What is the proper technique for manual in-line stabilization (MILS) of the cervical spine?

Proper Manual In-Line Stabilization Technique for Cervical Spine

Manual in-line stabilization (MILS) should be performed with the patient's head maintained in a neutral position by placing hands on both sides of the head, with thumbs along the temporal region and fingers extending toward the occiput, while avoiding traction. 1

Proper MILS Technique

Manual in-line stabilization is a critical skill for managing patients with suspected cervical spine injuries. The correct technique involves:

1. Patient positioning:

   • Position yourself at the head of the patient
   • Ensure patient is lying supine on a firm surface
   • Maintain neutral alignment of the head and neck (avoid flexion, extension, or rotation)

2. Hand placement:

   • Place hands on both sides of the patient's head
   • Position thumbs along the temporal region
   • Extend fingers toward the occiput (back of the head)
   • Apply gentle but firm pressure to maintain position

3. Key principles:

   • Avoid applying axial traction (pulling on the head)
   • Maintain neutral alignment throughout any procedures
   • Continue stabilization until definitive immobilization is achieved
   • Allow minimal movement during airway management if absolutely necessary

Evidence and Recommendations

The 2020 international consensus on first aid science acknowledges that manual stabilization techniques require proper education, training, and practice to perform correctly 2. While there is insufficient evidence for or against manual cervical spine restriction of motion, first aid guidelines in several countries (Japan, Australia, New Zealand, United Kingdom) recommend manual support of the head for adults with suspected cervical spine injury 2.

Research indicates that a lift-and-slide transfer method with full body immobilization creates less motion than a log-roll maneuver when transferring patients with suspected cervical spine injuries 3. Additionally, studies show that manual immobilization without traction might be preferable as it reduces the head extension necessary during procedures like laryngoscopy 4.

Special Considerations

When performing MILS during airway management:

• Recognize that direct laryngoscopy with MILS is standard of care for acute trauma patients with suspected cervical spine injury 5
• Be aware that MILS may degrade laryngoscopic view, which could potentially cause hypoxia 5
• Consider that allowing minimal flexion or extension may facilitate prompt intubation in difficult cases without causing secondary injury 5

For patient transfers:

• The Jackson table transfer method produces 2-3 times less cervical spine angular motion than manual transfer techniques 6
• When manual transfers are necessary, using a lift-and-slide technique is preferable to log-rolling 3

Multidisciplinary Approach

Early spine immobilization is strongly recommended for any trauma patient with suspected spinal cord injury to limit neurological deterioration 1. This should be followed by:

• Transfer to appropriate facility (Level 1 trauma center when possible)
• Surgical consultation for spinal cord compression, vertebral instability, or progressive neurological deterioration
• Involvement of a multidisciplinary team including neurosurgeons/orthopedic surgeons, intensivists, and rehabilitation specialists 1

Common Pitfalls to Avoid

• Avoid axial traction: Research suggests that immobilization without traction is preferable 4
• Don't rely solely on cervical collars: Extrication-type cervical collars have limited ability to control neck motion in injured patients 3
• Avoid excessive movement during transfers: Use lift-and-slide rather than log-roll techniques 3
• Don't release stabilization prematurely: Maintain MILS until definitive immobilization is achieved

Manual in-line stabilization is a critical skill that requires proper training and practice. When performed correctly, it helps minimize the risk of secondary injury in patients with suspected cervical spine trauma.