Background
Spinal motion restriction (SMR) has been a cornerstone of prehospital trauma care for decades, based on the premise that immobilization prevents secondary spinal cord injury. However, a new PECARN study published in Prehospital Emergency Care reveals a striking disconnect between SMR application and actual cervical spine injury (CSI) rates in children—raising important questions about current emergency medical services (EMS) practices [1].
How We Got These Answers
This wasn’t a simple chart review or survey study—we went directly to the source. Across 18 PECARN emergency departments, we enrolled 7,721 children transported by EMS after blunt trauma between 2018 and 2021. Most importantly, EMS providers completed case report forms immediately after transferring their patients, telling us in real-time what they saw, what they did, and why they did it.
This prospective approach gave us something rare: actual provider decision-making data, not just outcomes. When we asked EMS providers directly about their reasoning, we uncovered a disconnect between clinical teaching and real-world practice.
The “Severe Mechanism” Problem: Nearly 60% of providers cited “severe mechanism of injury” as their primary reason for immobilization [2]. Yet mechanism alone—the classic “high-speed MVCs get collars” mentality—isn’t predictive of actual cervical spine injury in children. As lead author Dr. Caleb Ward notes: “In our study, the single most common reason EMS clinicians said they applied SMR was a severe mechanism of injury. Mechanism of injury is not one of the factors in the recently published PECARN CSI clinical decision rule. I think we need to move away from the mindset of ‘trauma activation means cervical collar’.”
The complete picture of EMS decision-making revealed other common justifications: young age (38.6%), patient-reported neck pain (27.8%), and agency protocols (23.3%) [2]. Notably, many of these factors aren’t included in the PECARN cervical spine clinical prediction rule [3].
The Age Pattern: Interestingly, 38.6% of EMS providers said they immobilized because of “young age,” yet the data shows they’re actually less likely to immobilize very young children (22.0% for children <2 years versus 35.5-50.4% for older children) [2].
What This Means in Practice
If You’re in EMS: Stop and think about your last pediatric trauma call. Did you reach for the collar because of the mechanism (car crash, fall) or because of what you found during your assessment? Our data suggests most of us are still stuck in “big trauma = collar” mode.
Consider this reframe: Instead of asking “Was this a bad enough accident to need a collar?”, try “Does this child have signs that make me worried about their cervical spine?” The PECARN cervical spine clinical decision rule gives you those signs—altered mental status, neck pain, neurological symptoms, or significant head/torso injury [3].
If You’re in the ED: You’re getting a lot of immobilized kids who don’t need to be. The question isn’t whether EMS was “wrong”—they’re following protocols designed to be more conservative. The question is how quickly you can safely get these kids out of uncomfortable immobilization.
This study gives you ammunition to advocate for faster clearance protocols in your department. When 40% of your trauma patients are immobilized but only 1.6% have injuries, there’s enormous opportunity to improve patient comfort and throughput.
The Uncomfortable Truth About Disparities
One finding that demands attention: White children were significantly more likely to be immobilized than Black and Hispanic children [2]. This isn’t about provider bias necessarily—it could reflect differences in accident types, transportation patterns, or even communication during assessment. But it’s a pattern that needs investigation.
Study Strengths and Limitations
What makes this study strong: We captured real-time decision-making from EMS providers across 18 trauma centers, giving us unprecedented insight into actual practice patterns rather than just chart documentation [2].
Key limitations to keep in mind: We received EMS case report forms for only 57% of eligible patients—though the kids we missed had similar demographics and injury rates. We relied on provider documentation of SMR use and couldn’t verify that immobilization was actually applied correctly in the field [2].
The Path Forward
This isn’t about criticizing EMS providers who are following protocols designed with patient safety in mind. It’s about evolving those protocols on a systems level to be both safe and smart. The PECARN cervical spine rule gives us a roadmap—now we need implementation strategies that work in the real world of prehospital care [3].
The next chapter of this research should focus on implementation: Can we train providers to use clinical decision tools effectively? Will it reduce unnecessary immobilization without missing injuries? Can we eliminate the demographic disparities we’re seeing?
Take home messages |
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Why is this important for patients and caregivers
If your child is in an accident and gets immobilized, the odds are overwhelming that their spine is fine. The collar and backboard are precautions, not treatments for an injury. However, these devices aren’t harmless—they can cause discomfort, pressure sores, breathing difficulties, and may lead to unnecessary medical imaging with radiation exposure.
- Neck pain, numbness, or weakness are important worrisome clues.
- Ask questions once you reach the hospital: “Why is the collar still needed?” and “When can it come off?”
References
- Ramgopal S, Ward CE, Rogers A, Goldstein SD, Leonard JC, Martin-Gill C. Application of cervical spinal motion restriction to injured children in the prehospital setting. Am J Emerg Med. 2025;90:214-218. doi:10.1016/j.ajem.2025.02.006
- Ward CE, Browne LR, Rogers AJ, et al. Prevalence and Indications for Applying Prehospital Spinal Motion Restriction in Children at Risk for Cervical Spine Injury. Prehosp Emerg Care. Published online March 12, 2025. doi:10.1080/10903127.2025.2472269
- Leonard JC, Harding M, Cook LJ, et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. 2024;8(7):482-490. doi:10.1016/S2352-4642(24)00104-4
