Article

Title: Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries – A NAEMSP Comprehensive Review and Analysis of the Literature
Lead Author: Michael G. Millin
Journal: Prehospital Emergency Care
Year: 2025
DOI: 10.1080/10903127.2025.2541258

Main Objectives:

• Evaluate the longstanding hypothesis that post-injury movement leads to secondary spinal cord damage.
• Analyze the actual benefits (or lack thereof) of spinal immobilization techniques (longboard, cervical collar).
• Document potential harms associated with these interventions.
• Guide EMS practices toward evidence-based interventions rather than historical dogma.

1. Spinal immobilization: a sacred cow standing on shaky ground

Since WWII, the “don’t move or you’ll be paralyzed” mindset has been a cornerstone of prehospital spinal trauma care. Two papers from 1957 and 1966 are often cited to justify this practice, yet both are little more than case series with no control groups and questionable methodology. It’s like building a skyscraper on a foundation of Jell-O. What this review brilliantly points out is that this deeply entrenched belief, immortalized in early EMS textbooks, lacks scientific rigor and has no solid pathophysiological basis.

2. A systematic and rigorous methodology = no room for nostalgia

The NAEMSP team conducted a systematic literature review across four databases (PubMed, Embase, CINAHL, Web of Science), covering studies from 1900 to 2025. In total, 3,944 articles were screened, 769 fully read, and 115 included in the final analysis. Articles had to address one of four key research questions related to delayed neurological injury, harm, effectiveness, or contextual factors. Data extraction was standardized, double-reviewed, and the search was updated twice in 2024 and 2025. Bottom line: it was a cleanup job worthy of Marie Kondo — but with 125 years of spinal trauma clutter.

3. The real culprit? Hypoperfusion, not movement

Among the 115 selected studies, only two historical case series (Geisler 1966, Toscano 1988) suggested post-injury movement was responsible for neurological deterioration. On the other hand, eight more recent studies clearly pointed to spinal cord hypoperfusion as the leading factor. Notably, Clark (2023) and Haldrup (2020) showed improved outcomes when mean arterial pressure (MAP) exceeded 85 mmHg. In other words: it’s not about “don’t move,” it’s about “don’t underperfuse.”

4. When trying to help actually hurts

The authors don’t hold back: immobilization causes pain, respiratory compromise, increased intracranial pressure, pressure ulcers, treatment delays, and even missed diagnoses (especially in penetrating trauma). Even “gentler” alternatives like vacuum splints or soft collars are not off the hook. Attempting to help with a backboard sometimes feels like trying to put out a fire… with gasoline.

5. Does it even work? Spoiler: nope

If you’re still holding out hope that immobilization clearly prevents neurological injury…exhale. No strong study shows any definite benefit. Only one paper (Chen, 2022) suggests marginal improvement in a tiny subgroup, but its analysis is riddled with bias. Worse yet, some studies show no effect, and others reveal paradoxical increases in spinal movement because of immobilization. Yes, you read that right.

6. So… what now?

It’s time to move past the dogma and into the post-immobilization era. The focus should shift to shock management, perfusion, and patient comfort. Longboards should be reserved for active extrication only. The authors call on EMS systems to revise protocols, educate crews, and most importantly question everything we thought we knew. Spinal immobilization as a default practice? A habit with a poor risk-benefit ratio. In medicine, doing something “just in case” is no longer defensible when it likely causes more harm than good.

In the meantime follow your local protocols…but maybe don’t overreact if the patient moves a little!