The cervical spine (C-spine) consists of the seven vertebrae in the neck that support the head and protect the spinal cord. Stabilizing this area in a trauma emergency prevents movement of an injured vertebra. Uncontrolled movement of a fractured or unstable neck bone can cause secondary injury to the spinal cord, resulting in permanent paralysis or death. Immediate manual stabilization is a paramount first-aid priority until professional medical help arrives.
Identifying a Potential Spinal Injury
The decision to stabilize the C-spine is based primarily on the mechanism of injury (MOI), since symptoms may not be immediately obvious. High-impact trauma, such as a motor vehicle collision, a fall from a significant height, or a diving accident, warrants immediate stabilization. These incidents involve forces that commonly cause vertebral damage through hyperflexion, hyperextension, or axial loading.
Any patient reporting neck pain, tenderness, or exhibiting objective neurological signs must be stabilized. These signs include numbness, tingling, weakness, or altered sensation in the extremities. If the patient has an altered mental status due to intoxication or a head injury, a C-spine injury must be presumed due to the inability to reliably assess their condition.
A high index of suspicion is necessary when a patient has a distracting injury, such as a large burn, a major long bone fracture, or severe emotional distress. These painful conditions can mask spinal injury symptoms, leading to a missed diagnosis. If the MOI suggests a spinal injury, rescuers should always operate under the “assume the worst” protocol and begin stabilization immediately.
Executing Manual In-Line Stabilization
The definitive technique a layperson should employ is Manual In-Line Stabilization (MILS), which holds the head in a neutral, anatomic position. The rescuer should position themselves at the patient’s head, kneeling or lying down, to look down the plane of the spine. This positioning allows the rescuer to maintain a continuous hold without interfering with other life-saving efforts.
Hand placement requires a firm, gentle grip to prevent rotation and flexion. The rescuer should place their hands on both sides of the patient’s head, with thumbs positioned near the temples or anterior to the ears. Fingers should extend toward and support the occiput (the bony prominence at the back of the skull). This placement cradles the head, providing maximum support while avoiding pressure on the soft tissues of the neck.
The goal is to gently guide the head back to a neutral position (the position the patient would be in if looking straight ahead). This movement must be executed slowly and carefully. If the patient reports increased pain, muscle spasm is felt, or resistance is encountered, the head must be immediately held in the position found. Avoid applying any axial traction, which means pulling the head away from the body.
This manual hold must be maintained continuously until trained Emergency Medical Services (EMS) personnel take over. The rescuer should not release the hold until definitive immobilization devices, such as professional collars and head blocks, are secured in place by the EMS team. A layperson should never attempt to apply a rigid cervical collar or a backboard, as these professional tools can cause further harm if applied incorrectly.
Scene Management and Necessary Movement
Minimizing patient movement is the primary directive in managing a suspected spinal injury scene. The patient should only be moved if an immediate environmental hazard exists, such as a fire, explosion risk, or an unstable structure that prevents safe access. The priority remains maintaining the manual hold while calling emergency services immediately.
Airway management in an unconscious patient requires C-spine precautions, necessitating the use of the jaw-thrust maneuver. Unlike the head-tilt/chin-lift technique, the jaw-thrust opens the airway by lifting the lower jaw (mandible) forward without causing neck extension. The forward movement of the jaw pulls the tongue away from the throat, securing an open passage for breathing while preserving neutral spinal alignment.
If the patient must be turned—for example, to check for injuries or to clear an airway obstruction like vomit—a coordinated log-roll maneuver is necessary. This procedure requires a minimum of three to four rescuers working in unison to move the patient as a single unit. The rescuer at the head maintains MILS, while the others maintain alignment of the torso and pelvis, ensuring the head and body move simultaneously.
Helmets, such as those worn by motorcyclists or football players, should generally be left in place because removal can cause uncontrolled head movement. However, if the helmet prevents accessing the airway to perform the jaw-thrust maneuver or if it is necessary for cardiopulmonary resuscitation (CPR), a controlled, two-person removal technique is required by trained personnel.
Immediate Stabilization for Special Circumstances
Stabilization techniques require modification when dealing with children due to their distinct anatomy. Infants and young children have a proportionally larger head size. When they lie flat on their back, their prominent occiput forces the neck into a flexed position. To achieve a neutral, in-line position, padding (such as a small rolled towel or blanket) must be placed under the shoulders and torso to elevate the trunk.
If the injured patient is found in a seated position, such as in a vehicle or a chair, MILS must be adapted to that orientation. The rescuer should approach from the front, maintaining a continuous manual hold on the head and neck using a firm grip on the bony areas of the jaw and skull. This seated hold must be maintained until EMS can apply specialized extrication devices designed to secure the spine prior to movement. The most important action remains the immediate call to 911, communicating the need for spinal precautions, and maintaining the manual hold continuously until relieved.