Cervical-spine clearance and immobilisation

Cervical-spine care has two simultaneous aims: avoid harmful movement in a potentially unstable injury and avoid harm from unnecessary restriction. Begin with manual in-line stabilisation, airway and breathing care and a neurological examination. Do not force a painful or deformed neck into an arbitrary neutral position. If the airway needs intervention, open or remove the anterior collar while a trained assistant supports the head; oxygenation has priority over the device.

Clinical clearance depends on reliability. The Canadian C-spine rule first identifies high risk: age sixty-five or over, dangerous mechanism or paraesthesia. Any high-risk feature leads to imaging. If none exists, identify a low-risk feature permitting movement assessment, such as simple rear-end collision, comfortable sitting, ambulatory status, delayed neck pain or absence of midline tenderness. Only then ask for active rotation forty-five degrees each way; inability leads to imaging.

Do not apply the rule outside its context. Reduced GCS, intoxication, severe distracting injury, haemodynamic instability, inability to communicate and pre-existing cervical disease make examination unreliable. Children require age-appropriate assessment, and older adults have a lower imaging threshold. Ankylosed spines behave like long bones: fractures can be highly unstable after minor trauma, occur at several levels and be missed on plain radiographs.

CT is the preferred adult test when imaging is indicated. Reconstruct the cervical spine from appropriately acquired trauma CT, review alignment, vertebral bodies, posterior elements and prevertebral tissues and include the craniocervical and cervicothoracic junctions. A normal CT does not explain objective neurological deficit. NICE recommends MRI after CT when a neurological abnormality could be caused by spinal-cord injury, with urgent spinal-specialist input.

Movement restriction is a team skill. Use a scoop stretcher for lift and transfer, head blocks, straps and a vacuum mattress when appropriate, and minimise repeated log rolls. A rigid collar alone permits movement and can worsen airway access, aspiration, pressure, pain and agitation. Penetrating injury without neurological deficit does not automatically benefit from a collar. Record the position tolerated, device type and every area not adequately protected.

Clearance ends restrictions only when the clinical or imaging question has genuinely been resolved. Remove collars promptly after valid clearance, inspect skin and encourage safe movement. Persistent severe midline pain, objective deficit, radio-clinical discordance or inadequate CT coverage needs senior radiology and spinal discussion rather than indefinite collar use without a plan. Flexion-extension radiographs are not an acute self-directed clearance shortcut.

Handover should state mechanism, reliability, Canadian-rule features, neurological findings, imaging coverage and report, current device and the named person or team responsible for clearance. Reassess after analgesia, waking, sobriety and every transfer. At discharge, give advice on new weakness, numbness, gait, bladder or bowel change and worsening pain, with an urgent return route.