Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

NAEMSP Position Paper on Spinal Immobilization


The current issue of Prehospital Emergency Care, the official journal of the NAEMSP (National Association of EMS Physicians), NASEMSO (National Association of State EMS Officials), NAEMSE (National Association of EMS Educators), and the NAEMT (National Association of EMTs) includes a position statement. A big deal is being made about the improvements, but that is because we have been so far in the Dark Ages with our management of potential spine injuries, that any improvement looks wonderful.

This may be the EMS equivalent of Why are you hitting your head against the wall? Because it feels so good when I stop.

Why are we still abusing our patients with potential spinal injuries? Unfortunately, the answer to this question is not as wise as Because it feels so good when we stop.

Utilization of backboards for spinal immobilization during transport should be judicious, so that the potential benefits outweigh the risks.[1]


What benefit?

Where is the evidence that this improves outcomes for patients with unstable spinal injuries?

However, the benefit of long backboards is largely unproven[1]




There are no outcomes studies that show any benefit, but there are studies that show serious harm with back boards.[2],[3],[4]

Therefore, the risk/benefit ratio has either a question mark, or a zero as the benefit.

Real risk/?

Picture credit.




Picture credit from Voodoo Medicine Man.




Picture credit.

If there were some valid evidence of some benefit to backboarding patients, this position paper might have something positive, but it is only something that can be copied from a journal to be shown to the people who apparently ignore journals.

There is one positive.

Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for:

  • Patients who are found to be ambulatory at the scene
  • Patients who must be transported for a protracted time, particularly prior to interfacility transfer
  • Patients for whom a backboard is not otherwise indicated[1]


A collar and no board?

This is still not supported by good evidence of improved outcomes, but there is evidence that it is much less likely to cause movement to an unstable spine than a back board or a KED (Kendrick Extrication Device).[5],[6]


[1] EMS spinal precautions and the use of the long backboard.
[No authors listed]
Prehosp Emerg Care. 2013 Jul-Sep;17(3):392-3. doi: 10.3109/10903127.2013.773115. Epub 2013 Mar 4.
PMID: 23458580 [PubMed – in process]

Free Full Text in PDF Download format from NAEMSP.

[2] The cause of neurologic deterioration after acute cervical spinal cord injury.
Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ.
Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6.
PMID: 11224879 [PubMed – indexed for MEDLINE]

All but two patients had complete injuries at admission. One patient with incomplete injury and another that was neurologically intact had early complete cervical cord injuries after cervical immobilization.


Four of the five patients in the early group (mean age 56 years) developed neurologic worsening during application of cervical immobilization less than 24 hours after injury.


This paper was cited by the ACS (American College of Surgeons) as a justification for spinal immobilization for blunt trauma.

[3] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).


[4] Spinal immobilisation for trauma patients.
Kwan I, Bunn F, Roberts I.
Cochrane Database Syst Rev. 2001;(2):CD002803. Review.
PMID: 11406043 [PubMed – indexed for MEDLINE]

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.

We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded.


[5] Cervical spine motion during extrication.
Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS.
J Emerg Med. 2013 Jan;44(1):122-7. doi: 10.1016/j.jemermed.2012.02.082. Epub 2012 Oct 15.
PMID: 23079144 [PubMed – in process]

The results indicated a significant decrease in movement for all motions when the driver exited the vehicle unassisted with CC protection, compared to exiting unassisted and without protection. Decreases in movement were also observed for an event (i.e., Pivot in seat) during extrication with paramedic assistance and protection. However, no movement reduction was observed in another event (i.e., Recline on board) with both paramedic assistance and protection.

In this study, no decrease in neck movement occurred for certain extrication events that included protection and assistance by the paramedics. Future work should further investigate this finding.


There is a detailed evaluation of this paper in the article below by Dr. Brooks Walsh at Mill Hill Ave Command.

[6] In order to protect the c-spine, should we stop helping?
Mill Hill Ave Command
Saturday, December 15, 2012



  1. I was curious if you’d had a chance to look over this…the target audience is wilderness medicine providers, but they have some nice stuff in there. And their recommendations are graded, which is something I’ve not yet seen from NAEMSP.