10.4 Spinal Motion Restriction
Key Takeaways
- Spinal motion restriction is selective; the historical long-board-everyone reflex causes pain, hypothermia, and pressure injury without protecting every spine.
- A well-fitted cervical collar plus a padded, warmed vacuum mattress is the preferred flight package; the long board is mainly an extrication tool.
- Penetrating neck or torso injury generally does not need spinal motion restriction; do not delay hemorrhage control for a standing takedown.
- Helmet removal is a two-person in-line skill; a combative wrestle on a rigid board creates more spinal motion than a controlled, padded package.
- Reassess motor, sensory, and laterality after every transfer; spinal cord injury detail lives in Chapter 11.
Spinal motion restriction (SMR) is selective packaging, not a reflex long board. Domain 3.A of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests SMR because a rigid board that fit the ambulance often will not fit the aircraft door, and because two hours on unpadded plastic is a hypothermia and pressure-sore plan. Restrict the spine when the exam or the mechanism says you must. Do not board everyone who rode in a car.
Selective SMR versus board them all
Historical emergency medical services (EMS) practice put every motor-vehicle occupant on a long board with a hard collar and head blocks. That practice caused pain, respiratory restriction, pressure injuries, and missed injuries under the board. Current teaching—National Association of EMS Physicians (NAEMSP), American College of Surgeons (ACS), and Advanced Trauma Life Support (ATLS)-style practice—is selective SMR.
Apply SMR when any of the following are present:
- Midline spinal tenderness
- Focal neurologic deficit (weakness, numbness, incontinence)
- Unreliable exam: intoxication, altered mentation, a language barrier you cannot resolve, or a distracting injury that hides spinal pain
- High-risk mechanism plus an exam you cannot trust
Clear SMR when the patient is reliable, has no midline pain, has a normal neurologic exam, and has no distracting injury. Those ideas echo National Emergency X-Radiography Utilization Study (NEXUS) and Canadian C-spine teaching. They are clinical tools, not a BCEN-owned algorithm, and they do not replace imaging at the trauma center.
Penetrating neck or torso injury generally does not need SMR. Eastern Association for the Surgery of Trauma–style and NAEMSP teaching is that a missile or knife that damaged the cord has already done the anatomic damage, and a long board delays hemorrhage control. Do not withhold a collar if you have a clear deficit and it will not delay the flight. Do not delay a hypotensive stabbing for a standing takedown.
What flies: collar plus vacuum mattress
For the aircraft, a well-fitted cervical collar plus a padded, warmed vacuum mattress is the preferred SMR package. The mattress conforms, fills voids, and does not leave scapulae and occiput on a hard plank. It is kinder to door geometry: you can mold it to clear the sill without losing the shape you just set. It also steals less heat than a naked board in rotor wash—if you pad it and cover the patient. A leaking mattress is no longer restriction; re-evacuate it on the ground if you still can.
A long board is an extrication and transfer tool. Use it to get the patient out of a wreck or off pavement, then move them onto the vacuum mattress or aircraft litter before lift when you can. Flying the board the whole way is what you do when you have no mattress and no time, not because the board is better medicine. Document why the board stayed. A board that will not clear the door is not "more spinal protection"; it is a stuck package.
| Package | Flight role | Harm if misused |
|---|---|---|
| Cervical collar plus vacuum mattress | Preferred in-flight SMR | Leaks, wrinkles, and cold if unpadded |
| Long board | Extrication and short transfer | Pressure sores, hypothermia, door-geometry fights |
| Scoop stretcher | Lift with less roll | Not a two-hour mattress |
| No SMR | Reliable exam, or most penetrating neck/torso | Boarding a bleeder who needed an operating room |
Helmets, combativeness, and moving the patient
Helmet removal is a two-person skill. One provider maintains in-line stabilization from below; the other expands the helmet and lifts it off without flexing the neck. Motorcycle full-face helmets hide the airway; they almost always come off before flight. Do not cut the chin strap and yank. Sports helmets with attached shoulder pads are a special-team problem—take the helmet if you cannot manage the airway through the face mask.
A combative patient on a rigid board is worse spinal motion than a sedated patient in a mattress. Fighting against straps increases flexion, extension, and rotation. Treat hypoxia, hypoglycemia, and herniation first. Then use the least force that keeps the patient and crew safe, including rapid sequence intubation (RSI) when the airway and brain require it. Do not win a wrestling match on a long board and call it SMR.
Log-roll versus lift. A log-roll is for vomiting and for examining the back. It still rotates the spine. A coordinated lift-and-slide or scoop-stretcher close-and-lift moves the patient with less axial twist when you have the hands. Say the plan out loud. Aircraft doors punish sloppy long-axis moves; load the head in the direction the cabin requires, then re-establish alignment.
Recheck the cord after every transfer
Every stretcher-to-litter move can change the exam. After packaging, after loading, after any in-flight reposition, and at handoff, recheck:
- Glasgow Coma Scale (GCS) or Alert-Voice-Pain-Unresponsive
- Pupils and laterality
- Motor in all four limbs
- Sensory level if you can obtain one
- Collar fit and mattress vacuum
A new deficit after a move is a new injury until proven otherwise. Spinal cord injury pathophysiology, neurogenic shock, and steroid non-use live in Chapter 11. This section is the packaging decision that keeps you from causing the deficit that chapter will then have to manage.
A flight-indicated patient needs spinal motion restriction and will be in the aircraft for a 40-minute hop. Which packaging is preferred?
A hemodynamically unstable patient has a single stab wound to the anterior chest and a reliable exam without neurologic deficit. What is the correct spinal motion restriction plan?
After transferring a collared patient from the scene stretcher onto the aircraft litter, what is the flight nurse's next spinal-protection action?