Introduction

Spinal precautions are important to minimise possible neurologic damage (to the spinal cord) that may be caused by inappropriate spine mobilisation, in a patient with suspected unstable spinal injury.  Log rolling is a spinal precaution technique that restricts movement of the spine and aims to protect and maintain spinal integrity and alignment whilst facilitating the assessment of the patient’s back, preventing development of pressure injuries and facilitating procedures. RCH is committed to ensuring all log rolls are clinically safe, responsive, efficient and effectively coordinated.

Aim

This guideline outlines the process of log rolling any patient with suspected unstable spinal injury or disease, and under spinal precautions. It aims to provide guidance to clinical staff to prevent direct spinal cord injury (SCI), and further secondary injury due to unnecessary movement, by detailing safe technique to maintain correct anatomical alignment in patients with suspected or confirmed SCI.

Definition of Terms

• Cervical Spine: The cervical (neck) region consists of seven bones, C1-C7 vertebrae, which are separated from another by intervertebral discs which act as shock absorbers and allow the spine to move freely during activity.
  
• Lumbar Spine: The lower back region of the spine; consists of the five vertebrae between the ribs and the pelvis. The Sacrum has 5 fused vertebrae and coccyx has 4 fused vertebrae located at the base of the spine.
  
• Thoracic Spine: The region of the spine is attached to the ribcage; located between the cervical and lumbar areas, it consists of 12 vertebrae.
  
• Spinal Cord injury (SCI): Any interruption of spinal cord function by disease or injury at a particular level may result in a loss of sensation and motor function below that level. Depending on the severity of the disease or injury, the loss of function may be permanent. Spinal cord injury is categorised into two classifications; primary and secondary injury. Primary SCI is irreversible damage sustained at time of trauma due to mechanical insult. Secondary injury is sustained post trauma likely due to cord hypoperfusion, however consideration for further trauma due to movement is imperative.
  

Indications

Log rolling should be utilised for any trauma patient with a high suspicion of spinal injury based on mechanism, presenting signs/symptoms, or the inability to perform a reliable assessment (i.e., unconscious/sedated patients).

Log rolling is used to prevent spinal injury or ascension of injury to facilitate procedures and clinical assessment, and to prevent pressure injuries.

High risk mechanism for suspicion of spinal cord injury includes but not limited to:

• Axial load to the head (diving, trampoline, falling from height)
• Forced neck hyperflexion (includes low velocity mechanism with high force e.g. rugby scrum collapse)
• Ejection from a vehicle including motorbike
• Improper restraint in a motor vehicle collision (MVC)
• Passenger in an MVC of >60 km/hr, head on collision, rollover, or any accident with a passenger death
• Pedestrian vs vehicle
• Fall >3 metres (or twice the patient’s height)
• Kicked by, or fall from, a horse
• Substantial torso injury
• History of conditions known to predispose to CSI
  • Previous cervical spinal surgery
  • Trisomy 21
  • Osteogenesis imperfecta, Achondroplasia
  • Other rheumatological, genetic or metabolic conditions
• Persistent symptoms: pain, paraesthesia, weakness

Please see C-Spine assessment guideline for C-spine clearance guidance. Even where C-spine clearance has occurred, log rolling may be required to protect an uncleared or injured thoracic and / or lumbar spine.

It is important to note that occasionally there is potential for further injury to certain patient groups by log rolling. Consideration of the appropriateness of conducting log rolling should be discussed amongst the team, and certain patient groups may require increased caution, for example complex spinal fractures that have not been stabilised.

Management

Preparation for log rolling

• Personnel: 4-5 people depending on the size of child with training in log rolling
• Collar if required/ordered
• PPE
• Clean sheets if required
• Ensure haemodynamically stable, including assessment of airway and breathing, complete a set of observations if required. Consider analgesia and/or sedation prior to log rolling as required for pain relief or ICP management.
• Any anticipated equipment to treat any findings, including positioning adjuncts for the comfort of the head hold person in case of prolonged hold.
  

Please note, for taller or bariatric patients, you may require more staff to assist with a move.

Procedure

1. Explain procedure to patient and family; apply semi-rigid collar if required. Ensure equipment and monitoring is prepared for the roll, including sufficient length for line and tubing movement, Extra Ventricular Drain clamped, etc.
   
2. Adjust bed to correct height.  Ensure the bed is set at hip height of the head holder, aiming to reduce excessive forward trunk flexion of the person allocated to hold the head. Procedure is safest if the tallest staff member is at the chest area.
   
   Image 1, Log roll positioning, photo courtesy of Trauma Service RCH.
3. Ensure everyone is aware of their roles, the direction of the roll, and the terminology that will be used. “We will roll on the word roll, 'one, two, three, roll, or ready, set, roll” (script can be changed according to the preference of the person holding the head). Ensure direction of roll is clear, and where possible avoiding side of any obvious injury.
   
4. Personnel take their positions with hip person placing left hand over, and right hand under the leg to support and ensure patient is supine and anatomically aligned.
   Ensure patients head remains in neutral anatomical alignment to maximise venous return and minimise raises in intracranial pressure (ICP). Patients <8 years old will require a thoracic elevation device (Occian Airway Pad) to ensure correct spinal alignment.
   
   The chest, torso and hips of the patient should be supported from above, with hands over the patient. The leg and thigh should be supported from underneath with underhand hold.
   
   Proximal arm of the patient must be adducted to avoid rolling on IV or monitoring. Distal Arm should be extended in alignment with the thorax and abdomen or bent over the patient chest if appropriate. (i.e. If the arm is uninjured).
   
   

   Image 2, Log roll hand positioning, photo courtesy of Trauma Service RCH.

5. Head hold person commences directing the turn as outlined above, and leg person placing hands underneath leg for support. Count to “one, two, three, roll” or similar, and all personnel roll patient together. Task/ Assessment person reassures patient and supports the airway and lines, ensuring sufficient slack, and EVD / monitoring taps are turned as per protocol, until patient in a stable position on their side or completed roll 
   
   

   Image 3, Log roll mid roll, photo courtesy of Trauma Service RCH.

6. Task/Assessment person assess skin integrity, paying close attention to the occipital region under collar. Assess for signs of pressure, including integrity, oedema, pain, non -blanching redness. Meet any hygiene needs required, change sheets if necessary.
   
   

   Image 4, Log roll spinal assessment, photo courtesy of Trauma Service RCH.

7. Head Hold person asks if everyone is ready to roll back. When ready, head hold person states “we will roll back on roll, one, two, three roll”. Count is made and everyone rolls together.
8. Task/Assessment person reduces risks of linen creases underneath, gently pulling on sheets as patient is lowered down, and when patient anatomically aligned, head hold person gives permission to release grip sequentially from the legs up. If patient <8 years old, and in spinal precautions, transfer the patient onto the Thoracic Elevation Device (TED) in supine position ensuring the ear is in line with the shoulder in the sagittal plane. The patient’s head is positioned off the TED. Feet may be on or off the pad according to patient length.
    
   

   Image 5, TED device, photo courtesy of Trauma Service RCH.

9. Head hold person removes hands while shoulders are braced by a second person. A third person supports the head to minimise movement. 
10. Document log rolling in the notes, and any assessment of the posterior that was undertaken.

Daily assessment of need for spinal precautions with continual investigations are necessary to review the necessity of precautions, as immobilisation can come with its own set of complications. Regular review of the Spinal Management Orders is imperative for prevention.

Manual Handling considerations

During all patient movements, ensure handlers have a wide base of support, the use of a split stance can be used to minimise the forward flexion of the low back. If log roll duration prolonged, then using the bed or positioning supports to lean against/support arms may reduce fatigue of handlers and risk of musculoskeletal injury.

Companion Documents

• TBI guideline PICU
• Smart Move Smart Lift
• TED Thoracic Elevation Device
• Cervical Spine Assessment
• The Paediatric Trauma Manual

Evidence Table

Coming soon. 

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Ari Woodward, CNC, Trauma, approved by the Nursing Clinical Effectiveness Committee. First published June 2024.