Patients who have sustained injuries through the following mechanisms should have a rigid cervical collar if available, or some other form of cervical stabilization placed in the prehospital environment if the tactical situation allows:

- Trauma resulting in loss of consciousness or even the question of loss of consciousness due to any form of head injury.
- Trauma resulting in temporary amnesia/loss of consciousness.
- Major explosive or blast injury.
- Mechanism that produces a violent impact on the head, neck, torso or pelvis.
- Mechanism that creates sudden acceleration/deceleration or lateral bending forces on the neck or torso.
- Fall from height (vs. fall from standing).
- Ejection or fall from any motorized vehicle.
- Vehicle rollover.

The Canadian C-Spine Rule was developed to reduce unnecessary imaging of the cervical spine in low risk patients.13 The Rule was subsequently validated and applied to the prehospital setting.14 The Rule comprises the following three main questions:

1. Is there any high-risk factor present that mandates radiography (i.e. age ≥65 years, dangerous mechanism, or paresthesias in extremities)?

2. Is there any low-risk factor present that allows safe assessment of range of motion (i.e., simple rear-end motor vehicle collision, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness)?

3. Is the patient able to actively rotate neck 45° to the left and right?

When combined, the Canadian C-Spine Rule has a 100% sensitivity for ruling out clinically important cervical injuries.13 While combat injury mechanisms generally fall within the definition of a “dangerous mechanism” as listed above, dismounted Improvised Explosive Device (IED) blast injuries without associated head trauma have been found to have a low incidence of cervical spine fractures.14 Thus, it warrants consideration that injured patients without neurologic symptoms, who are ambulatory, and who have full painless range of motion of the cervical spine may not require prehospital cervical collar placement.14

Any patient complaining of neck pain or displaying neurological impairment following a trauma should have a cervical stabilization performed and maintained until the cervical spine has been “cleared” by a qualified provider.15,16 Removal of the collar may be safely performed without further radiographic imaging if the answers to the Canadian C-Spine Rule are “No” to the first question and “Yes to questions 2 and 3.

In general, patients with penetrating cervical injury from an explosive mechanism should have a cervical collar placed if possible. However, patients with isolated penetrating cervical injury who are conscious and have no neurologic signs should not have a cervical collar placed in the prehospital environment. When a blunt mechanism is combined with a penetrating injury, the cervical collar is an important protection until an unstable spinal injury is ruled out. All providers must be aware that the collar may hide other injuries as well as and developing pathology such as expanding hematoma. Patients with isolated penetrating brain injury do not require a cervical stabilization unless the trajectory suggests cervical spine involvement.17 On the battlefield, preservation of the life of the casualty and medic are of paramount importance. In these circumstances, evacuation to a more secure area takes precedence over spine immobilization.

If a patient has indications for cervical collar placement, and one had not been placed in the prehospital environment for whatever reason, the collar should be placed at the earliest opportunity. unless cervical clearance has been clearly documented in the record or directly communicated to the receiving treatment team, a rigid cervical collar should be placed at each transition in care from downrange and maintained until it is officially cleared by the receiving providers. This highlights the need for clear and consistent communication along the echelons of care.