Cervical collars and spinal immobilization have been core elements of EMS trauma care for decades, but the evidence supporting routine immobilization has become increasingly controversial. For years, the conversation shifted from "should we place a cervical collar or use a backboard" to the broader concept of spinal motion restriction, but the focus in the literature has remained centered on "should we place a cervical collar or not," when it should instead be centered on the patient and on spinal cord protection. This is problematic because most clinicians are still at the bedside, and their train of thought often ends at "I should probably just put a cervical collar on the patient."

Recent literature, including the NAEMSP comprehensive review on prehospital spinal cord injury management, challenges long-standing assumptions that post-injury movement is a major driver of delayed neurologic injury, and highlights potential harms associated with rigid collars and backboards. While the evidence on best treatment practices for spinal cord injury is less robust than for traumatic brain injury, there are likely both management and hemodynamic considerations that should guide how we care for potential spinal cord injury patients.

This presentation will review the evolution of prehospital spinal immobilization, summarize the current evidence surrounding immobilization practices, discuss the hemodynamic factors we should be aggressively managing in these patients, such as hypotension and hypoxia, and consider how systems-level changes might best be approached. The talk will use case reports, current evidence, and best-practice models for guideline and system-level change to reframe the internal discussion from "I need a cervical collar" to "protect the spine," and to encourage patient-centered interventions rather than a focus on whether a piece of plastic makes a difference.

Outline:

1. Patient Care Practices
   A. Minimizing Movement
   • The historical basis for immobilization
   • What the current evidence suggests
   • Potential harms of routine immobilization, including special populations
   • Where the controversy remains
     B. Optimizing Hemodynamics in the Patient with Neurological Deficit
   • Hypotension
   • Hypoxia
2. Guideline Application
   • Reimagining the spinal motion restriction guideline to one that provides comprehensive care, addressing both spinal motion restriction and treatment of the potential spinal cord injury
3. System-Level Implementation
   • Updating protocols without creating confusion
   • Training EMS clinicians to move from "always collar" to risk-based decision-making
   • QA metrics to monitor
   • Aligning EMS, ED, trauma surgery, and radiology expectations
4. Take-Home Points
   • Routine cervical collar placement is no longer an automatic requirement
   • Spinal motion restriction should be selective, patient-centered, and risk-based
   • The goal is not simply to prevent movement, but to protect neurologic function by optimizing movement and hemodynamics while avoiding unnecessary harm
   • EMS clinicians need clear protocols, strong education, and trauma system alignment to apply modern spine care safely