EMS Management of Patients with Potential Spinal Injury

Approved by the ACEP Board of Directors January 2015

The American College of Emergency Physicians believes that current out-of-hospital management practices of patients with potential spinal injury lack evidentiary scientific support.  Practices which attempt to produce spinal immobilization include the use of backboards, cervical collars,straps, tape, and similar devices (e.g., sand bags, head wedges).  Evolving scientific evidence demonstrates that some of these current out-of-hospital care practices cause harm including airway compromise, respiratory impairment, aspiration,tissue ischemia, increased intracranial pressure, and pain, and can result in increased use of diagnostic imaging and mortality. 

Historically, the terms "spinal immobilization" and "spinal motion restriction" have been used synonymously. However, true "spinal immobilization" is impossible."Spinal motion restriction" in this policy refers to the preferred practice, which attempts to maintain the spine in anatomic alignment and minimizes gross movement, and does not mandate the use of specific adjuncts.

EMS medical directors should provide evidence-based spinal motion restriction protocols and procedures that describe specific indications and contraindications for application of spinal motion restriction. The role of adjuncts (e.g.,cervical collars) should be specifically addressed. The use of spinal motion restriction procedures and adjuncts should not interfere with critical airway management and other time-critical interventions, such as hemorrhage control, or rapid transport.  Spinal motion restriction procedures may require modification for certain conditions (e.g., rescue, vehicle racing,contact or extreme sports) as determined by the EMS medical director.

Spinal motion restriction should be considered for patients who meet validated indications such as the NEXUS criteria or Canadian C-Spine rules. Spinal motion restriction should be considered for patients with plausible blunt mechanism of injury and any of the following:

  • Altered level of consciousness or clinical intoxication
  • Mid-line spinal pain and/or tenderness
  • Focal neurologic signs and /or symptoms (e.g., numbness and/or motor weakness)
  • Anatomic deformity of the spine
  • Distracting injury

Backboards should not be used as as therapeutic intervention or as a precautionary measure either inside or outside the hospital or for inter-facility transfers.  Spinal immobilization should not be used for patients with penetrating trauma without evidence of spinal injury.

EMS medical directors should assure EMS providers are properly educated on assessing risk for spinal injury and neurologic assessment, as well as on performing patient movement in a manner that limits additional spinal movement inpatients with potential spinal injury.   Patient movement and transfer practices should be coordinated with receiving facility personnel.


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