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Who Needs Spinal Precautions?
Spinal Precautions are taken for patients with neurological deficits and those complaining of neck pain or tenderness after an injury. Examples include patients who have undergone a fall, a violent injury, a motor vehicle accident, any blunt trauma above the clavicles, or a collision injury. Spinal precautions may also be taken with patients who are found down and the mechanism of injury is unknown but trauma is suspected.

Think about this too- if you have a patient who is an unreliable historian (e.g. dementia patients, patients under the influence of drugs and/or alcohol) or a patient with altered mental status (AMS) from a head injury or one of the other gazillion reasons for AMS, the patient is not going to be able to tell you if they are having neck pain, numbness, tingling or other neurological deficits that could indicate spinal injury. So, to be on the safe side, these patients are immobilized. Also, a patient with a secondary injury or “distracting injury” may not be able to adequately assess pain in their neck.

Probably a great example of a patient needing immobilization...

In order to be cleared from spinal precautions there is certain criteria that must be met. Cover your ass! NEVER remove a cervical collar unless you have a written order from a physician who has personally viewed the radiology results or is physically present at the bedside to perform an exam. We will talk more about clearing spinal precautions later in this post.

EMS or whomever will immobilize the patient at the scene of the injury with a rigid cervical collar and often the patient will have been strapped to a backboard. I read somewhere that being strapped to a backboard will still allow a patient 5% of their normal movement, where as hard collars allow 30-50% of normal movement. Soft collars are the least restrictive and allow almost 75% of normal movement!

Cervical Collars and Cervical Traction
How do you spot spinal precaution patients in the ICU? Easy! They’ll be in skeletal traction (halo, tongs) or they’ll be wearing a rigid collar, aka Aspen, Philadelphia or Miami J or whatever the hospital is calling the latest fashion.

Aspen Collar

Halo Brace

Neuro ICU patients who have undergone spinal surgery may also be placed on spinal precautions to allow for proper healing. I have not, however, seen patients strapped to a backboard in the ICU. According to a quick Internet search, patients may be removed from the backboard without an order and would therefore need this specific order from the physician in order to be kept on a backboard. But of course, check with your facility as they may have a different policy. Remember, I’m a new nurse and far from an MD or an expert! If a patient WERE confined to a backboard, I imagine this would be extremely uncomfortable for the patient and padding would need to be provided along with skin checks to ensure skin integrity is preserved.

Spinal Precautions
Spinal precautions prevent the patient from twisting or bending the cervical spine. Head is placed in “eyes forward” with neutral neck position unless for some reason this is not possible due to anatomical defects or due to patient complaining of pain on the way to “eyes forward.” Don’t worry- it would be rare if the ICU RN were the one who was going to be placing the C-collar for the first time. But, you will occasionally need to change the pads on the C-collar and/or adjust the fit. You will also need to remove the collar in order to perform tracheostomy care. I know what you’re thinking- and I’m telling you- don’t be afraid to touch the collar you big wuss!

Adjusting C-collar & Performing Tracheostomy Care
It is required that you also have someone in the room with you to support the neck anytime you are going to remove the C-collar. Have another RN stand at the head of the bed to hold the patients neck in neutral position while you do what you need to do. If you are unsure, have an experienced nurse adjust the fit and you hold the c-spine in line from behind the patient’s bed. This way you’ll have a bird’s eye view of how it’s done. As for bed positioning, the physician needs to clarify whether the bed is to be kept flat or the head of bed can be elevated. Sometimes patients must remain flat but you can use reverse trendelenburg to sit the patient up slightly. Make sure you clarify the orders before you change the position of the bed and make sure the physician provides you with specific limits. You may see the physician order the bed LESS THAN 30 degrees (as opposed to greater than 30 degrees for Ventilator Associated Pneumonia protocol or patient’s receiving tube feeds).

Transferring Patients with Spinal Precautions
*Please refer to Logrolling blog post

Clearing Spinal Precautions
Clearing a patient from spinal precautions is not in the nurse’s scope of practice but there are a few things that might interest a new nurse and might help explain to family members why their loved one is wearing a C-collar. For a patient who is lucky enough to be wide awake, alert and oriented x3 and sober- it is easier for a physician to clear spinal precaution. Some of the criteria that may exclude patient from needing spinal precautions include a negative neurological exam, a denial of neck pain and neck tenderness, and full range of motion without pain.

A patient who has altered mental status can’t tell us if his neck hurts so he will need to have radiological studies taken before the physician can clear the spinal precautions. Again, to cover your ass, make sure you have a physician order to discontinue using spinal precautions and make sure the person you speak to has personally seen the films. Surgical patients may be required to wear a cervical collar for a certain amount of time to allow healing to take place and hopefully the surgical team has already shared this plan of care with your patient. If not, ask during rounds to better provide an answer for your patient and/or family.

If you want to learn more about clearing the c-spine, do a quick Google search for NEXUS- National Emergency X-Radiography Utilization Study or for Canadian C-spine rule.