Prehospital Management of Spinal Cord Injuries
TLDR: The standard of care for neck trauma is Spinal Motion Restriction (SMR), with c-collar and backboard, because this has long been hypothesized to prevent post injury neurologic deficits, without any real data to back it up. The National Association of EMS Physicians (NAEMSP) did a big literature review going back over 100 years looking at SMR and found that there were multiple studies that showed harm with SMR and no studies that showed a definitive benefit of SMR in early care of suspected spinal injuries. So, maybe c-collars are overkill…?
The Details
Published in Prehospital Emergency Care on August 7th, 2025. A literature of review of articles dating back to 1900 was performed and out of 3944 articles, 115 were chosen. Spinal immobilization became popular during WWII based on the hypothesis that movement of a cervical spine fracture could lead to instability and irreversible damage to the spinal cord. A few case reports and case series in the 1950’s and 1960’s further asserted the hypothesis and SMR became the standard of care by the 1970’s. The authors of this review were looking to answer 4 questions through this literature review, and this is what they found:
1. What are the underlying pathophysiological causes to the phenomenon of delayed neurological injury (DNI) in the setting of trauma with a focus on movement, hypoxia, and hypoperfusion?
a. Greater evidence was found supporting hypoperfusion as the cause of DNI, which was mostly associated with systemic vascular injury. Only 2 case series showed a possible association between movement and DNI, both of the studies were confounded by hypoperfusion as a possible underlying pathophysiologic process. Both of these studies also predated MRI and CT. Eight studies showed an association between hypoperfusion and DNI, with one showing MAP’s <80mmHg during prehospital, OR, and Neuro ICU care were associated with more DNI. In addition, the studies also showed that cord edema/contusions, epidural hematomas, and vascular injuries were are potentially related causes to DNI. None of the studies identified post-injury movement as the pathophysiologic cause of DNI.
2. Does the use of a backboard or cervical collar result in patient-oriented harms, with a focus on the formation of decubitus ulcers, developing respiratory depression, causing increased intra-cranial pressure, or direct harm to the nervous system?
a. Most of the data showed a significant risk of pressure ulcers associated with backboards. C-spine immobilization has been well documented to cause pain and discomfort and result in increased radiology use. Other studies of c-spine immobilization have shown worse neurologic outcomes with c-spine immobilization in traumatic brain injury, increased ICP, and missed injuries.
3. Are backboards and cervical collars effective at preventing delayed neurologic injury or effective at immobilizing the spinal column as intended?
a. One study was which showed a possible benefit to spinal immobilization, but did not show any improvement in neurologic outcome. Other studies have shown improved neurologic outcomes in patients who did not receive spinal immobilization as compared to those that did.
4. Are there other factors that may affect the utility of backboards and cervical collars such as patient anxiety, patient anatomy, patient age, or environmental conditions?
a. C-collars were found specifically to distort anatomy in pediatric patients and respiratory compromise on older patients.
The Bottom Line
This review really challenges the dogma of spinal immobilization and suggests more potential harm overall in spinal immobilization. No studies were able to show a definitive benefit of spinal immobilization. Neurologic deficits from spinal injury are likely multifactorial and we should focus on shock and hypoperfusion. More studies need to be done to study limiting use of spinal immobilization. I think at the end of the day, this review should make us all feel a little more comfortable clinically clearing c-collars and less likely to put a c-collar on pending c-spine imaging. That collar might be causing more harm than good.
The Details
Published in Prehospital Emergency Care on August 7th, 2025. A literature of review of articles dating back to 1900 was performed and out of 3944 articles, 115 were chosen. Spinal immobilization became popular during WWII based on the hypothesis that movement of a cervical spine fracture could lead to instability and irreversible damage to the spinal cord. A few case reports and case series in the 1950’s and 1960’s further asserted the hypothesis and SMR became the standard of care by the 1970’s. The authors of this review were looking to answer 4 questions through this literature review, and this is what they found:
1. What are the underlying pathophysiological causes to the phenomenon of delayed neurological injury (DNI) in the setting of trauma with a focus on movement, hypoxia, and hypoperfusion?
a. Greater evidence was found supporting hypoperfusion as the cause of DNI, which was mostly associated with systemic vascular injury. Only 2 case series showed a possible association between movement and DNI, both of the studies were confounded by hypoperfusion as a possible underlying pathophysiologic process. Both of these studies also predated MRI and CT. Eight studies showed an association between hypoperfusion and DNI, with one showing MAP’s <80mmHg during prehospital, OR, and Neuro ICU care were associated with more DNI. In addition, the studies also showed that cord edema/contusions, epidural hematomas, and vascular injuries were are potentially related causes to DNI. None of the studies identified post-injury movement as the pathophysiologic cause of DNI.
2. Does the use of a backboard or cervical collar result in patient-oriented harms, with a focus on the formation of decubitus ulcers, developing respiratory depression, causing increased intra-cranial pressure, or direct harm to the nervous system?
a. Most of the data showed a significant risk of pressure ulcers associated with backboards. C-spine immobilization has been well documented to cause pain and discomfort and result in increased radiology use. Other studies of c-spine immobilization have shown worse neurologic outcomes with c-spine immobilization in traumatic brain injury, increased ICP, and missed injuries.
3. Are backboards and cervical collars effective at preventing delayed neurologic injury or effective at immobilizing the spinal column as intended?
a. One study was which showed a possible benefit to spinal immobilization, but did not show any improvement in neurologic outcome. Other studies have shown improved neurologic outcomes in patients who did not receive spinal immobilization as compared to those that did.
4. Are there other factors that may affect the utility of backboards and cervical collars such as patient anxiety, patient anatomy, patient age, or environmental conditions?
a. C-collars were found specifically to distort anatomy in pediatric patients and respiratory compromise on older patients.
The Bottom Line
This review really challenges the dogma of spinal immobilization and suggests more potential harm overall in spinal immobilization. No studies were able to show a definitive benefit of spinal immobilization. Neurologic deficits from spinal injury are likely multifactorial and we should focus on shock and hypoperfusion. More studies need to be done to study limiting use of spinal immobilization. I think at the end of the day, this review should make us all feel a little more comfortable clinically clearing c-collars and less likely to put a c-collar on pending c-spine imaging. That collar might be causing more harm than good.
