This is an old article circa 2002 that is an excellant overview of selective spinal immobilization. Since I am having trouble finding it online anymore, I put it here for all to read and enjoy. I did not write it nor do I came any copywrite for it.

1. Selective Spinal
Immobilization
Keith Wesley, MD, FACEP
You’re called to a two vehicle 10-50 in which a trucked T-boned a car. First responders are attending to the driver of
the truck and are stabilizing his cervical spine. He states he was restrained and complains only of mild pain in his
left arm. He is awake and oriented and agrees to be transported.What do you do now? If you were to follow the
DOT curriculum to the letter, you would immediately apply a cervical collar and possibly a KED board and extricate
him from the vehicle onto a long backboard for transport.However, is that the most appropriate treatment? Are there
circumstances when spinal immobilization can be waived following trauma? Do you do it because of how you were
taught or is it simply protocol to immobilize everyone?
Until recently the general practice of EMS has been to place all trauma victims into cervical collars and onto
longboards despite their presentation and complaint. But now, research and review of our practice has shown that
there are safe and effective means to determine who does and does not require immobilization. In this article we will
review the anatomy and physiology of the spine and spinal injuries and discuss the implications of recent research
which has promoted the development of new immobilization protocols. We will examine these protocols and
determine how we might implement them in our service.
Before we go any further, it should be noted that I have not titled this topic cervical spine clearance but instead
selective spinal immobilization. As we will discover,the process of determining whether or not someone has a
spinal cord injury requires diagnostic tools unavailable to the pre-hospital provider. These tools are utilized on the
patient felt to be at a higher risk for injury and would by default arrive immobilized. Instead, we are talking about
the critical thinking process which must be undertaken to determine who does and does not require spinal
immobilization during transport.This we will term "selective immobilization."
Anatomy of the Spine
To better understand the implications of this discussion,it important that we first review the anatomy of the spine
and the types of injuries that can occur. The spinal cord exits the base of the skull through an opening called the
Foramen Magnumand extends down the length of the spinal column running through the spinal canal formed by the
vertebra. It terminates in the mid lumbar region with a tail of nerve fibers which extend downward and exit the
sacrum. While we are primarily concerned with the spinal cord itself, it is injury to the bony skeleton of the spinal
column and/or the associated soft tissue structures which results in the potential for spinal injury. The bony skeleton
consists ofseven cervical, twelve thoracic, and five lumbar vertebrae which can move when the body is in motion.
The five sacral and four coccygealbones are fused and are part of the pelvis. The movable vertebrae are supported
by ligaments and muscles to help maintain their alignment. These disks are separated by a cushion-like structure
called the intervertebral disk.
Various types of injuries can occur to the spinal column from a host of different mechanisms and a full discussion of
all of them is beyond the scope of this article. But suffice it to say,it is disruption of the integrity of the bony spinal
column which results in the injury to the spinal cord. This disruption occurs from either tearing of the ligamentous
support structures orthe compression or fracture of the bony elements. In fact, the ligamentous support is the most
crucial as their disruption determines how "unstable"

2. the likelihood of further injury occurring to the spine after the initial injury. The end result is either the compression
of the cord by bone fragments or stretching of the cord from excessive forces.
When energy is applied to the cervical spinal column as a result of trauma, it can come in multiple directions. The
cervical spine is best protected from compression and to some extent extension of the neck but poorly from flexion,
distraction, (hanging) and rotation. While it seems we are most often concerned with the cervical spine, it is
important to realize that the thoracic and lumbar spine can be injured to the same degree and by the same
mechanisms.
The next issue we must consideris that of primary and secondary injury. The primary spinal cord injury occurs at
the time of trauma with direct injury to the spinal cord. This presents immediately with neurological deficits.
Secondary injury occurs following the traumatic event and results from swelling of the cord, swelling of the
surrounding soft tissues,protrusion or herniation of the intervertebral disk or the formation of a hematoma next to
the cord. These injuries present slowly and progressively and may not be noticeable for hours, days and even months
after the injury. Spinal immobilization is theoretically based on the premise that further injury to the injured spine
will be reduced by keeping the spinal column in the natural and anatomic position.
How big is the problem?
To determine just how common these injuries are and how to discover them a multi-center study has been underway
since 1998. The National Emergency X-Radiography Utilization Study (NEXUS) is a large, multi-center, nationally
funded prospective study designed to define just how well the presence of certain physical findings can be used to
determine who does and does not have a significant spinal injury. In their initial report of 34,069 blunt trauma
patients,they found that 2.4% sustained a cervical spinal injury. The second cervical vertebra (axis) was the most
common level of injury representing 24% of the injuries. The combined injuries to the two lowest cervical vertebrae
(C6 and C7) represented 39% of the injuries. A fracture of the vertebral body was the most frequent site of fracture.
More importantly, nearly one third of the injuries were considered to be clinically insignificant.
Thoracolumbar spine injures occur in about 6% of blunt trauma or about twice as often as cervical spine injuries.
They are fairly evenly distributed between the 12th thoracic and the 3rd lumbar vertebrae accounting for 52% of the
injuries. This is easy to understand since this region is the most flexible of the lower spine.
The NEXUS and other studies examined the presence of abnormal x-ray studies which would identify the patients
with primary injuries. But what about the patient with a secondary injury who’s x-rays are normal? This condition is
called spinal cord injury without radiographic abnormality (SCIWORA) and is determined through the use of
magnetic resonance imaging (MRI). NEXUS informs us that this occurred in only 0.08% of their patients.That’s
only eight out of every 10,000 trauma patients!
More from NEXUS
The primary focus of the NEXUS research was to determine whether or not the pres ence and absence of certain
physical findings could be used to decide which blunt trauma patients can safely be excluded from having x-rays
taken to "clear" their cervical spine. These criteria were defined as 1) midline cervical tenderness,2) altered level of
consciousness,3) evidence of intoxication, 4) neurologic abnormality, and 5) presence of painful distracting injury.
Of the 34,069 patients,818 patients were found to have a cervical spine injury (CSI). Utilizing these criteria they
found that all but 8 of those with CSI and all but two of the 578 with significant CSI were identified by using these
criteria. More importantly, 29% of those with CSI and 30% of those with significant CSI met only one of the five
criteria. Therefore, neglecting to utilize ALL five criteria during the examination significantly reduced the ability of
this process to identify the patient with CSI. To put it anotherway, by using the criteria, 99.8% of the patients with
cervical spine injuries were identified. That value rivals the predictive value of a pregnancy test,an EKG, and most
of the

3. other tools we routinely use to screen patients.Moreover, using these criteria appropriately would reduce the
unnecessary use ofx-rays by more than 30% resulting in significant cost savings to the patient and healthcare in
general.
Once this study was completed, the natural question was asked, "Can these criteria be safely used in the pre-hospital
arena to selectively determine which patients warrant spinal immobilization?" The reason for this question is that it
has already been determined that patients presenting to the hospital in spinal immobilization are significantly more
likely to get x-rays merely because they have been immobilized regardless of the presence or absence of these
criteria and because the mere process of placing a blunt trauma victim in immobilization increases their complaints
of pain and therefore increases the likelihood that they would receive x-ray tests.The preliminary results are in and
the answer is yes,if the criteria are appropriately utilized.
Applying these criteria in the street
The primary reservation of applying the NEXUS criteria by EMS is the concern that EMTs may not be as proficient
as physicians in assessing the presence of the five criteria. Current studies are underway to determine whether or not
this is in fact true and therefore, organizations such as the American College of Surgeons has suggested that they be
modified to reflect the impact of mechanism of injury and otherfactors in their pre-hospital application. For
example, a deeper examination of the data indicates that CSI occurred twice as often in the elderly and in particular
that 20% of their fractures were of the second cervical vertebrae compared to only 5% or the non-geriatric group.
Further, the prevalence of CSI in children is not well documented and the ability to apply the criteria to both age
extremes appears to be difficult. Also, we know that certain mechanisms of injury just seem too great not to put the
patient in spinal immobilization regardless of how good they look. This is not a bad recommendation and gives you
more leeway in applying the criteria in the field. So let’s look at the criteria and determine how you would apply
them. We will take them in reverse order as their presence would negate the need to perform any of the others.
A painful distracting injury is any injury which is causing the patient so much pain that they don’t recognize that
their neck hurts or that they have numbness or weakness. The most common distracting injuries are obvious
fractures and severe soft tissue injuries such as large lacerations, crush injuries, burns and contusions.If you are
unable to keep the patient from concentrating on these injuries, you will be unable to proceed and shou ld immobilize
the patient.
The most common neurological abnormality is weakness. This weakness can be bilateral or only one sided.
Numbness is rare and is more commonly perceived as a "funny" feeling in the extremities such as tingling or
burning in the extremities. By asking the patient to grip your fingers with both hands and wiggle their feet you
should sufficiently exclude gross weakness.However, don’t be afraid to test individual extremities for more subtle
findings. You must ask them about numbness and attempt to determine its presence by touching or pinching the
patient in all four extremities. Any abnormality should lead to immobilization.
The presence of intoxication becomes very subjective.Merely smelling alcohol on their breath does not mean they
are intoxicated, but the most conservative approach would be to assume that any alcohol or drug use could interfere
with the patients’ability to answer your questions accurately and therefore prompt selective immobilization.
An altered level of consciousness is defined as any deviation from being fully awake and alert. Emotions such as
anxiety and apprehension must also be taken into consideration when examining the patient. A report of a loss of
consciousness,no matter how brief, should be considered an alteration even if the patient is not fully awake and
alert. In the elderly or mentally challenged patient, the presence of dementia or impaired thought process limits your
ability to perform an accurate exam.
Midline cervical tenderness is either a complaint by the patient that their neck hurts or a finding of pain on
examining the neck. The examination is performed by palpating the entire cervical spine. While

4. maintaining manual immobilization, run your finger down the posteriorcervical spine along the spinous process
from the base of the skull to the level of the shoulderblades. In this way you can be sure you have felt the entire
cervical spine.Once that is complete, ask the patient to gently turn their head from side to side, stopping if they
experience pain. Have them look up, then down, repeating the same instructions.Once all of these criteria has been
met, you may safely decide not to immobilize the patient and can address any otherinjury or complaint.
Putting this all togetherinto a protocolwould look like this chart which is adapted from the 5th edition of Mosby’s
Prehospital Trauma Life Support.This protocol incorporates the NEXUS criteria and the potential influence of
mechanism of injury and extremes of age. Most important is the caveat "Use clinical judgement, if in doubt,
immobilize."
Why not just immobilize everyone?
Certainly the safest thing to do, at least from a liability perspective,would be to immobilize everyone.But is that the
best care? Immobilization is uncomfortable. It takes time and will increase yourscene time. It increases the
likelihood that the patient will be subjected to unnecessary x-rays and it can interfere with your ability to treat the
patient’s other complaints. Further, if the patient vomits, it is difficult to maintain their airway and for the elderly
and obese,it can compromise their breathing. Like everything in medicine we must weigh the good with the bad.
So where do you go from here?
If you think this is something your service should consider, I suggest you first meet with your medical director to
discuss the issue.Provide him (or her) with the literature and give him time to research it for himself. If he still has
reservations,suggest implementing it with a strong quality improvement program such as having the ED physicians
determine whether they would or would not have immobilized the patient. For this to work they must make that
assessment based on the same criteria you did and not after getting a bunch of x-rays and CAT scans.You could
also prepare a worksheet to use in the field to record yourfindings and the criteria that you used in making your
decision. Once yourmedical director agrees,it is vital that training be developed covering spinal cord injury in
general and the specifics of how to assess each and every criteria. As stated earlier, it is critical that all five criteria
be assessed before deciding not to immobilize the patient since any one of the five may be the only indicator of an
underlying problem.
Summary
As medicine moves further along towards science, it is important that we make changes to our practice based on
sound research.NEXUS and othersimilar projects is one of the best examples of how to apply that principle.
Examine the problem, suggest a solution,and measure the effect. As more data is collected, I believe that we will
learn that EMTs can safely apply the same assessment principles in the field that are used in the hospital and
ultimately our patients will benefit from both.
Suggested Reading
1. Domeier RM: "Position Paper, National Association of EMS Physicians: Indications for prehospital spinal
immobilization," Prehospital Emergency Care. 3(3):251-253, 1999
2. Domeier RM, Evans RW, Swor RA, et al: "Prehospital clinical findings associated with spinal injury,"
Prehospital Emergency Care. 111-15, 1997
3. Goldber W, et al: "Distribution and patterns of blunt traumatic cervical spine injury." Annals of Emergency
Medicine.38:17-21, 2001
4. Hendey GW, et al: "Spinal Cord Injury without Radiographic Abnormality: Results of the National Emergency X-
Radiography Utilization Study in Blunt Cervical Trauma." Journal of Trauma. 53(1):1-4, 2002

5. 5. Hoffman JR, Wolfson AB, Todd K, Mower WR: "Selective cervical spine radiography in blunt trauma:
methodology of the National Emergency X-Radiography Utilization Study (NEXUS)." Annals of Emergency
Medicine.32(4):461-9, 1998
6. Holmes JF, et al: "Epidemiology of thoracolumbar spine injury in blunt trauma." Academic Emergency Medicine.
8(9):866-72, 2001
7. Panacek EA, et al: "Test performance of the individual NEXUS low-risk clinical screening criteria for cervical
spine injury." Annals of Emergency Medicine. 38(1):22-5, 2001
8. Stroh G, Braude D: "Can an out-of-hospitalcervical spine clearance protocol identify all patients with injuries?
An argument for selective immobilization." Annals of Emergency Medicine. 37(6)6098-615, 2001
9. Ullrich A, et al: "Distracting painful injuries associated with cervical spinal injuries in blunt trauma." Academic
Emergency Medicine. 8(1):25-9, 2001
10. Viccellio P, et al: "A prospective multicenter study of cervical spine injury in children." Pediatrics.108(2):E20,
2001
EMS Professionals November - December 2002
Dr. Wesley is Medical Director/Advisorfor the Wisconsin EMS Association,and Medical Co-director of Eau Claire
County EMS. He is the Medical Director for EMS Education and Trauma Care at Sacred Heart Hospital in Eau
Claire.