Potential Neck/Spinal Injury
Spinal Motion Restriction (SMR) for low-risk spinal cord injury (ages 16-65)
Definitions
Spinal precautions: Gently maintain midline alignment (by patient or provider) during assessment
Spinal motion restriction: Cervical collar, firm surface, backboard, straps
Start with spinal precautions, then decide if full SMR needed based on assessment
Step 1: High-Risk Mechanism of Injury
Apply SMR if ANY of these:
- Penetrating trauma to head/neck
- Multi-trauma
- High speed MVC (>100km/h), rollover, ejection, death in same vehicle
- MVC with bus or large/heavy vehicle
- Axial load to head (diving, object fall from above)
- ATV/recreational vehicle collision or rollover
- Bicyclist/pedestrian struck by vehicle
- Sports contact injuries
- Falls from standing height or greater
- Diving and submersion injuries
- Electrocution/lightning strike
- Explosions
Step 2: Clinical Presentation (PCP, RPN, LPN, RN, ACP)
Apply SMR if ANY of these present:
- Posterior midline cervical-spine tenderness
- Sensory or motor abnormalities
- Abnormal level of alertness
- Intoxication or inability to feel pain
- Presence of distracting injuries
Step 3: Additional Risk Factors
Apply SMR if ANY of these:
- Age >65 years
- Falls >3 meters
- Prior fracture history
- Spinal surgery history
- Rheumatoid arthritis
- Ankylosing spondylitis
- COPD with frequent steroid use
Decision Rule
If high risk based on MOI → Apply SMR
If high risk based on clinical presentation → Apply SMR
If high risk based on additional factors → Apply SMR
If unsure → Apply SMR
If NOT applying SMR → Consider spinal precautions during transport
Initiating SMR
- Perform critical interventions only (protect airway)
- Brief assessment before SMR applied
- Permit self-extrication if no distracting injuries, neuro symptoms, spinal pain, high-risk features
- Brief neuro assessment after SMR (GCS, grip strength, foot movement, sensation)
- Maintain neutral alignment (requires minimum 2 people)
- Consider Gravol for nausea
- Position: Supine or semi-sitting on stretcher
- Stay with patient at all times after SMR applied
Disposition
SFA, FR, EMR, PCP, RPN, LPN, RN: Once SMR applied, only provider authorized to "clear" c-spines may discontinue
ACP, RN (EM/CC): Follow Canadian C-Spine Rule or Nexus Criteria per training
⚠️ Caution: Vomiting, supine, secured patient unable to protect airway. Minimize backboard time to reduce complications.
Source: Odyssey Medical Consulting
Version: 2023-01-19