Case: A 71-year-old man is the restrained driver in a 25-mph front-end motor-vehicle crash (MVC). He self-extricates but experiences midline posterior neck pain and bilateral hand paresthesias. EMS applies manual in-line stabilization, moves him with minimal manipulation to the cot (to avoid prolonged backboard use), administers oxygen for an SpO₂ of 89 percent, and notes a systolic BP dropping to 92 mm Hg. He arrives hemodynamically borderline, cervical collar in place, Glasgow Coma Scale (GCS) score of 15, with persistent hand tingling. 

Background: Out-of-hospital care for suspected spinal cord injury (SCI) involves two main priorities: preventing secondary cord injury while avoiding iatrogenic harm. Traditionally, EMS focused on rigid “immobilization” (using a long backboard and rigid cervical collar) due to concerns that movement after injury could cause delayed neurological deterioration. Over the past two decades, emergency care has shifted toward selective spinal motion restriction (SMR) and the earlier removal of collars when suitable, reflecting a better understanding of risks, test accuracy, and the harms associated with prolonged immobilization.

In the ED, validated decision tools such as the NEXUS criteria and the Canadian C-Spine Rule assist in identifying very-low-risk patients who do not require imaging. When imaging is necessary, modern multidetector CT scans have been shown to outperform plain radiography in detecting clinically significant cervical spine injuries (CSIs). A large cohort from the Western Trauma Association (10,276 patients) demonstrated that CT has approximately 98.5 percent sensitivity and nearly 100 percent negative predictive value for such injuries. They also report that misses are rare and typically occur in patients with focal neurologic deficits, who then require MRI. [1]

Out-of-hospital protocols are increasingly focused on reducing time spent on a backboard and avoiding prolonged collar use due to pressure injuries and other complications. The Eastern Association for the Surgery of Trauma (EAST) systematic review supports collar removal after a negative high-quality CT in obtunded adults, emphasizing the downstream harm caused by extended immobilization without additional benefit.[2] 

Pediatrics and geriatrics remain special populations. NEXUS demonstrated high sensitivity in children, although confidence intervals are wider in the very young. Clinicians should maintain a low threshold for imaging in older adults, who are vulnerable to serious CSI from low-energy mechanisms.[3]

Clinical Question: In trauma patients suspected of SCI, what evidence supports the idea that movement after injury leads to delayed neurological worsening? Additionally, what are the benefits and harms of out-of-hospital spinal immobilization and spinal motion restriction?

Reference: Millin MG, Innes JC, King GD, et al. Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries – A NAEMSP Comprehensive Review and Analysis of the Literature. Prehosp Emerg Care. 2025 Aug 7:1-13. doi: 10.1080/10903127.2025.2541258. Epub ahead of print. PMID: 40736221.