What is the best position for an awake patient with a suspected spinal injury?

Best Position for an Awake Patient with Suspected Spinal Injury

For an awake patient with suspected spinal injury, maintain spinal motion restriction in a supine position with manual in-line stabilization (MILS) combined with a rigid cervical collar, avoiding any unnecessary movement. 1, 2, 3

Immediate Positioning Principles

The primary goal is to minimize cervical spine movement while maintaining airway patency and patient comfort. 4

Supine Position with Immobilization

• Keep the patient supine with the head, neck, and chest aligned in a neutral position 1, 2
• Apply manual in-line stabilization immediately upon suspicion of spinal injury 1, 2, 3
• Place a rigid cervical collar as soon as possible to supplement manual stabilization 1, 2
• The American College of Surgeons emphasizes that early spinal immobilization prevents onset or worsening of neurological deficit 1

If Lateral Positioning is Required

If the patient must be turned to the side (e.g., for vomiting or airway protection), use the HAINES position rather than standard lateral recovery position. 4, 5

• The HAINES (High Arm IN Endangered Spine) position involves raising one arm above the head in full abduction to support the head and neck 5
• This position produces less than half the cervical spine lateral flexion compared to standard lateral recovery position 5
• The American Heart Association and American Red Cross note that the HAINES position appears safer than lateral recumbent positioning for suspected cervical spine injury 4

Critical Positioning Caveats

What to Avoid

• Never use head tilt-chin lift maneuver; use jaw thrust only if airway intervention is needed 4
• Avoid the flat supine position without any immobilization devices, as this provides inadequate motion restriction 4
• Do not use passive leg raising or Trendelenburg positioning, as there is insufficient evidence for benefit and potential for harm in spinal trauma 4

Transport Considerations

• For transport, the optimal immobilization uses a spine board with head blocks and immobilization straps, with or without cervical collar 6
• A vacuum mattress with cervical collar and head blocks is an acceptable alternative when spine board use is not feasible 6
• The spine board should be used judiciously as it can cause respiratory compromise, pain, and pressure sores with prolonged use 7

Special Circumstances

Awake, Cooperative Patients

• If the patient is awake and cooperative without distracting injuries, guided self-extrication with cervical collar application shows the least spinal movement 8
• This applies primarily to extrication scenarios where the patient can follow commands 8

Patients Requiring Airway Management

• Maintain the patient supine with cervical spine in neutral axis 1, 2
• Remove only the anterior portion of the cervical collar if intubation becomes necessary, maintaining posterior stabilization 1, 2

Common Pitfalls to Avoid

Delaying immobilization in suspected spinal cord injury leads to worsening neurological outcomes 1, 2, 3

• Do not assume the absence of pain means no spinal injury; altered mental status, intoxication, and distracting injuries can mask cervical spine injury 4
• Avoid excessive movement during positioning changes; every repositioning carries risk 1
• Do not leave patients on hard spine boards longer than necessary due to risk of pressure ulcers and respiratory compromise 7
• Failing to maintain neutral head-neck-chest alignment during any position change increases risk of secondary injury 1