Is there a benefit to pre‑hospital spinal immobilisation in trauma patients?

Pre-Hospital Spinal Immobilization: Evidence-Based Recommendations

Routine rigid spinal immobilization with cervical collars and long spine boards should NOT be performed in pre-hospital trauma care, as current evidence shows no benefit in preventing neurological injury and may actually increase mortality, particularly in penetrating trauma. 1

Key Recommendation: Minimize Movement, Not Rigid Immobilization

For suspected spinal injury, have the patient remain as still as possible and activate emergency services—but avoid routine use of rigid cervical collars and long spine boards. 1

Why This Paradigm Shift?

The gradual de-emphasis and abandonment of routine spinal immobilization by professional EMS systems has not been associated with any increase in disabling spinal cord injuries, demonstrating that the traditional practice was likely unnecessary. 1

Specific Clinical Scenarios

Penetrating Trauma (Gunshot/Stab Wounds)

Do NOT perform spinal immobilization in penetrating trauma. 1

• Systematic review and meta-analysis demonstrates that routine spinal immobilization in penetrating trauma is associated with increased mortality (risk ratio 2.4,95% CI 1.07-5.41) with no beneficial effect on mitigating neurological deficits. 2
• The number needed to harm is only 66 patients (one additional death per 66 immobilized), while the number needed to treat to potentially benefit one patient is 1,032. 3
• Unadjusted mortality is twice as high in spine-immobilized penetrating trauma patients (14.7% vs 7.2%). 3
• Even in patients with direct neck injury from penetrating trauma, no study has shown benefit to immobilization. 2

Blunt Trauma

Selective immobilization based on clinical criteria is appropriate—not routine immobilization of all patients. 4, 5

When Immobilization IS Indicated:

Immobilize only when the patient fails ANY of these five criteria: 4, 5

1. Altered mental status: GCS < 15 requires immobilization 4
2. Intoxication: Any alcohol or drug intoxication mandates immobilization 4
3. Distracting injuries: Significant injuries (e.g., long-bone fractures) that may mask spinal symptoms 4
4. Midline cervical tenderness or pain: Any cervical spine symptoms require immobilization 4
5. Inability to perform full active cervical range of motion or presence of neurological deficit 4

When Immobilization Can Be Safely Omitted:

Only when ALL five criteria are simultaneously met can immobilization be safely withheld. 4, 5 This approach captures 94.9% of patients with spine injuries, and the 5% missed are predominantly stable compression or vertebral process fractures. 5

Critical Harms of Prolonged Immobilization

Remove patients from spine boards as soon as feasible—complications escalate sharply after 48-72 hours: 4

• Pressure ulcers requiring skin grafting (average cost $30,000) 4
• Increased intracranial pressure worsening outcomes in concurrent head injury 4
• Life-threatening airway problems 4
• Ventilator-associated pneumonia and prolonged ICU stays 4
• Thromboembolic events in 7-100% of patients without adequate prophylaxis 4
• Among elderly patients with cervical injuries, 26.8% die primarily from respiratory complications 4

Airway Management During Necessary Immobilization

If immobilization is required and intubation is needed, remove the anterior portion of the cervical collar while maintaining manual in-line stabilization (MILS). 4, 6

• Keeping the collar fully in place significantly worsens glottic visualization and increases intubation failure rates. 4, 6

Transport Priorities

Direct transport to a Level 1 trauma center within the first hours reduces morbidity and mortality by enabling earlier surgical intervention. 4, 6

Maintain systolic blood pressure > 110 mmHg continuously during transport to reduce mortality. 4, 6, 7

Common Pitfalls to Avoid

• Do not rely on mechanism of injury alone to determine need for immobilization—it is unreliable with wide confidence intervals (RR 4.0-17.0 for head injury). 4
• Do not routinely immobilize penetrating trauma—this increases mortality without benefit. 1, 3, 2
• Do not leave cervical collars in place during intubation attempts—remove the anterior portion while maintaining MILS. 4, 6
• Do not prolong rigid immobilization beyond 48-72 hours without definitive treatment—complications rapidly escalate. 4

Evidence Quality Note

No randomized controlled trials exist comparing spinal immobilization versus no immobilization in trauma patients. 8 The possibility that immobilization may actually increase mortality and morbidity—particularly through airway compromise, a major cause of preventable death—cannot be excluded. 8 Current recommendations are based on observational studies and systematic reviews showing lack of benefit and potential harm. 2, 9