certainly not anything close to near-universal agreement that there is any benefit to C-spine immobilization.
In EMS, our goal is spine protection. What techniques best achieve spine protection without causing harm? What was the C-collar designed to do for spine protection? Stop neck extension? The surface on which one is immobilized helps block this extension. The backboard does this poorly because it causes neck extension for the majority of patients unless the occiput is padded. Stop lateral motion or axial rotation? The head needs to be immobilized to prevent this motion. Cervical flexion then appears to be what the C-collar is designed to prevent. Are there other ways to prevent cervical flexion? Is a collar in fact necessary?
When the backboard was found to be a poor surface for providing spine protection, instead of asking, “Is the backboard necessary?” a Band-Aid was applied: Pad the backboard. I want us to ask, is the C-collar necessary, and not just attempt to modify the C-collar.
The vacu-mattress provides an excellent spine protection surface. It can be contoured to hold the head in place, and it often can be contoured or have forehead tape added to block flexion, no C-collar needed. And you have the added benefit of being able to visualize the neck.
Anthony DeMond, MD
Dr. DeMond is the medical director of EMS Ground Transports in La Plata County, CO.