When is prehospital spinal immobilisation indicated and when can it be omitted in the prehospital setting?

Prehospital Spinal Immobilisation: Indications and When to Omit

Direct Answer

Immobilize all trauma patients who cannot meet ALL five clinical clearance criteria: (1) GCS=15 with alert/oriented status, (2) no intoxicants, (3) no distracting injuries, (4) no midline cervical tenderness/pain, and (5) full active range of motion without neurological deficit. 1 If even one criterion fails, immobilization is mandatory, as clinical criteria alone miss approximately 10% of cervical spine injuries in the prehospital setting. 1

When Immobilization is Indicated

Immobilize immediately if ANY of the following are present:

• Altered mental status (GCS <15) 1
• Head injury or high-energy mechanism 1
• Intoxication from alcohol or drugs 1
• Neurological deficit or symptoms 1
• Midline cervical spine tenderness or pain 1
• Inability to perform full active range of cervical motion 1
• Significant distracting injuries (e.g., extremity fractures) 1
• Unconscious or obtunded state 1

The evidence is clear: all patients with cervical spine injury fail at least one of these preconditions, making clinical clearance highly sensitive when strictly applied. 1

When Immobilization Can Be Omitted

Omit immobilization ONLY when ALL five criteria are simultaneously met:

1. GCS = 15 with patient alert and fully oriented 1
2. No intoxicants or drugs consumed 1
3. No significant distracting injuries present 1
4. No cervical spine symptoms: no midline tenderness, no pain 1
5. Full active range of motion without neurological deficit 1

Critical caveat: This requires strict clinical judgment and application. 1 Mechanism of injury alone is unreliable—multivariate analysis shows wide confidence intervals (relative risks: 4.0–17.0 for head injury, 5.4–25.0 for high-energy mechanism), limiting its utility for excluding injury in individual patients. 1

Optimal Immobilization Technique

Use rigid cervical collar combined with head blocks and straps on a spine board when spinal motion restriction is indicated and feasible—this provides the best motion restriction (motionscore 27-45). 2, 3

Alternative techniques based on clinical scenario:

• Spine board with head blocks and straps (with or without cervical collar): Most effective overall restriction 2
• Vacuum mattress with cervical collar and head blocks: Superior alternative when spine board is impractical (motionscore 103 vs. 152 without collar/blocks) 2
• Minimal immobilization (ambulance cot, cervical collar, pillow, tape): Only for unstable patients requiring rapid transport to minimize scene time (motionscore 92) 2

Do NOT use sandbags and tape alone—this long-standing practice is not recommended due to inadequate motion restriction. 3

Critical Pitfalls to Avoid

Prolonged Immobilization Complications

Remove patients from spine boards as soon as feasible—complications escalate rapidly after 48-72 hours of immobilization: 1, 4

• Pressure sores requiring skin grafting (each costing ~$30,000) 1
• Increased intracranial pressure worsening head injury outcomes 1
• Life-threatening airway problems 1
• Ventilator-associated pneumonia and prolonged ICU stays 1
• Thromboembolic events in 7-100% with inadequate prophylaxis 1
• Among elderly patients with cervical injuries, 26.8% died primarily from respiratory complications 1

Airway Management During Immobilization

Remove the anterior portion of the cervical collar during intubation attempts while maintaining manual in-line stabilization (MILS)—leaving the collar fully in place significantly worsens glottic visualization and increases intubation failure. 5, 6, 7

Transport Considerations

Transport directly to Level 1 trauma centers within the first hours—this reduces morbidity, mortality, and improves neurological outcomes through earlier surgical intervention. 5, 6

Hemodynamic Management During Transport

Maintain systolic blood pressure >110 mmHg continuously during transport and assessment to reduce mortality. 5, 6, 7 Target mean arterial pressure ≥70 mmHg during the first week post-injury to limit neurological deterioration. 5, 6

Evidence Limitations

No randomized controlled trials exist comparing immobilization versus no immobilization in trauma patients. 8 The possibility that immobilization may increase mortality through airway compromise cannot be excluded, as airway obstruction is a major cause of preventable death. 8 However, given the catastrophic consequences of missed unstable cervical injuries and the 10% false-negative rate of clinical criteria alone, the current standard remains immobilization for all patients who fail clinical clearance criteria. 1, 3