Traditionally, EMS has immobilized all patients with potential spinal injury to include backboards and associated adjuncts (BB/AA). However, studies indicate that traditional spinal restriction with BB/AA has risks and may even cause harm in select cases. SMR has been modified to more accurately reflect appropriate indications and methods for spinal restriction. Spinal precautions for at risk patients remain paramount. This protocol does not indicate that EMS no longer immobilizes the spine; it simply provides a different means of restriction in selected patients.

Blunt trauma (falls, MVC)

1. All patients with clinical indications of a spinal injury (such as focal neurologic deficit including paralysis) and or with altered levels of consciousness (including those who are combative, confused, or intoxicated, i.e. patients who are unable to follow commands) must be immobilized with both a C- collar and a spinal restriction device (e.g., spine board, KED, vacuum splint).

2. Additionally pediatric trauma patients less than 3 years of age with a GCS of < 15 must be immobilized with both a C-collar and a spinal restriction device.

3. Other alert trauma patients, including all those listed below, should have a c-collar placed and moved with caution in-line as a unit to the cot. This does not mean on a BB.

  •  Neck pain

  •  Midline neck or spinal tenderness

  •  Pain on motion of the neck

  •  High risk mechanism (high speed MVC, fall > 10 feet, axial loading injury)

Penetrating Trauma

  •  Patients with penetrating trauma do not need to be immobilized with either a CC or BB.

  •  Delays in transport are to be minimized.

Airway or Ventilatory Management

      Patients who are immobilized and require airway and or ventilatory intervention (including intubation) may have the collar removed with in-line stabilization performed during the intervention. The collar should then be reapplied.


  •  Patients who do not tolerate restriction (e.g., shortness of breath, anxiety, and body habitus) should have restriction adjusted to the point of removal if necessary based on clinical response. They should be maintained in the manner of restriction that they can tolerate (e.g., a patient may not tolerate a backboard but may tolerate sitting up with a c-collar).

  •  Spinal restriction devices may be utilized for movement from a site of injury to the cot. Patients who do not require restriction as above should be removed from the device prior to transport and kept in-line during transport. This is referred to as, “Move patients on hard things; transport on soft things.”

Sporting Injuries

  •  In an emergency situation with equipment intensive sports such as football, hockey and lacrosse, the protective equipment shall be removed prior to transport to an emergency faciliy

How should I determine the level of Spinal Motion Restriction for potential spinal injury?

Potential spinal injury may come from: high risk MOI including high speed MVC, falls > 10 ft., axial load injuries and blunt force above the shoulders

Full Spinal Motion Restriction

  • Patients with GCS < 15 including confusion and intoxication

  • Patients with altered LOC

  • Patients with neurologic deficits including paralysis, or clinical indications of a spinal injury

  • Patients < 3 y/o with GCS < 15

C-Collar and move in-line to cot

  • Patients with neck pain, midline neck tenderness, pain on motion of the neck

  • Patients with GCS of 15

Patients Not Requiring SMR

  • Penetrating trauma

  • Pts not falling into the other two conditions


  • Patients who require airway or ventilatory intervention may have the collar removed with inlinestabilization during the intervention

  • Patients who do not tolerate restriction should have it adjusted to the point of removal if necessary


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