# Spinal precautions

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{{short description|Efforts to prevent movement of the spine in those with a risk of a spine injury}}
{{Infobox medical intervention
| name         = Spinal precautions
| synonym      = Spinal immobilization, spinal motion restriction
| image        = Cervical Collar Emergency.jpg
| caption      = A person with a hard cervical collar on a long board
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'''Spinal precautions''', also known as '''spinal immobilization''' and '''spinal motion restriction''', are efforts to prevent movement of the bones of the spine in those with a risk of a [spine injury](/source/Spinal_cord_injury).<ref name=Pol1999>{{cite book|last=Pollak|first=Andrew|title=Refresher: Emergency Care and Transportation of the Sick and Injured|year=1999|isbn=9780763709129|page=302|publisher=Jones & Bartlett Learning |url=https://books.google.com/books?id=xuCTtGx_ukkC&pg=PA302}}</ref> This is done as an effort to prevent injury to the [spinal cord](/source/spinal_cord)<ref name="Pol1999" /> in unstable [spinal fracture](/source/spinal_fracture)s.<ref>{{Cite journal |last1=Vaccaro |first1=A. R. |last2=Silber |first2=J. S. |date=2001-12-15 |title=Post-traumatic spinal deformity |journal=Spine |volume=26 |issue=24 Suppl |pages=S111–118 |doi=10.1097/00007632-200112151-00019 |issn=0362-2436 |pmid=11805617}}</ref> About 0.5-3% of people with [blunt trauma](/source/blunt_trauma) will have a spine injury,<ref name=":22">{{Cite journal |last1=Ahn |first1=Henry |last2=Singh |first2=Jeffrey |last3=Nathens |first3=Avery |last4=MacDonald |first4=Russell D. |last5=Travers |first5=Andrew |last6=Tallon |first6=John |last7=Fehlings |first7=Michael G. |last8=Yee |first8=Albert |date=August 2011 |title=Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines |journal=Journal of Neurotrauma |volume=28 |issue=8 |pages=1341–1361 |doi=10.1089/neu.2009.1168 |issn=1557-9042 |pmc=3143405 |pmid=20175667}}</ref><ref name=":12">{{Cite journal |last1=Connor |first1=D. |last2=Greaves |first2=I. |last3=Porter |first3=K. |last4=Bloch |first4=M. |last5=consensus group, Faculty of Pre-Hospital Care |date=December 2013 |title=Pre-hospital spinal immobilisation: an initial consensus statement |journal=Emergency Medicine Journal |volume=30 |issue=12 |pages=1067–1069 |doi=10.1136/emermed-2013-203207 |issn=1472-0213 |pmid=24232011}}</ref> with 42-50% of injuries due to motor vehicle accidents, 27-43% from falls or work injuries, and the rest due to sports injuries (9%) or assault (11%).<ref name=":12" /><ref>{{Cite book |last=Winn |first=Richard |title=Youmans & Winn Neurological Surgery |date=January 21, 2022 |publisher=Elsevier |isbn=978-0-323-67499-7 |edition=8th |pages=2415–2426}}</ref><ref name=":32">{{Cite journal |last1=Stein |first1=Deborah M. |last2=Knight |first2=William A. |date=September 2017 |title=Emergency Neurological Life Support: Traumatic Spine Injury |journal=Neurocritical Care |volume=27 |issue=Suppl 1 |pages=170–180 |doi=10.1007/s12028-017-0462-z |issn=1556-0961 |pmid=28913694}}</ref> The majority of spinal cord injuries are to the cervical spine (neck, 52%), followed by the thoracic (upper back) and lumbar (lower back) spine.<ref name=":12" /> Cervical spinal cord injuries can result in [tetraplegia](/source/tetraplegia) or [paraplegia](/source/paraplegia).<ref name=":32" /> Of spine injuries, only 0.01% are unstable and require intervention (either surgery or a spinal [orthosis](/source/Orthotics)).<ref name="NAEMSP201423">{{cite journal |last=White CC |first=4th |author2=Domeier, RM |author3=Millin, MG |author4=Standards and Clinical Practice Committee, National Association of EMS, Physicians |date=Apr–Jun 2014 |title=EMS spinal precautions and the use of the long backboard - resource document to the position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. |journal=Prehospital Emergency Care |volume=18 |issue=2 |pages=306–14 |doi=10.3109/10903127.2014.884197 |pmid=24559236 |s2cid=207521864}}</ref><ref name=":5">{{Cite book |last=Cifu |first=David X. |title=Braddom's Physical Medicine and Rehabilitation, Sixth Edition |publisher=[Elsevier](/source/Elsevier) |isbn=978-0-323-62539-5 |edition=6th |publication-date=2020 |pages=248–260}}</ref>

Spinal precautions are controversial because benefits are unclear and there are drawbacks including [pressure ulcer](/source/pressure_ulcer)s, increased pain, and delayed transport times.<ref name=":04">{{Cite journal |last1=Velopulos |first1=Catherine G. |last2=Shihab |first2=Hasan M. |last3=Lottenberg |first3=Lawrence |last4=Feinman |first4=Marcie |last5=Raja |first5=Ali |last6=Salomone |first6=Jeffrey |last7=Haut |first7=Elliott R. |date=May 2018 |title=Prehospital spine immobilization/spinal motion restriction in penetrating trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST) |journal=The Journal of Trauma and Acute Care Surgery |volume=84 |issue=5 |pages=736–744 |doi=10.1097/TA.0000000000001764 |issn=2163-0763 |pmid=29283970}}</ref><ref name="NAEMSP201423"/><ref name="Ot2015" /> Spinal boards can also be uncomfortable.<ref>{{Cite web |last1=National Association of EMS Physicians |last2=American College of Surgeons Committee on Trauma |date=2012 |title=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 |url=https://www.facs.org/media/zbrg5sfw/9_backboardpositionpaper-final-approved_2012.pdf |access-date=November 27, 2024 |website=American College of Surgeons}}</ref>

== Indications ==
Spinal precautions are often first initiated by [emergency medical services](/source/emergency_medical_services) in the prehospital setting.<ref name=":04" /> There are multiple decision rules to determine who should be immobilized.<ref name=":22" /><ref name=":12" /><ref name="NAEMSP201423"/>

Due to concerns of side effects, the National Association of EMS Physicians and the [American College of Surgeons](/source/American_College_of_Surgeons) recommend its use only in those at high risk.<ref name="NAEMSP201423"/> This includes: those with blunt trauma who have a [decreased level of consciousness](/source/decreased_level_of_consciousness), pain or tenderness in the spine, those with numbness or weakness believed to be due to a spinal injury, and those with a significant trauma mechanism who are intoxicated or have other major injuries.<ref name="NAEMSP201423"/> The use of a backboard is recommended only to move the person from the scene to the stretcher, after which it should be removed.<ref>{{cite journal |last1=Millin |first1=MG |last2=Innes |first2=JC |last3=King |first3=GD |last4=Abo |first4=BN |last5=Kelly |first5=SM |last6=Knoles |first6=CL |last7=Vezzetti |first7=R |last8=White CC |first8=4th |last9=Yee |first9=A |last10=Gallagher |first10=JM |title=Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries - A NAEMSP Comprehensive Review and Analysis of the Literature. |journal=Prehospital Emergency Care |date=7 August 2025 |pages=1–13 |doi=10.1080/10903127.2025.2541258 |pmid=40736221}}</ref>

These recommendations are also endorsed by the Consortium for Spinal Cord Medicine.<ref name=":4">{{Cite journal |last=Consortium for Spinal Cord Medicine |date=2008 |title=Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals |journal=The Journal of Spinal Cord Medicine |volume=31 |issue=4 |pages=403–479 |doi=10.1043/1079-0268-31.4.408 |doi-broken-date=12 July 2025 |issn=1079-0268 |pmc=2582434 |pmid=18959359}}</ref> Immobilization is also recommended in those with a definite spinal cord injury.<ref name="Ahn20112">{{cite journal |last1=Ahn |first1=H |last2=Singh |first2=J |last3=Nathens |first3=A |last4=MacDonald |first4=RD |last5=Travers |first5=A |last6=Tallon |first6=J |last7=Fehlings |first7=MG |last8=Yee |first8=A |date=August 2011 |title=Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines. |journal=Journal of Neurotrauma |volume=28 |issue=8 |pages=1341–61 |doi=10.1089/neu.2009.1168 |pmc=3143405 |pmid=20175667}}</ref>

Spinal motion stabilization is not supported for penetrating trauma to the back, including that caused by gunshot wounds.<ref name=":04" /><ref name=Stuke2011>{{cite journal|last1=Stuke|first1=LE|last2=Pons|first2=PT|last3=Guy|first3=JS|last4=Chapleau|first4=WP|last5=Butler|first5=FK|last6=McSwain|first6=NE|title=Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee.|journal=The Journal of Trauma|date=September 2011|volume=71|issue=3|pages=763-9; discussion 769-70|pmid=21909006|doi=10.1097/ta.0b013e3182255cb9}}</ref>

== Prehospital ==

=== Methods ===
Spinal precautions generally include [long spine board](/source/long_spine_board)s, [cervical collar](/source/cervical_collar)s, head blocks, and [straps](/source/Grady_straps) with the goal of immobilizing or reducing movement throughout the entirety of the spine.<ref name=":12" /><ref name="NAEMSP201423"/><ref name=":4" /> They also include methods to reduce spinal movement while moving a patient, such as [logrolling](/source/Logrolling_(medicine)).<ref name="NAEMSP201423"/> Measures to reduce intracranial pressure, such as lowering the feet of the bed while keeping it flat, are also sometimes used.<ref name="NAEMSP201423"/>

If a longboard is used, cushioning it is useful to decrease discomfort due to pressure.<ref name="Ahn20112"/> A [vacuum mattress](/source/vacuum_mattress) and [scoop board](/source/scoop_board) typically results in lower pressures.<ref name="Ahn20112" />

=== Contraindications ===
Spinal precautions should not be used in patients who are at low risk of spinal injury.<ref name="NAEMSP201423"/> If [intubation](/source/intubation) is required the cervical collar should be removed and neck stabilization provided by a trained staff member holding the patient's head.<ref name=":22" /><ref name="Ahn20112"/> Whenever possible, intubation methods that decrease spinal motion should be used such as awake fiberoptic intubation.<ref name=":32" />

In those with penetrating neck or head trauma spinal immobilization may increase the risk of death.<ref name="Stuke2011" /><ref name="Ot2015">{{cite journal |last1=Oteir |first1=AO |last2=Smith |first2=K |last3=Stoelwinder |first3=JU |last4=Middleton |first4=J |last5=Jennings |first5=PA |date=12 January 2015 |title=Should suspected cervical spinal cord injury be immobilised?: A systematic review. |journal=Injury |volume=46 |issue=4 |pages=528–35 |doi=10.1016/j.injury.2014.12.032 |pmid=25624270}}</ref>

=== Controversy ===
There is little high quality evidence for spinal motion stabilization of the neck before arrival at a hospital.<ref name=":4" /><ref name="Ot2015" /><ref>{{cite journal |last1=Sundstrøm |first1=T |last2=Asbjørnsen |first2=H |last3=Habiba |first3=S |last4=Sunde |first4=GA |last5=Wester |first5=K |date=15 March 2014 |title=Prehospital use of cervical collars in trauma patients: a critical review. |journal=Journal of Neurotrauma |volume=31 |issue=6 |pages=531–40 |doi=10.1089/neu.2013.3094 |pmc=3949434 |pmid=23962031}}</ref> Multiple studies have demonstrated that current methods used to immobilize the spine in the field do not improve patient outcomes.<ref name=":04" /> Additionally, because spinal cord injury is rare, it is estimated that if everyone at risk for spine injury was placed on spinal precautions, approximately 50-100 people would be put on precautions for every one person who actually had an injury.<ref name=":12" /> The benefit of spinal precautions is also questioned because the initial forces that lead to spine injury tend to be massive, while forces experienced during transport are subsequently minor.<ref name="NAEMSP201423"/> Thus, there is skepticism that movement during transport could cause a new or worsened spinal cord injury if an initial high-impact injury, such as a car crash, did not.<ref name="NAEMSP201423"/>

Spinal precautions including a cervical collar and rigid board have been shown to delay time to [intubation](/source/intubation), increase risk of [aspiration](/source/Pulmonary_aspiration), raise [intracranial pressure](/source/intracranial_pressure) and cause pain, agitation, and [pressure ulcer](/source/pressure_ulcer)s.<ref name=":12" /><ref name=":4" /><ref name="NAEMSP201423"/>  A systematic review found [cervical collar](/source/cervical_collar) related skin ulcers from the devices in 7 to 38%.<ref>{{cite journal |last1=Ham |first1=W |last2=Schoonhoven |first2=L |last3=Schuurmans |first3=MJ |last4=Leenen |first4=LP |date=April 2014 |title=Pressure ulcers from spinal immobilization in trauma patients: a systematic review. |journal=The Journal of Trauma and Acute Care Surgery |volume=76 |issue=4 |pages=1131–41 |doi=10.1097/ta.0000000000000153 |pmid=24662882 |s2cid=23746350}}</ref>

There are no high-quality randomized trials supporting the practice of spinal cord immobilization in the field.<ref name=":4" /> However, secondary injury (i.e. injury to the spinal cord during transport after an initial trauma), is suspected to be the cause of up to 1/4 of spinal cord injuries.<ref name=":4" /> Because of the devastating consequences of spinal cord injury and the theoretical benefit of spinal precautions in preventing secondary injury to the spinal cord, the use of spinal precautions is still recommended in high-risk patients by major societies.<ref name=":4" />

== Clearance ==
Due to their side-effects, backboards should be removed as soon as possible, even before imaging.<ref name=":32" /><ref name="NAEMSP201423"/> It is also recommended to remove cervical collars as soon as possible.<ref name=":32" /> If people require ongoing cervical spine precautions, they should be switched to an adjustable cervical collar such as a Miami J collar<ref name=":32" /> or [halo-gravity traction device](/source/halo-gravity_traction_device) for long-term immobilization.<ref name=":4" />

=== Cervical spine ===
[[File:The_Canadian_C-spine_rule_for_those_with_a_normal_Glasgow_coma_scale_and_who_are_otherwise_stable.png|thumb|upright=1.3|The Canadian C-spine rule for those with a normal [Glasgow coma scale](/source/Glasgow_coma_scale) and who are otherwise stable]]
{{Main|Clearing the cervical spine}}
There are two main algorithms, the [Canadian C-spine rule](/source/Canadian_C-spine_rule) and NEXUS, which are used to decide who requires cervical spine imaging via [CT scan](/source/CT_scan)<ref name=":32" /> after blunt trauma, and who can be cleared without imaging.<ref name=":12" /> The Canadian C-spine rule appears to have greater sensitivity and specificity (i.e. fewer false positives and false negatives).<ref>{{cite journal |last1=Michaleff |first1=ZA |last2=Maher |first2=CG |last3=Verhagen |first3=AP |last4=Rebbeck |first4=T |last5=Lin |first5=CW |date=6 November 2012 |title=Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. |journal=Canadian Medical Association Journal |volume=184 |issue=16 |pages=E867-76 |doi=10.1503/cmaj.120675 |pmc=3494329 |pmid=23048086}}</ref> However, following either rule is reasonable.

If the chosen decision rule (NEXUS or Canadian C-spine) is negative, or if cervical spine imaging is negative, the cervical collar can be removed if the patient does not have significant midline tenderness and can move the neck 45 degrees to both sides.<ref name=":32" /> If a patient cannot do both, the collar should be replaced and additional imaging or follow-up should be pursued depending on facility guidelines.<ref name=":32" />

=== Thoracic and lumbar spine ===
The NEXUS and Canadian C-Spine rules do not apply to suspected thoracic or lumbar injury; indeed, there are currently no validated guidelines for who requires imaging in this setting.<ref name=":12" /><ref name=":32" /> Instead, imaging should be obtained according to physician gestalt.<ref name=":32" /> High-risk features include tenderness in the center spine, new numbness or weakness, or spinal fracture of another area; imaging of the thoracic and lumbar spine should be pursued in patients with these findings.<ref name=":32" /><ref name=":4" /> If a patient's cervical spine has been cleared, but they have a thoracic or lumbar spine injury, the cervical collar can be removed but they must maintain thoracolumbar immobilization using a firm padded bed and careful maneuvers for transfers and repositioning.<ref name=":4" />

If a person has new numbness or weakness but without evidence of a spinal fracture on CT-scan, they may have [spinal cord injury without radiographic abnormality (SCIWORA)](/source/SCIWORA), and may require MRI to confirm or rule out the diagnosis.<ref name=":4" /> Spinal precautions should be maintained while pursuing further imaging.<ref name=":4" />

== Postoperative ==
[[File:Teardrop_fracture.jpg|thumb|Fracture of the cervical spine (left red arrow showing vertebral body fracture) treated with [open reduction and internal fixation](/source/open_reduction_and_internal_fixation) (ORIF) (hardware seen on the right)]]
Patients with spinal cord injury due to trauma tend to have other life-threatening traumatic injuries or complications of spinal cord injury such as [neurogenic shock](/source/neurogenic_shock)<ref name=":4" /> that take precedence to repair of the spine.<ref name=":32" /> Thus, spinal motion restriction should be maintained while other medical interventions are begun.<ref name=":32" /> Neurological outcomes may be better with early spine repair when possible,<ref name=":62">{{Cite book |last=Cifu |first=David X |title=Braddom's Physical Medicine and Rehabilitation |date=2020 |publisher=[Elsevier](/source/Elsevier) |isbn=9780323625395 |edition=6th |pages=1049–1100}}</ref> however the evidence is low-quality.<ref name=":4" />

In all patients with spinal cord injury, high-quality skin care to prevent pressure ulcers is essential.<ref name=":4" /> This includes adequate cushioning, frequent repositioning of the patient, keeping the skin dry and clean, and ensuring adequate nutrition.<ref name=":4" />

After surgery for an unstable [spinal fracture](/source/spinal_fracture), methods to reduce movement of the spine vary depending on the severity of injury and method of repair.<ref name=":5" /> Surgeons strongly recommend to avoid smoking, as it slows healing.<ref name=":7">{{Cite journal |last1=Debono |first1=Bertrand |last2=Wainwright |first2=Thomas W. |last3=Wang |first3=Michael Y. |last4=Sigmundsson |first4=Freyr G. |last5=Yang |first5=Michael M. H. |last6=Smid-Nanninga |first6=Henriëtte |last7=Bonnal |first7=Aurélien |last8=Le Huec |first8=Jean-Charles |last9=Fawcett |first9=William J. |last10=Ljungqvist |first10=Olle |last11=Lonjon |first11=Guillaume |last12=de Boer |first12=Hans D. |date=May 2021 |title=Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations |journal=The Spine Journal|volume=21 |issue=5 |pages=729–752 |doi=10.1016/j.spinee.2021.01.001 |issn=1878-1632 |pmid=33444664|doi-access=free }}</ref> There is also debate that [NSAID](/source/Nonsteroidal_anti-inflammatory_drug) medications such as aspirin, ibuprofen, and naproxen may delay bone repair after spinal fusion or grafting, however there is some evidence that short-term use around the time of surgery is not associated with worse outcomes.<ref name=":7" /> Finally, patients should avoid activities that cause movement to the spine, including bending, lifting more than 5-10 pounds, or twisting the spine for 4–12 weeks after surgery.<ref name=":0">{{Cite web |title=Activities of Daily Living After Spinal Injury or Surgery - 08/2023 {{!}} Health Online |url=https://healthonline.washington.edu/record/activities-daily-living-after-spinal-injury-or-surgery |access-date=2024-11-12 |website=healthonline.washington.edu}}</ref> Patients can learn special ways to get out of bed and do other activities during this time.<ref name=":62" /> Other activities that should be avoided until a provider permits them include soaking in water like a bathtub or hottub, sports (running, horseback riding, etc.), and chores (vacuuming, sweeping, opening windows/jars etc.).<ref name=":0" />

=== Methods ===
thumb|Depiction of the halo traction device.
There are multiple devices that can be used in addition to avoiding maneuvers or activities that move the spine.<ref name=":5" /><ref name=":62" /> Long-term cervical spine immobilization in patients with cervical spine fracture who did not undergo surgery can be performed using a long-term cervical collar (Miami J,<ref name=":32" /><ref name=":5" /> Philadelphia,<ref name=":5" /> or Aspen<ref name=":5" />) or halo traction device.<ref name=":5" /><ref name=":4" /> When using a traction device such as the halo to hold the spine in place while it heals, this is called closed reduction, as opposed to a surgery which is termed [open reduction with internal fixation (ORIF)](/source/Internal_fixation).<ref name=":62" />  In general, the halo traction device is preferred for unstable fracture, while the cervical collars are used for neck sprain, stable fracture, or after surgical fixation.<ref name=":5" /> Soft cervical collars do not restrict head movement and are more so used for comfort.<ref name=":5" /> The [sternal occipital mandibular immobilizer (SOMI)](/source/Sternal_occipital_mandibular_immobilizer) can also be used to provide support for cervical spine sprain, stable fracture, or postoperative support.<ref name=":5" />

For thoracic and lumbar spine, support can be provided using custom-fit, hard-shell [back braces](/source/Thoracolumbosacral_orthosis), most commonly after surgery.<ref name=":5" />
[[File:US Navy 040723-N-8977L-008 Navy Hospital Corpsmen and Medical Officers assess the treatment and prognosis of a patient with a gunshot wound.jpg|thumb|A patient in the LA County Medical Center [intensive care unit](/source/intensive_care_unit) with a Halo orthosis in place. (July 2004)]]
These devices are used while the spine is healing and are not needed permanently.<ref name=":5" />

== History ==
Spinal precautions including prehospital use of a backboard and cervical collar were first introduced in the United States in the 1960s.<ref name="NAEMSP201423"/> Before the widespread use of spinal precautions in the 1970s, 55% of patients referred to spinal cord injury centers had [complete spinal cord injury](/source/complete_spinal_cord_injury).<ref name=":4" /> In the 1980s, spinal immobilization was initially used routinely for people who had experienced physical trauma, with little evidence to support its use.<ref name="Ot2014">{{cite journal |last1=Oteir |first1=AO |last2=Smith |first2=K |last3=Jennings |first3=PA |last4=Stoelwinder |first4=JU |date=August 2014 |title=The prehospital management of suspected spinal cord injury: an update. |journal=Prehospital and Disaster Medicine |volume=29 |issue=4 |pages=399–402 |doi=10.1017/s1049023x14000752 |pmid=25046238 |s2cid=19574297}}</ref> However, the majority of patients in the 1980s had [incomplete spinal cord injury](/source/incomplete_spinal_cord_injury), indicating an improvement in outcomes from the 1970s to the 1980s.<ref name=":4" />

The widespread use of routine spinal precautions drew criticism and prompted studies investigating the ability of EMS providers to selectively determine who required spinal precautions in the field in the late 1990s and early 2000s.<ref name=":4" /> These studies led to the 2008 recommendation by the Consortium of Spinal Cord Medicine to only immobilize high-risk patients.<ref name=":4" />

== References ==
{{reflist|32em}}

{{Emergency medical services|state=uncollapsed}}
{{Trauma}}

Category:First aid
Category:Spinal cord injury
Category:Vertebral column disorders

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Adapted from the Wikipedia article [Spinal precautions](https://en.wikipedia.org/wiki/Spinal_precautions) by Wikipedia contributors ([contributor history](https://en.wikipedia.org/wiki/Spinal_precautions?action=history)). Available under [Creative Commons Attribution-ShareAlike 4.0 International](https://creativecommons.org/licenses/by-sa/4.0/). Changes may have been made.