Spine Injury Protocol: When NOT to Move Someone

Mechanisms That Demand Spinal Precautions

Not all trauma requires spinal immobilization. But certain mechanisms carry enough force to fracture vertebrae even in young, healthy adults. Treat the mechanism with respect:

High-risk mechanisms:

• Motor vehicle crash with significant damage or ejection
• Fall from greater than standing height (some sources: 3× the patient's height)
• Diving into shallow water (the classic cervical spine mechanism)
• High-speed sports impact (bicycle crash, skiing collision)
• Direct blow to the head or neck
• Hanging or near-hanging
• Any penetrating trauma near the spine

Lower-risk mechanisms:

• Standing-height falls in healthy adults
• Minor sports contact
• Blunt trauma to the extremities without head/neck involvement

Neurological Symptoms: Red Flags

Any of these findings = assume spinal injury:

• Midline tenderness: Tenderness directly over the spinous processes (the bumpy midline protrusions along the spine). Not paraspinal tenderness (muscles on either side) — midline bony tenderness.
• Numbness or tingling anywhere in the body following trauma
• Weakness in any extremity
• Inability to feel sensation in the extremities when asked
• Diaphragmatic breathing only: if the patient is breathing with only the belly rising (diaphragm only, no chest wall movement), this suggests high cervical cord injury eliminating intercostal muscle function
• Priapism (persistent involuntary erection): indicates thoracic or lumbar spinal cord injury — sympathetic pathway disruption
• Loss of bowel or bladder control after trauma

Clearing the Cervical Spine in the Field

The NEXUS Low-Risk Criteria were developed for emergency departments but are applied to field scenarios by wilderness medicine practitioners.

You can clear the cervical spine (remove immobilization precautions) ONLY if all five criteria are met:

1. No midline cervical tenderness. Palpate along the midline of the neck from the base of the skull to the top of the shoulders. There should be no pain.

2. No focal neurological deficit. Normal strength and sensation in all four extremities. Ask the patient to grip your hands and compare grip strength. Ask them to push their feet against your resistance. Ask if sensation is normal throughout.

3. Normal alertness. The patient is oriented, follows commands, and gives a coherent history.

4. No intoxication. Any alcohol, drugs, or sedating medications disqualify the patient from clinical clearance.

5. No painful distracting injury. The most underappreciated criterion. A patient with a severe femur fracture may not complain of neck pain even if it is present — the femur pain is overwhelming all other input. Any severe painful injury elsewhere disqualifies clinical spine clearance.

If you cannot confirm all five, the spine is not cleared. Immobilize.

Field Immobilization: What You Can Do

Complete immobilization of the spine in the field is not achievable. The goal is meaningful reduction of movement during evacuation, particularly protecting against the most dangerous movement: axial loading (compression) and flexion-extension of the cervical spine.

Cervical Immobilization

Commercial cervical collar: Sized and applied to limit flexion-extension. Does not eliminate movement. Use as adjunct to manual stabilization and cautious movement.

Improvised cervical collar:

• Wrap a Sam splint or rigid foam into a collar shape
• Rolled clothing, bandana, or towel wrapped and taped can provide some resistance
• These improvised collars provide less reliable immobilization than commercial devices — do not rely on them alone

Manual in-line stabilization: A trained person places their hands on either side of the patient's head, maintaining neutral alignment without traction. This is the gold standard for limiting cervical movement while the patient is being moved.

Logroll Technique

When the patient must be moved or turned:

1. Assign one person to the head, maintaining neutral alignment throughout
2. Additional people control the shoulders and hips, maintaining the spine in one plane
3. The person at the head calls the roll and maintains alignment
4. Roll as a single unit — no twisting of the torso relative to the head or pelvis

Carrying and Evacuation

A patient with suspected spinal injury should be moved on a rigid surface: a long backboard, a litter, a door, wide planks, or a ladder. The surface prevents the spine from sagging in the middle during carrying.

The improvised litter for spinal injury should extend from head to feet. Secure the patient to prevent rolling. Padding around the head on both sides prevents lateral movement.

What Not to Do

Do not flex the head to the chest. Even checking for nuchal rigidity (meningitis test) is contraindicated if spinal injury is possible.

Do not apply traction. Manual in-line stabilization is neutral, not traction. Pulling on the head can worsen a distraction injury.

Do not remove a helmet on a helmeted patient unless absolutely necessary. Remove the helmet only if airway access requires it or the helmet is obstructing your assessment. Helmet removal requires two people and must be done in coordinated sequence that maintains head alignment.

Do not rush. The urgency of spinal injury evacuation is about getting the patient to surgical care for definitive treatment — not about fast movement at the scene. Fast movement without immobilization at the scene causes secondary spinal cord injury.

The Exception: Immediate Threats

When an immediate life threat is present, move the patient regardless of spinal injury risk. The sequence:

1. Remove from burning vehicle, drowning, crush — use logroll technique if possible, but do not delay life-saving action for perfect technique
2. Establish airway
3. Control massive hemorrhage
4. Then address spinal immobilization

A dead patient with a perfectly immobilized spine is not the goal.

Evacuation and Definitive Care

Spinal cord injury is a neurosurgical emergency. The window for meaningful intervention is narrow — corticosteroid administration and surgical decompression are most effective when performed early.

There is no field treatment for spinal cord injury. The treatment is getting the patient to a spinal surgery center as fast as possible while preventing additional cord damage during transport.

If you suspect spinal cord injury, every decision about movement, transport, and evacuation route should prioritize getting to advanced medical care. Evacuation by helicopter is preferred over ground transport for significant distances.