EBQ:Prehospital Spine Immobilization

Clinical Question

Which patients require spine immobilization (Cervical or Thoracic/Lumbar) in the prehospital environment

NAEMSP Position Statement

The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma advises the targeted use of backboards with emphasis on high risk patients.[1]

Immobilization NOT Necessary in the Following:

  • Normal level of consciousness (Glasgow Coma Score GCS 15)
  • No spine tenderness or anatomic abnormality
  • No neurologic findings or complaints
  • No distracting injury
  • No intoxication

Immobilization the following patients:

  • Blunt trauma and altered level of consciousness
  • Spinal pain or tenderness
  • Neurologic complaint (e.g., numbness or motor weakness)
  • Anatomic deformity of the spine
  • High-energy mechanism of injury and any of the following:
      • Drug or alcohol intoxication
  • Inability to communicate
    • Distracting injury

"Whether or not a backboard is used, attention to spinal precautions among at-risk patients is paramount. These include application of a cervical collar, adequate security to a stretcher, minimal movement/transfers, and maintenance of inline stabilization during any necessary movement/ transfers." -NAEMSP[1]

Potential Harm with C1-C2 injuries

In the presence of severe injury, collar application resulted in 7.3 mm +/- 4.0 mm of separation between C1 and C2 in a cadaver model[2]

Self Extrication vs Provider Extrication

Conventional extrication techniques record up to four times more cervical spine movement during extrication than controlled self-extrication (Rigid Collar and patient then self extricating).[3]

Penetrating Trauma

Prehospital spine immobilization is associated with higher mortality in penetrating trauma and should not be routinely used in every patient with penetrating trauma.[4][5]

Intubating with Cervical Collar

There is significant decreases in mouth opening when the cervical collar is left in place. In-line stabilization should be used for intubation with the cervical collar removed.[6]


  1. 1.0 1.1 National Association of EMS Physicians and American College of Surgeons Committee on Trauma. EMS Spinal Precautions and the Use of the Long Backboard. Prehospital Emergency Care 2013;17:392-393 PDF
  2. Ben-Galim, P et al. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma. 2010 Aug;69(2):447-50. PMID: 20093981
  3. Dixon, M et al. Biomechanical analysis of spinal immobilization during prehospital extrication: a proof of concept study. Emerg Me J. 2014 Sep;31(9):745-9.
  4. Haut, ER et al. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010 Jan; 68(1):115-20. PMID: 20065766.
  5. Vanderlan, WB et al. Increased risk of death with cervical spine immobilization in penetrating cervical trauma. Injury. 2009 Aug;40(8):880-3. PMID: 19524236.
  6. Goutcher, CM et al. Reduction in mouth opening with semi-rigid cervical collars. Br J Anaesth. 2005 Sep;95(3):344-8. PMID: 16006487.