SMR Update


Spine Injury assessment and Spinal Motion Restriction (SMR) update and message from the Alameda County EMS Agency.

There has been an additional 28% decrease from the date of publication through 2014.

There has been an additional 28% decrease in the use of rigid backboards from the date of publication through 2014.

We have seen a tremendous reduction in the use of the hard backboard in Alameda County. As published in our Prehospital Emergency Care (PEC) peer reviewed journal, within four months of implementing our new spine injury assessment guidelines, we reduced the use of hard backboard immobilizations by 58%.  We want that trend to continue.

It all starts with a proper assessment. In emergency medicine it is important to figure out what is wrong with a patient. It is equally important to figure out what is NOT wrong with the patient and not subject them to unnecessary and potentially harmful treatments, including spine immobilization. It is clear that traditional spine immobilization causes more harm than good in subset of trauma patients. There has never been any study, or research that shows any benefit of spine immobilization.

So, that being said, we want our EMS practitioners to “clear” those patients who are clearable and not put anyone in SMR who does not need it. Simply stated:

  • If the patient is awake and alert (good mental status)
  • And their spine does not hurt (negative exam findings)
  • And everything works (motor/sensory normal)
  • Then the patient does not have an unstable spine injury requiring any degree of SMR

For those patients who do require some degree of SMR, we are strongly advocating for a “kinder and gentler” patient centric method of protecting the patient from gross movement. Self splinting, collar only, position of comfort, gurney only are all acceptable methods of protecting patients. The newly deployed half-back vacuum splints are a wonderful tool for those requiring a more significant level of SMR. The half-back can be used by itself on a gurney without a backboard, even with the patient in a semi-sitting position. We would prefer that the backboard be removed before transportation of the patient. We believe that backboard alone should NOT be used during transport for trauma patients.

Percent change in the number of procedures from 2013 to 2014

Percent change in the number of procedures from 2013 to 2014

I have used the following analogy to illustrate the point, “the backboard is like a spatula, and at some point, the burger needs to be put on a bun”. The “bun” being the gurney itself, with or without the half-back. Remember that standard backboard immobilization has never been shown to have any benefit to the patient. More recent evidence has shown significant and life threatening complications associated with the use of a hard backboard and standard strapping techniques.  In Alameda County we have an enlightened and forward thinking EMS system and are not afraid to buck the trend if evidence supports a new way of doing business. We are proud of the EMTs and Paramedics who embrace evidence based changes that will benefit to the patients we serve.

In summary, the backboard is a tool to move patients, but in most cases should be removed before transport. The gurney itself offers a reasonable level of spinal motion restriction.

Please look on our web site for dozens of article, papers, studies, policies and white papers on this topic. Go to Spine Injury Resources

Please send questions, comments, concerns to

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Alameda County EMS is a high performance EMS system located in the Bay Area of Northern California.There are over 140,000 9-1-1 call each year in the system.
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1 Comment

  1. What’s your take on the X-Collar?

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