- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL
- Department of Orthopaedics, University of South Florida, Tampa, FL
- Department of Orthopaedics, University of Texas Medical Center, Houston, TX
- Department of Orthopaedics, Duke University, Durham, NC
- Bay Pines Veterans Administration Healthcare System, Bay Pines FL
Bryan P. Conrad
Bay Pines Veterans Administration Healthcare System, Bay Pines FL
DOI:10.4103/2152-7806.98584Copyright: © 2012 Conrad BP. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Conrad BP, Rossi GD, Horodyski MB, Prasarn ML, Alemi Y, Rechtine GR. Eliminating log rolling as a spine trauma order. Surg Neurol Int 17-Jul-2012;3:
How to cite this URL: Conrad BP, Rossi GD, Horodyski MB, Prasarn ML, Alemi Y, Rechtine GR. Eliminating log rolling as a spine trauma order. Surg Neurol Int 17-Jul-2012;3:. Available from: http://sni.wpengine.com/surgicalint_articles/eliminating-log-rolling-as-a-spine-trauma-order/
Background:Currently, up to 25% of patients with spinal cord injuries may experience neurologic deterioration during the initial management of their injuries. Therefore, more effective procedures need to be established for the transportation and care of these to reduce the risk of secondary neurologic damage. Here, we present more acceptable methods to minimize motion in the unstable spine during the management of patients with traumatic spine injuries.
Methods:This review summarizes more than a decade of research aimed at evaluating different methods of caring for patients with spine trauma.
Results:The most commonly utilized technique to transport spinal cord injured patients, the log rolling maneuver, produced more motion than placing a patient on a spine board, removing a spine board, performing continuous lateral therapy, and positioning a patient prone for surgery. Alternative maneuvers that produced less motion included the straddle lift and slide, 6 + lift and slide, scoop stretcher, mechanical kinetic therapy, mechanical transfers, and the use of the operating table to rotate the patient to the prone position for surgical stabilization.
Conclusions:The log roll maneuver should be removed from the trauma response guidelines for patients with suspected spine injuries, as it creates significantly more motion in the unstable spine than the readily available alternatives. The only exception is the patient who is found prone, in which case the patient should then be log rolled directly on to the spine board utilizing a push technique.
Keywords: Cervical spine, emergency, pre-hospital management, spinal cord injury
This review synthesizes previous investigations and presents methods for a continuum of care, which minimizes motion of an unstable spine. Research indicates that up to 25% of patients with traumatic spine injuries may experience neurologic deterioration after coming under the care of trained medical personnel.[
A schematic of the typical sequence of care for a patient who suffers a traumatic spine injury. Although each step of this sequence may not apply to every patient, there are numerous transfers and maneuvers involved in the management of the patient with spine trauma. Each step of this sequence presents a risk of secondary neurologic injury
For over a decade, our research team has investigated each phase of initial management (i.e. pre-hospital care and early in-hospital care) of a spinal cord injury with the goal of identifying the best practices for minimizing movement of an unstable spine.
In 2001, we developed an experimental model for evaluating the effects of different spine boarding techniques on the motion of an unstable cervical spine. We chose to use a cadaver model rather than an in vivo model. Although cadaver tissue lacks muscle tone present in vivo, cadavers offer two unique advantages. First, a cadaveric model allowed us to create a simulated traumatic injury. Simulating a traumatic injury is not possible with an in vivo model because it is unethical to create an injury in healthy volunteers or experiment with different techniques in patients with an actual injury. Second, the cadaveric model allowed us to measure accurate segmental motion because we were able to attach sensors directly onto the vertebrae adjacent to the level of injury.
Tracking spinal motion for the stable vs. unstable spine
In the intact spine, all transfer techniques appear acceptable with respect to the amount of segmental motion they produce. The most widely used method for tracking motion in healthy volunteers is capturing global motion of the head relative to the torso. Unfortunately, this does not provide data about the movement of the individual motion segments or the effect of the movement on a destabilized segment. In fact, the motion occurring in the intact spine is negligible to the point that we have stopped testing the uninjured condition because we noted little to no abnormal motion.
For the patient with a traumatic spine injury, we believe that early in the patient's care, the spine has to be presumed to be unstable until proven otherwise. Based upon the aforementioned, using a cadaver model with a simulated injury is the only method to reliably test the motion of an unstable spine.
In our studies, segmental motion at the level of injury is measured using a 3D electromagnetic tracking system (Liberty, Polhemus Inc., Colchester, VT, USA). Motion sensors are attached directly to the vertebral segment where the instability is created. An anatomic coordinate system is defined for each motion sensor. The motion sensors produce direction cosines which describe the sensor position and orientation with respect to the global transmitter.
Joint angles and translations are calculated by determining the position and orientation of the proximal sensor with respect to the distal sensors. Range of motion is calculated by subtracting the maximum angulation or translation from the minimum value. This technique allows accurate measurement of angular displacements [flexion–extension (FE), axial rotation (AR), lateral bending (LB)], as well as linear displacements [medial–lateral (ML) translation, anterior–posterior (AP) translation, and superior–inferior (SI) translation].
The results of each phase of the management of spine injuries are divided into the following sections: collar usage, spine boarding, removal of the spine board, bed transfers, continuous lateral therapy, and prone positioning for surgery [Tables
Ineffectiveness of collars in cervical spine injuries
During the initial stages of pre-hospital care, the current accepted practice is to apply a rigid cervical collar to the patient with a suspected cervical spine injury. However, a recent study noted that cervical collars are insufficient for immobilizing an unstable spine during passive range of motion tests.[
Continued role of cervical collars to alert medical providers to an injury
Nevertheless, cervical collars can play other important roles, such as alerting medical providers to the presence of a spine injury. For now, their continued usage is justified. However, it is important to be aware that collar usage alone will not be sufficient to provide immobilization of the unstable spine.
Transfer to spine board: Supine
There are four standard methods described for transferring an injured individual onto a stretcher or spine board from the supine position:[
A minimum of four rescuers is required for the log roll procedure. One rescuer maintains manual inline stabilization of the head, while another one is responsible for positioning the spine board. At least two people are positioned on the same side of the patient to perform the roll. During the roll, the patient is rotated axially to an angle of approximately 30°–90°, at which point the spine board is placed at an angle beneath the patient. After the spine board is in place, the patient and the board are rolled back to the ground. Finally, the team must center the patient on the spine board in the supine position.
Straddle lift and slide
Five rescuers are required for the straddle lift and slide maneuver. One rescuer maintains manual inline stabilization of the head, while another one is responsible for positioning the spine board. The three other rescuers straddle the body at the level of the chest, pelvis, and lower extremities to perform the lift. Once the patient is lifted 10–20 cm off the ground, the board is slid beneath the patient, from the feet toward the head. The patient is then carefully lowered onto the board.
6 + Lift and slide
Eight rescuers are required during the 6 + lift and slide maneuver. One rescuer maintains manual inline stabilization of the head, while another one is responsible for positioning the spine board. Six additional rescuers are placed in pairs across from one another at the chest, pelvis, and lower extremities to perform the lift. Once the patient is lifted 10–20 cm off the ground, the board is slid beneath the patient from the feet toward the head. The patient is then carefully lowered onto the board.
Four rescuers are required for the scoop stretcher transfer. One rescuer maintains manual inline stabilization of the head. Three rescuers position and secure the scoop stretcher: two are located at shoulder level on either side of the patient and the third one is located at the feet. The two longitudinal halves of the scoop stretcher are separated and then positioned on either side of the patient. Each half of the scoop stretcher is carefully wedged beneath the patient until both ends are securely locked into place.[
Transfer to spine board: Supine summary
In our initial study, neither the log roll nor the straddle lift and slide technique emerged as a clearly superior transfer method.[
Statistically significant differences between transfer techniques
In further studies, statistically significant differences between transfer techniques emerged. The log roll produced significantly greater LB and AR motion in the unstable cervical spine compared with the straddle lift slide technique [
We found a similar pattern when we evaluated the effect of spine boarding on thoracolumbar injuries. Again, the execution of the log roll maneuver produced more motion than any other technique.
Transfer to a spine board: Prone
While the above methods have been proposed for spine boarding when a patient with a spinal cord injury is found in the supine position, less is known about how to best manage the spine injured prone patient.[
Prone log roll push
The prone log roll push requires five rescuers. One rescuer takes the lead and is positioned at the patient's head to provide manual inline stabilization to the cervical spine. Three rescuers perform the roll, and are positioned at the shoulders/chest, hips, and legs on the side that the patient's head is facing. The final rescuer is in charge of the spine board. The three rescuers performing the roll push the patient toward the fifth rescuer, who is holding the spine board at a 45° angle beneath the patient. The patient is then slowly lowered onto the spine board [
Prone log roll pull
Five rescuers were also required for the prone log roll pull maneuver. One rescuer takes the lead, and is positioned at the patient's head to provide manual inline stabilization to the cervical spine. Three rescuers perform the roll, and are positioned along the patient's body opposite to the direction that the patient's head is facing: one rescuer is positioned at the shoulders/chest, one at the hips, and one in control of the patient's legs. The fifth rescuer is in charge of the spine board. The rescuers performing the roll slowly pull the patient toward them as the spine board is positioned between their arms and the patient's body. The patient is then slowly lowered onto the spine board [
We have recently investigated the two prone log rolling techniques described above for both thoracolumbar[
Spine board removal
Upon arrival at the emergency department, a patient should be removed from the spine board as soon as possible. However, removal of the spine board is often overlooked during the initial management of trauma patients. Even in healthy volunteers, tissue perfusion in the sacral area is adversely affected in as little as 30 minutes on a rigid spine board.[
Preferred use of lift–slide technique for removing patient from spine board
Motion during removal of the spine board is decreased compared to the motion produced during the initial placement of the patient onto the spine board. Nevertheless, spine board removal must be performed with the appropriate technique to minimize the risk of further neurologic compromise to the spinal cord of the injured patient. We have investigated two methods for the removal of a spine board: the 6 + lift and slide, and the log roll.[
Lack of training in alternative maneuvers
Perhaps the log roll endures because of lack of training in alternative maneuvers. The NATA has published a position statement with recommendations on how to best manage a catastrophic spine injury in the athlete.[
Assessment of penetrating injuries
In cases of penetrating injury, it might be argued that log rolling is necessary to examine the patient's back for potential wounds. However, in most cases where a penetrating trauma exists, unless the patient has experienced multi-trauma, it is unlikely that the patient will have an unstable spine. In situations where the patient has multi-trauma, computed tomography (CT) scans are generally obtained as soon as possible and can help to determine if the spine is stable.
Continuous lateral therapy
Patients with a spinal injury are at a high risk for multisystem complications due to secondary injuries and prolonged immobilization. Immobilization can pose significant risks to the pulmonary, hematological, renal, and integumentary systems. Changing a patient's body position on a regular basis [continuous lateral therapy (CLT)] is one way to reduce the risk of comorbidities associated with immobilization. The most commonly used method to perform CLT is manual log rolling. During this procedure, nurses roll the patient laterally onto one side and place pillows or wedges under the contralateral side to maintain the position. Mechanical devices are also available to provide continuous body position changes to the patient.[
The unstable cervical spine
In both embalmed[
Utility of a mechanical bed for the spine-injured patient
In the case of CLT, in addition to reducing motion to the unstable spine, there are other advantages to using a mechanical bed. By reducing the manual effort required by the nursing staff, the risk of injuries to the staff could be reduced. Also, the timing and degree of rotation can be precisely specified to ensure that the desired effect is achieved.
Prone positioning for surgery
Patients with unstable cervical spine injuries will ultimately require surgery to achieve definitive internal stabilization of the spine. We know of two techniques that can be used to position a patient prone for posterior spine surgery in the operating room: log rolling and the Jackson Spinal Table (OSI, Union City, CA, USA) [
Superiority of Jackson table for cervical spine immobilization
Significantly more cervical motion was produced utilizing the manual log roll method compared to the Jackson table method [
The utility of the Jackson table for safe spinal positioning
Training for positioning the spine-injured patient is not only an issue in the pre-hospital setting, but also is critical in the operating room. We have shown that using a Jackson table to position a patient prone in the operating room produces significantly less motion than the log roll with a C1–C2 injury,[
In two recent studies, for both a cervical[
Motion for spine-injured patients transferred between hospital beds
During a typical hospital stay, a patient with an unstable spine will require numerous transfers between beds within the hospital (i.e. to different diagnostic locations and imaging facilities), making this an important phase of care to be evaluated. The studies by Prasarn and colleagues[
Data against log rolling and difficulty determining baseline neurologic status
Despite at least 25 years of overwhelming data from our research team and others[
Ineffectiveness of log roll maneuver
The ineffectiveness of the log roll maneuver can be explained by examining the human anatomy. The head, shoulders, torso, and hips vary in dimensions, and when the body is rolled onto the side, it is very difficult to maintain spinal alignment. In addition, the job of the person manually stabilizing the head and neck is complicated by the fact that the head must be rotated and translated in two planes in coordination with the motion of the torso. If the motion does not follow the correct path or the timing is off, relative motion between the head and torso will occur. Contrast this with the movements required during the lift–slide transfer in which the head holder is required to move in only one dimension.
False assurance of log roll technique
One reason for continued use of the log roll is that experience can sometimes provide false assurance. For instance, a surgeon who was asked why he insisted on using the log roll maneuver responded: “I have never had a problem with it.” This is a faulty premise and can be demonstrated statistically. Four percent of patients admitted for blunt trauma injuries have a spine fracture or neurologic deficit.[
Prepare for the few cases of spinal instability
We should not base our guidelines on the many incidences when a patient with a stable spine is transported; instead, our focus should be on being prepared for the few cases when a patient truly has an instability that places them at risk of secondary neurologic injury. This same rationale is behind the Advanced Trauma Life Support (ATLS) guidelines of the American College of Surgeons which recommend that “all trauma patients should be presumed to have an unstable cervical spine injury … until all aspects of the cervical spine have been adequately studied and an injury excluded.”[
Too much motion and secondary neurologic injury
At this point, we have been unable to determine how much motion of the unstable spine is required to cause secondary neurologic injury. Our goal is to minimize motion as much as possible. In every situation that we have evaluated, the log roll maneuver has produced more motion than any of the readily available alternatives. Guidelines for patients with spine trauma should be based on the safest techniques available [
This material is the result of work supported with resources and the use of facilities at the Bay Pines VA Healthcare System. The authors received no other external funding for preparing this review paper.
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