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