1. Purpose
To determine which trauma patients require spinal motion restriction (SMR) and which patients may safely have SMR — cervical collar and/or immobilization device — omitted.
2. Criteria for Omitting SMR
Patients for whom SMR — cervical collar and/or spinal immobilization device — is NOT necessary include those with ALL of the following present:
a. Normal level of consciousness, with no acute alteration (e.g., GCS 15) and no evidence of intoxication
b. No midline spine tenderness
c. No anatomic deformity of the spine
d. No focal neurologic findings or complaints
e. No distracting injury or distracting circumstance (e.g., long-bone fracture, degloving or crush injury, large burns, significant emotional distress, or communication barrier) that impairs the patient’s ability to provide a reliable exam
3. Situations Where a Backboard Is Not Required
A rigid backboard is NOT REQUIRED in the following situations. When SMR is indicated, a scoop stretcher, vacuum mattress, or securement directly to the ambulance cot are acceptable alternatives to the long backboard.
a. Penetrating trauma to the head, neck, or trunk without a focal neurologic deficit. SMR — including cervical collar — should NOT be applied in isolated penetrating trauma; prioritize rapid transport. If a focal neurologic deficit referable to the spine is present, apply full SMR per Section 2.
b. Isolated fall from standing position, provided Section 2 criteria are met. Use caution in patients age 65 or older or with known spinal deformity/fusion (e.g., ankylosing spondylitis) — low-energy falls carry disproportionate fracture risk in these populations. Apply the full Section 2 assessment before omitting SMR, and avoid forcing a flat supine position in a patient with fixed spinal deformity.
c. Ambulatory motor vehicle collision (MVC) patient meeting Section 2 criteria
4. Cervical Collar Application
Cervical collar application follows the same Section 2 criteria used for SMR overall. A cervical collar is NOT required when a patient meets all Section 2 criteria — including patients evaluated after nursing home or other ground-level falls. When any Section 2 criterion is present, apply an appropriately sized cervical collar as part of full SMR.
5. Positioning for Back Pain
Trauma patients with back pain should be transported in a SUPINE position. The head of the EMS stretcher may be inclined 10–20 degrees if any of the following are present:
a. Head injury
b. Respiratory compromise
c. Morbid obesity
When SMR is indicated, it should extend to the entire spine — head, neck, and torso maintained in alignment — not the cervical region alone. If the head of the device is elevated, maintain neck-to-torso alignment throughout.
6. Spinal Precautions and Device Removal
Whether or not a patient is secured on a backboard, spinal PRECAUTIONS should always be observed, i.e., limited movement and securing to the EMS stretcher.
Once a patient is safely secured to the ambulance cot, the backboard or scoop stretcher may be removed if sufficient trained personnel are present to minimize movement during the transfer. Weigh the benefit of removal against expected transport time and the risk of further spinal movement — if transport time is short, it may be preferable to transport on the device and remove it at the receiving facility. Minimizing time on a rigid backboard reduces the risk of pressure injury, pain, and respiratory restriction.
7. Pediatric Considerations
a. Age alone should not be the basis for a decision to apply or withhold SMR.
b. Apply a cervical collar to pediatric patients if any of the following are present: complaint of neck pain; torticollis; neurologic deficit; altered mental status (GCS <15, intoxication, agitation, apnea, hypopnea, or somnolence); or involvement in a high-risk motor vehicle collision, high-impact diving injury, or substantial torso injury.
c. Use additional padding under the shoulders/torso of young children to compensate for their proportionally larger head and avoid excessive cervical flexion.
d. Minimize time on a rigid backboard in pediatric patients; use a vacuum mattress or padding if extended transport time is anticipated.
8. Approved SMR Devices
SMR may be achieved using a long backboard, scoop stretcher, vacuum mattress, or by securing the patient directly to the ambulance cot with a cervical collar in place. Device selection should minimize patient discomfort and transport delay while maintaining spinal alignment.