The movement away from spinal immobilization in suspected spinal trauma may be the most significant change in out-of-hospital trauma care of our lifetimes. While this may be a bold statement, it becomes more understandable as one considers the depth and breadth of this training.
From a depth standpoint, holding the cervical spine in place has for years been considered one of the first if not the first action one takes in a trauma patient after ensuring an airway. In many A-B-C trauma algorithms, “C” has stood for both “Circulation” and “C-spine”. In many cases, individuals would be tasked with holding this position as a priority until a rigid cervical collar could be applied and the patient be put on a backboard. Even as the use of backboards has been challenged, C-spine stabilization and immobilization with a rigid cervical collar have remained a deeply entrenched practice within trauma care, regardless of evidence base.
From a breadth standpoint, few techniques cross over so many practice levels as immobilization of the spine in suspected spinal trauma. This teaching applies to first aiders taking a trauma class lasting a few hours to doctorate level practitioners of emergency and trauma care. For all these individuals, immobilization of the spine for most patients and addressing it as a consideration in all trauma patients, has been a critical step in trauma care.
The fundamental premise behind this practice was the supposition that given an appropriate mechanism of injury, vertebrae of the neck or back could be fractured or the spinal cord injured, and that preventing further movement could reduce the chance of further injury including delayed neurological deficits. This was advanced as a theory in the 1940s and in subsequent decades became entrenched in trauma care of all levels, despite the fact that the theory was never subjected to the normal subsequent steps of the scientific method. There is no credible data supporting the hypothesis that post-injury movement can lead to neurological deficits or the corresponding routine and widespread practice of immobilizing potential spinal injuries.
Since the early 1990s, the wilderness medical community has been at the forefront of exploring the utility of spinal immobilization in trauma patients. In 1991 and 1993, the Rural EMS Committee in the National Association of EMS Physicians, led by Dr. Peter Goth, established a series of groundbreaking policy statements that included many of the “exceptions” now associated with wilderness medicine, including principles of selective spinal immobilization. This effort was notable in a wilderness medicine context because Goth was not only an EMS physician, but also had an extensive role in the development of modern wilderness medicine via his work with Outward Bound and then founding Wilderness Medical Associates. Supported by data from the NEXUS trial and the Canadian C-Spine Rule, both developed at the turn of the 20th into the 21st century, wilderness clinicians and first aiders more and more implemented rubrics or mnemonics designed to exclude people from needing immobilization. This shift was primarily driven by the recognition that immobilizing a patient in the wilderness necessitates a carryout, and later, recognition that this action has been shown to cause harms to the patient. Around the start of the 21st century, Dr. Marc Hauswald published a notable study in 1998 showing increased rates of subsequent neurological deficits in immobilized patients in Albuquerque when compared to patients in Malaysia who were not immobilized. Limitations of study design here were necessitated by that fact that it was considered unethical to withhold spinal immobilization in the US and thus no Institutional Review Board (IRB) would approve a more robust, prospective, controlled trial of the two approaches in an American community. In the same era, a major Cochrane Review concluded there were no high quality trials involving spinal immobilization and that the possibility this action could increase mortality and morbidity “cannot be excluded”. This review was updated in 2007 with no change to that conclusion.
As the 21st century progressed, more evidence accumulated that spinal immobilization could be harmful, while no meaningful evidence accrued suggesting it delivered a benefit. By 2013, the Wilderness Medical Society published Clinical Practice Guidelines for Spinal Immobilization in the Austere Environment, built by an expert panel led by orthopedist Dr. Robert H. Quinn. These guidelines (minimally revised in 2014) further explained and codified pathways by which patients could be selectively excluded from immobilization. In 2018, the textbook Wilderness EMS became the first edited, multiauthor EMS textbook to argue there was no requisite role for rigid cervical collars, backboards, or immobilization, and in the 2019 update to these CPGs, WMS became the first professional society to make this assertion. This same update (since revised in 2024) also contributed a major innovation to the dialogue by shifting the terminology away from “spinal immobilization” (SI, an action) to “spinal cord protection” (SCP, a goal). This goal-directed language mirrored other, similar changes in medical epistemology, including movement away from “CPR” (an action) to “resuscitation” (a goal) and “intubation” (an action) to “airway management” (a goal).
Despite all these movements towards an evidence-based approach to improve the care of patients with possible spinal cord injuries - including limiting the use of immobilization procedures - the practice has until recently remained the standard in nearly all EMS systems, including wilderness EMS ones. This is also despite the evidence that only 1-2% of trauma patients have a clinically significant spinal injury, suggesting that in the vast majority of patients this likely harmful and potentially fatal intervention was not even addressing an actual clinical pathology in the first place. This represents a massive violation of a primum non nocere (“do no harm”) medical heuristic which supposedly drives our medical decision-making and practices, as well as a violation of the principles of evidence-based medicine.
The immediate precipitant to writing this article is the 2025 publication of a comprehensive review and analysis of the literature on spinal cord injuries from the National Association of EMS Physicians. This publication, as groundbreaking as any of the ones described above, offers the most comprehensive literature review and systematic analysis to date on this topic, screening 3944 publications in a review back to 1900 on the topic. This NAEMSP review committee concluded:
There are no data in the published literature to support spinal immobilization and spinal motion restriction as standard of care. Efforts aimed to reduce the use of cervical collars should be considered, and the use of backboards and full body vacuum splints should be limited to the point in time of active patient extrication.
In the context of wilderness EMS (typically considered a merged subspecialty of wilderness medicine and EMS), this means that both primary specialty societies constituting WEMS have now published statements arguing that the existing literature on trauma management and spinal injuries does not support immobilization, rigid cervical collars, or backboards as an appropriate or evidence-based management tool for the goal of preventing further neurological deficits. While both do recognize a role for such tools in potential patient movement, based on literature analysis, both argue that they should then be immediately removed.
Further, and perhaps more important, the recent NAEMSP review identified a greater level of evidence supporting the hypothesis that hypoperfusion of the spinal cord is the cause of delayed neurological injury rather than post-injury movement. Within this context the authors also wrote that “EMS clinicians should focus on shock and hypoperfusion.”
Whether or not this moves the needle in a medical community firmly committed to the dogma of immobilization remains to be seen. However, it does constitute yet another installment in an ongoing re-evaluation of our management of this condition. In those who advocate to practice evidence-based medicine, less and less are supporting the prevailing practice of spinal immobilization of any sort and a renewed focus on resuscitation. For those still using immobilization procedures on their patients - an intervention developed more than a half century ago in the absence of any evidence - if they care about patient-centered management or evolving care based on evidence—it is time to stop that practice.