6+ Person Lift and Slide - Spinal Board Transfer Technique

Overview

Personnel Setup (8 Total)

Step-by-Step Procedure

Pre-procedure preparation

1. Apply a properly sized rigid cervical collar before initiating movement (reduces but does not eliminate cervical motion).
2. Rescuer 1 takes position at the patient's head, placing hands on either side of the skull to provide manual in-line stabilization in the neutral position.
3. Six lifters position themselves alongside the patient: pairs at the chest/axilla level, pelvis level, and lower leg level. Rescuers kneel or crouch on both sides.
4. Rescuer 8 stands at the foot end of the patient, holding the spinal board ready.

Lifting phase

1. Rescuer 1 commands (e.g., "On my count - one, two, three, LIFT").
2. All 6 rescuers simultaneously lift the patient 4-6 inches (10-15 cm) off the ground in a single coordinated motion.
   • Hands are placed under the patient's body - not on straps or clothing - to distribute force evenly across thorax, pelvis, and legs.
   • All rescuers must maintain their segment's alignment without allowing sagging between segments.
3. The body must rise as a rigid unit - no bending, sagging, or twisting at any spinal level.

Board placement

1. While the patient is held suspended, Rescuer 8 slides the spinal board from the foot end, pushing it smoothly along the ground under the entire length of the patient's body.
2. The board is advanced until it is fully centered under the patient (head end of board at the patient's head).

Lowering phase

1. On Rescuer 1's command, all lifters simultaneously and gently lower the patient onto the board.
2. Make minor adjustments to center the patient on the board if needed - do this with small coordinated slides, not lifts.

Securing to the board

1. Secure the torso with straps in the order: chest first, then pelvis, then lower extremities (so securing the body before the head to avoid levering forces on the cervical spine).
2. Apply lateral head blocks/foam blocks on either side of the head.
3. Apply a forehead strap and chin strap to secure the head to the board last.
4. Reassess neurological status after full immobilization.

Key Principles & Evidence

• Why 6+ is preferred over log roll: The log roll generates significantly more lateral flexion and axial rotation at an unstable cervical segment. The 6+ lift keeps the spine in a more neutral axis by lifting straight up rather than rotating.
• Lift height: Only 4-6 inches. More than necessary introduces risk; less prevents board insertion.
• Board entry from the foot: Never from the side - this forces lateral tilt of the board which could shift the spine.
• Do not lift unevenly: If one pair lifts faster or higher than another, segmental bending occurs. Rescuer 1's count is law.
• Rescuer 1 does NOT lift - they maintain cervical stabilization throughout and serve as the sole commander of the procedure.
• Cervical collars alone restrict only ~70-75% of flexion-extension; manual in-line stabilization by Rescuer 1 must be maintained at all times until the patient is fully secured (Roberts and Hedges' Clinical Procedures in Emergency Medicine).

Comparison with Other Techniques

Contraindications / Special Situations

• Penetrating trauma to head, neck, or torso with no signs of spinal injury: spinal immobilization on a backboard is not required per current guidelines.
• Pediatric patients (<8 years): the large occiput causes neck flexion on a flat board - place a pad under the back at chest level or use a board with an occipital cutout.
• Suspected pelvic fracture: pelvic straps may not be tolerated; modify accordingly.
• Obese/kyphotic patients: pad hollow spaces under the spine to maintain neutral alignment on the hard board.

Log Rolling Technique in ATLS

Context in ATLS

1. Examine the entire posterior surface (back, buttocks, posterior thighs) for injuries
2. Slide the spinal board under the patient if not already done
3. Remove the patient from a backboard once in-hospital

Personnel Required

Step-by-Step ATLS Log Roll Procedure

Pre-roll preparation

• Apply a correctly sized rigid cervical collar before any movement begins.
• If sizing is difficult or collar not available, maintain manual in-line stabilization at all times.

• Rescuer 1 (Team Leader) - at the patient's head, applies bilateral manual in-line stabilization. Hands placed on either side of the skull, not the collar.
• Rescuer 2 - kneels on the side the patient will be rolled toward, at the level of the chest/shoulder - reaches across and places one hand on the far shoulder, other hand on the far hip.
• Rescuer 3 - kneels same side as Rescuer 2, at pelvis/hip level - one hand on far lower back/hip, other hand under the far thigh.
• Rescuer 4 (if available) - same side as 2 & 3, at the lower legs/knees.
• Rescuer 5 (examiner or board handler) - opposite side, ready with the backboard.

• Extend the patient's arms alongside their body with palms resting on the lateral thighs. Some prefer arms crossed over the thorax to prevent the patient grabbing a rescuer. Straighten the lower extremities.

• Place the spinal board on the opposite side (the side that is more painful/injured) - so when the patient is rolled, they rotate toward the less-injured side.
• The board should be positioned at approximately 45° to the patient ready to slide under.

Rolling phase

• Rescuer 1 gives the command: "On my count - 1, 2, 3, ROLL"
• All rescuers roll the patient as one rigid unit onto the side, toward Rescuers 2, 3, and 4.
• Rescuer 1 does NOT pull or push - they maintain in-line stabilization and move the head in synchrony with the torso, preventing any independent head/neck movement.
• The roll angle is typically 30-90° to the horizontal.
• The body must not sag between segments - chest, pelvis, and legs must move at the same rate and angle.

• With the patient on their side, the examiner inspects and palpates the entire posterior spine (cervical, thoracic, lumbar, sacral), looking for:
  • Step deformities
  • Midline tenderness
  • Lacerations, contusions, penetrating wounds
  • Perianal sensation / rectal tone (if indicated for SCI assessment)

• Rescuer 5 slides the backboard under the patient against the patient's back at approximately 45°.
• The board should be angled to account for rolling the patient back onto it.

Roll-back and securing

• Rescuer 1 commands roll back: "1, 2, 3, ROLL BACK"
• Patient is lowered supine onto the board.
• At this point minor adjustments may be needed to center the patient.

• To center without re-rolling: support cervical spine, shoulders, and hips and slide patient in a zigzag caudal-then-cephalad pattern to avoid uneven lateral or rotational force on the spine.

1. Chest/thorax strap - first
2. Pelvis strap
3. Upper legs / lower legs strap
4. Head and lateral neck stabilizers - last

Critical Technical Points

Log Roll vs. 6+ Lift: ATLS Perspective

When NOT to Log Roll (Current ATLS Guidance)

• Penetrating trauma to head/neck/torso without neurological signs: do NOT immobilize on backboard
• Normal GCS, no midline tenderness, no distracting injury: spinal motion restriction may not be required
• Patients should be removed from the backboard as soon as possible once in-hospital, as prolonged boarding causes pressure ulcers, respiratory compromise, and pain
• Sabiston Surgery: "Prehospital practice has evolved such that all patients with a potential mechanism to produce spinal injury are no longer systematically immobilized on long spine boards with cervical collars"

Brown-Séquard Syndrome & Cauda Equina Syndrome

Part 1: Brown-Séquard Syndrome (BSS)

Definition & Anatomy

Classic Triad

• Band of ipsilateral anesthesia (all modalities)
• LMN signs at that level (flaccidity, loss of reflex at lesion level)
• Ipsilateral Horner's syndrome if cervical cord is involved (interruption of descending sympathetic fibers)

• Ipsilateral: Spastic paresis/paralysis (UMN - corticospinal tract), loss of proprioception, vibration sense, and discriminative touch (dorsal columns); Babinski sign ipsilateral
• Contralateral: Loss of pain and temperature sensation (spinothalamic tract), beginning 2-3 segments below the lesion

BSS-Plus (More Common in Practice)

Etiology

Prognosis - Best of All Cord Syndromes

• Most recovery occurs in the first few months; improvement possible up to 2 years
• Gait usually recovers within 6 months
• Most patients regain bowel and bladder continence
• Upper extremity predominant weakness = favorable ambulation outcome
• If anatomic cord transection from penetrating trauma: significant recovery is unlikely
• Only central cord syndrome and BSS are statistically associated with improved recovery at 2 years

Part 2: Cauda Equina Syndrome (CES)

Anatomy & Definition

Classic Triad

1. Bilateral lower extremity weakness and reduced sensation
2. Saddle anesthesia (S3, S4, S5 roots) - numbness in the perineum, inner thighs, genitalia, buttocks
3. Bowel/bladder dysfunction - urinary retention (most common early sign), urinary/fecal incontinence

Detailed Clinical Features

• L4 compression: reduced knee extension power, reduced knee jerk
• L5 compression: reduced foot/toe dorsiflexion
• S1-S2 compression: reduced ankle jerk
• S3-S5 compression: perineal numbness, bladder/bowel dysfunction

Etiology

Investigations

1. Emergent MRI lumbar spine - imaging of choice; confirms compression and guides surgical planning
2. CT myelogram - if MRI contraindicated
3. Bladder ultrasound / catheterisation - measure post-void residual volume (>100 mL is significant)
4. Digital rectal examination - assess anal sphincter tone - mandatory

Management - SURGICAL EMERGENCY

• CES is a surgical emergency - obtain emergent MRI and spine surgery consultation simultaneously, not sequentially
• Surgical decompression by laminectomy + removal of offending lesion
• Timing: Within 48 hours of symptom onset (recommendation); given unclear symptom timelines in practice, emergent decompression within hours is typically pursued
• Up to 85% of patients return to previous bowel/bladder and motor function within 1 year after decompression (Sabiston Surgery)
• IV corticosteroids: determined by the treating spine surgeon on a case-by-case basis

Head-to-Head Comparison: BSS vs. CES

CES vs. Conus Medullaris Syndrome (Key Differentiator)