UTSW/BioTel Policy: Spinal Motion Restriction

November 2014

*****New! Spinal Motion Restriction Flow Chart and FAQs (PDF)*****

Purpose: The purpose of this policy is to better ensure the most optimal application of spinal motion restriction measures in the prehospital environment.

    Spinal motion restriction is MANDATORY for any patient for whom a mechanism of injury with the potential to have caused injury to the patient’s spine (MVC, fall, or an injury resulting in ANY evidence of trauma above the clavicles), AND ANY ONE OR MORE of the following criteria is present:
    1. The patient offers a subjective report or objective evidence of otherwise unexplainable numbness, tingling, weakness or paralysis of any extremity.
    2. ANY alteration in the patient’s level of consciousness at the time of evaluation;
    3. A report by the patient, bystander or witness that the patient had experienced a loss of consciousness;
    4. Suspicion of intoxication due to drugs or alcohol;
    5. A significant language or communication barrier exists between EMS personnel and the patient;
    6. Evidence of inadequate systemic perfusion;
    7. Patient is younger than 8 years or older than 60 years of age;
    8. The patient has an injury that could reasonably be thought to distract from the patient’s ability to recognize pain or tenderness in the neck or spine.
  2. EXCEPTION TO IMMOBILIZATION: Clinical Clearance of the Cervical Spine:

    If the patient meets NONE of the above clinical indications, paramedics may elect to implement “clinical clearance” procedures. Paramedics MAY STILL apply SPINAL MOTION RESTRICTION whenever it is determined to be appropriate, or when the injury mechanism or other factors may preclude clearance of the spine in the out-of-hospital setting.

For the purpose of “clinical clearance”, the following procedure shall be followed:

  1. Maintain manual stabilization of the head and neck and ask the patient: “Does your neck hurt?”
    1. If the answer is “yes”, apply spinal motion restrictions and transport the patient.
    2. If the answer is “no”, continue to step b.
  1. Palpate the posterior cervical spine beginning at vertebrae prominens (C7) while asking: “Does this cause you any pain?”
    1. If the answer is “yes”, apply spinal motion restrictions and transport the patient.
    2. If the answer is “no”, continue palpating along the entire cervical spine.  If, at any point, the patient complains of tenderness, apply spinal motion restrictions and transport the patient.  Upon reaching the occiput, if the patient has not complained of tenderness, move on to step c.
  2. Tell the patient, “I am going to ask you to slowly move your head.” Instruct the patient to immediately stop and tell you if moving his/her head causes the patient ANY pain in the neck, or any funny sensation, such as “pins and needles” in either his/her arms or hands. Then ask the patient to:
    1. Slowly move his/her head forward (bending the chin to the chest), then backward, then side to side.
    2. If the patient reports ANY discomfort or paresthesias, slowly return their head to neutral position, apply spinal motion restrictions and transport the patient.
    3. If there is no discomfort and no paresthesias, spinal motion restrictions are not required.
    4. Clearly DOCUMENT each step on the ePCR and indicate: “cervical spine clinically cleared”.
    5. Palpate the remainder of the patient’s spine.  If there is ANY midline tenderness, place the patient on a rigid spine board for transport.  If there is NO midline tenderness, a spine board is not indicated.
    6. If moving the patient’s neck into a more neutral position causes pain/discomfort/paresthesias, then immobilize the spine in a less painful position, as optimally as possible.
    1. Be conservative! Spinal motion restrictions measures are rapidly reversible. When in doubt, apply spinal motion restrictions.
    2. Patients with penetrating injuries to the neck generally do not require spinal motion restriction.
    3. Be conservative when evaluating patients who are found down with new weakness or paralysis. While these patients may have suffered a cardiovascular event, hypoglycemia or some other problem, they may have also injured their neck and possibly their spinal cord. Generally, spinal motion restrictions must be applied in any patient with new paralysis and any evidence/suspicion of trauma above the clavicles, no matter how minor.
    4. As stated previously, patients who appear to be intoxicated and who have evidence of trauma above the clavicles MUST have spinal motion restrictions applied.
    5. When indicated, spinal motion restrictions should be applied prior to any movement of the patient, unless an immediate life-threatening danger exists for the patient or the rescuers. If the patient must be moved to prevent injury to the patient or to the rescuers, manual stabilization of the head and neck shall be maintained to the degree possible.
    6. In the rare event that a patient is believed to require spinal motion restrictions but cannot or will not tolerate them due to other factors such as congestive heart failure, respiratory insufficiency or for very small children, manual stabilization of the head and neck shall be maintained with fixation of the patient to a backboard if possible. The circumstances surrounding this deviation from guidelines shall be reported through BioTel en route to the receiving hospital and shall be documented on the ePCR.
    7. Ultimately, the concept is to restrict spinal movement and not simply apply adjuncts if such interventions create movement or creates improper immobilization/alignment.

    Spinal motion restrictions, when applied, shall generally include:
    1. Rigid spine board or similar transporting device.
    2. Semi-rigid, properly sized cervical collar. When a properly sized cervical collar is not available, alternative immobilization methods (towel rolls, vacuum or other splinting materials, etc.) may be used, provided that they do not impinge upon the patient’s ability to breathe.
    3. Lateral neck rolls or approved head immobilization device.
    4. Tape or securing straps across the forehead and cervical collar.
    5. Straps across the patient’s chest, hips, abdomen, and legs to secure the patient to the device and to minimize pivoting movement in any direction.

EMS Spinal Precautions and the Use of the Long Backboard

Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma

The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma believe that:
  1. Long backboards are commonly used to attempt to provide rigid spinal immobilization among EMS trauma patients. However, the benefit of long backboards is largely unproven.
  2. The long backboard can induce pain, patient agitation, and respiratory compromise. Further, the backboard can decrease tissue perfusion at pressure points, leading to the development of pressure ulcers.
  3. Utilization of backboards for spinal immobilization during transport should be judicious, so that potential benefits outweigh risks.
  4. Appropriate patients to be immobilized with a backboard may include those with:
    1. Blunt trauma and altered level of consciousness;
    2. Spinal pain or tenderness;
    3. Neurologic complaint (e.g., numbness or motor weakness)
    4. Anatomic deformity of the spine;
    5. High energy mechanism of injury and:
      1. Drug or alcohol intoxication;
      2. Inability to communicate; and/or
      3. Distracting injury.
  5. Patients for whom immobilization on a backboard is not necessary include those with all of the following:
    1. Normal level of consciousness (GCS 15);
    2. No spine tenderness or anatomic abnormality;
    3. No neurologic findings or complaints;
    4. No distracting injury;
    5. No intoxication.
  6. Patients with penetrating trauma to the head, neck or torso and no evidence of spinal injury should not be immobilized on a backboard.
  7. Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for:
    1. Patients who are found to be ambulatory at the scene;
    2. Patients who must be transported for a protracted time, particularly prior to interfacility transfer; or
    3. Patients for whom a backboard is not otherwise indicated.
  8. 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 in-line stabilization during any necessary movement/transfers.
  9. Education of field emergency medical services personnel should include evaluation of risk of spinal injury in the context of options to provide spinal precautions.
  10. Protocols or plans to promote judicious use of long backboards during prehospital care should engage as many stakeholders in the trauma/EMS system as possible.
  11. Patients should be removed from backboards as soon as practical in an emergency department.

NAEMSP Board of Directors Approved: December 16, 2012 / ACS-Committee on Trauma Approved: October 30, 2012