Suspected Spinal Injury — Immobilisation & Care

A spinal injury that results in paralysis is devastating. But the initial injury to the spinal cord — the moment of fracture or ligament disruption — does not always cause immediate paralysis. Secondary injury occurs when a damaged, unstable spine is moved incorrectly, allowing bone fragments or displaced structures to lacerate the spinal cord. Correct handling in the first few minutes after injury can be the difference between temporary and permanent neurological damage.

This guide covers how to recognise a suspected spinal injury, how to stabilise a casualty, and how to move them only when movement is absolutely unavoidable.

---

When to Suspect a Spinal Injury

Any trauma patient who has experienced one or more of the following mechanisms must be treated as having a potential spinal injury until proven otherwise:

Mechanism	Reason
Fall from height (any height with significant impact)	Axial loading fractures the cervical or thoracic spine
High-speed vehicle accident	Deceleration forces cause flexion-extension injury
Diving injury (especially into shallow water)	Head-first impact causes cervical compression fractures
Direct blow to the head, neck, or back	Local force disrupts vertebral alignment
Sports collision (rugby, American football, equestrian)	Multiple mechanisms combine
Any unconscious trauma patient	Cannot assess symptoms — assume spinal injury until cleared
Patient found with neurological symptoms after trauma	Numbness, tingling, weakness below any level

Symptoms That Support Suspicion

• Pain or tenderness at any point along the spine (press gently on the spinous processes from neck to tailbone)
• Radiation of pain into arms or legs (nerve root irritation)
• Numbness or tingling in any extremity
• Weakness or loss of movement in limbs below the injury level
• Diaphragmatic breathing (chest breathing only, no abdominal movement) — suggests cervical cord involvement
• Priapism (sustained erection in males) — indicates spinal shock

⚠️ A conscious patient who says "I can't feel my legs" or "my hands feel strange" after trauma must be treated as having a spinal injury. Do not allow them to stand or move until assessed by trained personnel.

---

The Immobilise vs Move Dilemma

Pre-hospital spinal management has evolved significantly. Rigid cervical collars and full spinal immobilisation on a long board are no longer universally recommended by resuscitation bodies, because:

1. Rigid collars do not eliminate all spinal movement — they restrict it by approximately 50%
2. Immobilising an unconscious patient on a flat board can increase aspiration risk
3. Full immobilisation on a long board is painful and can delay recognition of other injuries
4. For penetrating trauma (stab/gunshot wounds), immobilisation is not beneficial and delays treatment

The modern guidance: manual in-line stabilisation (MILS) — holding the head in a neutral position with gentle hand support — provides adequate cervical protection for most pre-hospital situations. Full board immobilisation is largely a hospital/EMS decision.

For the first responder, the practical guidance is:

• Keep the head and neck in the position found (or gently guide to neutral if safe)
• Do not allow the patient to move independently
• Call emergency services and describe the mechanism
• Move only if the patient is in immediate danger and remaining in place will cause greater harm

---

Manual In-Line Stabilisation (MILS)

MILS is performed by holding the patient's head gently in a neutral position — spine aligned, no traction applied.

How to Perform MILS

1. Position yourself at the patient's head — kneel directly behind or above the patient's head
2. Place both hands on either side of the head — palms over the ears, fingers spread across the skull, thumbs resting on the cheekbones
3. Support without traction — hold the head still; do not pull or lift
4. Neutral position — eyes facing forward, ear in line with the shoulder, natural resting position; do not force the head into any position if it results in pain or resistance
5. Maintain until EMS arrives — or until another trained person takes over

If the head is found in a non-neutral position:

• In the conscious patient: ask the patient if moving their head to neutral causes pain or worsens symptoms — if yes, hold it where it is
• In the unconscious patient: gently bring the head to neutral unless significant resistance is encountered

Handing Off MILS

If you need to release the patient's head (to give CPR, treat another wound), place rolled clothing or a folded blanket on either side of the head to provide lateral restriction, and inform the next person taking over MILS before releasing your hands.

---

The Log Roll Technique

The log roll allows a patient with suspected spinal injury to be turned from supine to side-lying (for airway management or examination) or from side-lying to supine, while maintaining spinal alignment.

Requirements

• Minimum 3 people for a safe log roll; 4–5 is preferable
• One person controls the head — this is the team leader for this manoeuvre
• Two or three people manage the body

Technique (3-Person)

1. Team leader — kneels at head, applies MILS; gives commands
2. Person 2 — kneels at chest level; will control the shoulders and chest
3. Person 3 — kneels at hip level; will control the hips and legs

The roll:

1. Team leader: "On my count, we roll to [right/left]. Ready? Three, two, one, roll."
2. Simultaneously, persons 2 and 3 grip the patient at the hip and shoulder and roll the body as a single unit
3. The body must rotate as a rigid block — no twisting at the waist
4. The head must rotate synchronously with the body — team leader maintains in-line stabilisation throughout
5. Hold in the side-lying position for assessment or airway management
6. Return to supine using the same count-coordinated technique in reverse

---

Moving a Patient from Water

Suspected spinal injury in a drowning or swimming pool accident requires specific technique because the movement from horizontal-in-water to on-land removes the buoyancy support that has been maintaining spinal alignment.

1. In shallow water — one rescuer supports the head in MILS while another slides a flat rigid surface (surfboard, pool-side rigid board) under the patient
2. Exit from pool or sea — the rigid surface allows multiple rescuers to lift the patient horizontally from the water
3. Without a rigid support — a careful log roll on to the pool edge by multiple rescuers, with coordinated MILS, is acceptable
4. CPR priority — if the patient is in cardiac arrest, CPR takes absolute priority; remove from water as quickly as possible with minimum spinal attention to begin resuscitation

---

Improvised Cervical Collar — Limitations

A cervical collar can be improvised from:

• A folded newspaper or magazine rolled to approximately 10 cm high and 4 cm wide, wrapped around the neck and secured with triangular bandage
• A folded towel or jersey wrapped firmly around the neck

These devices provide very limited restriction of movement and are primarily useful as a reminder to others (and the patient) that the neck must not be moved. They should not be relied upon as effective immobilisation devices. Manual stabilisation is more reliable.

---

After-Rescue Care

Once the patient is on the ground or flat surface:

• Maintain MILS
• Conduct a primary survey (airway, breathing, circulation)
• If unconscious and breathing — maintain airway position with MILS rather than standard recovery position; the compromised airway outranks spinal precautions if you cannot maintain both
• Keep the patient warm — spinal shock causes vasodilation and heat loss
• Reassure the patient — "we are keeping your neck still to protect your spine while we wait for help"

---

Quick Reference

Situation	Action
Mechanism suggests spinal injury	Treat as spinal injury — keep still
Head in neutral, no pain	Maintain MILS in neutral
Head not in neutral, moving causes pain	Hold in position found
Patient wants to move	Firmly ask them not to; explain why
Must move patient (immediate danger)	Log roll with coordinated MILS
Unconscious — airway compromised	Airway management takes priority over spinal immobilisation
Water extrication	Rigid board under patient if available; coordinated horizontal lift
CPR needed	Start CPR; spinal considerations secondary
Improvised collar	Limited effectiveness — supplement with MILS
On EMS arrival	Hand over MILS directly — do not release until instructed

---

The Core Principle

In spinal injury management, the watchwords are: less is more, slower is safer, team is better. The single most dangerous action is uncoordinated, hurried movement without spinal protection. The most protective action is calm, systematic manual stabilisation while waiting for trained help — combined with the judgement to know when immediate movement is unavoidable.