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Spinal Injury

Category: Trauma Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-03

Overview

Spinal injury encompasses injury to the vertebral column and/or spinal cord from trauma. The EMT-B's goal is to prevent secondary spinal cord injury by appropriate spinal motion restriction (SMR) in patients at risk for unstable spinal injury, while avoiding unnecessary immobilization of patients who do not require it.

NM protocols reflect current evidence-based practice: selective SMR based on clinical criteria rather than universal spine boarding for all trauma patients. Mechanism alone is insufficient to determine the need for SMR — clinical assessment is required.

Key Points

  • Spinal cord injury without radiographic abnormality (SCIWORA) can occur — injury can be present without visible fracture
  • Selective immobilization: not all trauma patients need c-spine immobilization; clinical assessment determines need
  • Criteria for c-collar application (per NM protocol): midline neck/spine pain or tenderness, abnormal mental status (including extreme agitation), neurologic deficit, alcohol/drug intoxication, severe/painful distracting injury, torticollis in children, or communication barrier
  • If NONE of those criteria apply: c-collar should NOT be applied
  • Penetrating neck injury: spinal immobilization without hard collar may be needed if neurologic deficits present — hard collar may impede management of active bleeding or airway
  • Long board: NM protocol states patients should NOT routinely be transported on long boards unless clinically warranted (multiple extremity fractures, unstable patient)
  • Rapid extrication WITHOUT KED: scene unsafe OR patient is in cardiac arrest

Assessment Relevance

History (history-taking): - MOI: MVC (speed, rollover, unrestrained), fall >10 feet, axial loading (diving, head strike), substantial torso injuries, ATV/snowmobile crashes - Pain or numbness/tingling in neck or spine? - Any LOC? - Weakness or sensory changes in extremities?

Physical exam (secondary-assessment): - Mental status: can a reliable assessment be performed? Intoxication or AMS → apply c-collar - Midline neck palpation: pain or tenderness (even mild) → c-collar - Neuro exam: PMS (Pulse, Motor, Sensation) all four extremities; grip strength, ability to wiggle toes - Evidence of axial loading: head/spine pain from vertical fall or head-first impact

Clinical clearance criteria (to NOT apply c-collar): 1. No midline neck or spine pain 2. No midline tenderness with palpation 3. Normal mental status (no extreme agitation, intoxication) 4. No neurologic deficits 5. No severe distracting injury 6. No torticollis (pediatric) 7. No communication barrier

If ALL criteria met, c-collar is not required.

Procedures

C-collar application (when indicated): 1. Manual c-spine stabilization established before collar application 2. Baseline PMS (pulse, motor, sensation) documented before collar 3. Measure and select correct collar size 4. Apply collar; confirm fit (two fingers between collar and neck) 5. Maintain manual stabilization until head is secured to board (if boarding) 6. Post-collar PMS reassessment

Spinal immobilization (see spinal-immobilization-supine and spinal-immobilization-seated): - Supine patient: c-collar, log roll technique to long board, body straps before head straps - Seated patient (MVC): KED device for stable patient; c-collar, KED, then transfer to board - Rapid extrication: when scene is unsafe OR patient in cardiac arrest — direct transfer to board without KED

Self-extrication (per NM 2022 protocol): - Children in booster seats and adults may be allowed to self-extricate after c-collar placed, if indicated - Infants and toddlers in car seats with built-in harness: extricate while strapped in car seat

NM Protocol Notes

From NM EMS Treatment Guidelines (2022):

EMT-B scope — spinal injury assessment: - Assess scene to determine risk of injury — mechanism ALONE does NOT determine need for c-collar - Higher-risk mechanisms: - MVCs (automobiles, ATVs, snowmobiles) - Axial loading injuries to the spine - Associated substantial torso injuries - Falls >10 feet - Assess patient in position found; initial assessment determines c-collar need

C-collar criteria (apply if ANY of these present): - Patient complains of midline neck or spine pain - Any midline neck or spinal tenderness with palpation - Any abnormal mental status (including extreme agitation) or neurologic deficit - Any evidence of alcohol or drug intoxication - Another severe or painful distracting injury - Torticollis in children - Communication barrier preventing accurate assessment

If none of above apply: patients should NOT have c-collar placed

Penetrating injuries: - Spinal motion restriction without hard cervical collar may be required in penetrating neck injuries with neurologic deficits, especially with concern for ongoing bleeding and/or airway management needs

Extrication: - Vehicles: after c-collar placed (if indicated), children in booster seats and adults may be allowed to self-extricate; infants/toddlers in built-in harness car seats: extricate while strapped in seat - Other situations: padded long board for extrication using lift-and-slide (not log-roll) technique

Long board use: - Patients should NOT routinely be transported on long boards unless clinical situation warrants it - Warranted: facilitate immobilization of multiple extremity injuries, or unstable patient where board removal delays transport/other treatment - When used: long boards should be padded or have vacuum mattress to minimize secondary injury

Helmet removal: - Football helmet: recommended to remove face mask first, then manual helmet removal (not automated devices) while keeping neck immobilized; apply occipital padding as needed to maintain neutral c-spine - Other helmet types: evidence lacking; use clinical judgment

NREMT Relevance

  • Mechanism alone does NOT determine SMR need — selective immobilization based on clinical assessment
  • C-collar criteria: any one of the criteria → apply collar
  • Manual stabilization must be maintained until head is fully secured
  • Body straps before head straps when boarding
  • PMS (pulse, motor, sensation) before and after any spinal intervention
  • Rapid extrication: unsafe scene OR cardiac arrest
  • New NM/national trend: minimize long board use; selective SMR reflects current evidence

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Spinal Injury protocol (p. 78–79)