Hrev_master The management of spinal trauma in the pre-hospital setting is based on techniques of immobilization for prevention of secondary neurological damage in high-risk patients during transportation.1 Since the ’70s, the traditional form of Preventive Spinal Immobilization (PSI) has been carried out using a long spinal board, head blocks, and immobilization straps often associated with the placement of a cervical collar.2 The first documentation of this practice comes from the early 19th century, when pre-hospital trauma care was introduced on the battlefields of the Napoleonic Wars.3 This strategy is still adopted by many pre-hospital medical services worldwide and taught as the gold standard on many trau- ma courses. The traditional form of PSI is indeed based more on pragmatism than on high-quality studies supporting its efficacy.3 It is well demonstrated that PSI can have both psychological and physical impacts with severe and harmful consequences,4,5 including anxiety, combativeness, raised intracranial pressure,6,7 pain, discomfort,8 pressure ulcers,9 difficulties in airway manage- ment, decreased lung functional residual capacity,10 and dural sac compression.11 Furthermore, the application of PSI increases the on-scene time and consequently delays the arrival at a trauma center with a negative impact on patient outcome.12,13 A systematic review of the literature conducted between 1990 and 2020 by Hawkridge et al. demonstrated that none of the nine eligible studies reported any benefits of spinal collars in the pre-hospital setting.14 PSI is associated with higher mortality in penetrating trauma.15 In a retro- spective observational study from January 1, 2013, to December 31, 2015, including patients with traumatic injury, possible spinal trau- ma, and verified spinal trauma using hospital discharge ICD-9/10 diagnosis codes, no change in the incidence of spinal cord injury was identified following implementation of spinal motor restriction protocols, which reduced the use of long spinal boards.16 The same results have been reached in a 4-year retrospective study of patients older than 60 years with a suspected cervical spine injury (fracture or cord). After protocol implementation, the authors observed less full immobilization (59.4% to 28.1%, p<0.001), an increase in the use cervical collar only (8.9% to 27.2%, p<0.001), and less use of immobilization device (15.5% to 31.6%, p=0.003), with no diffe- rences in the incidence of neurologic deficits and mortality.17 In 2018, a joint position paper of the American College of Surgeons Committee on Trauma (ACS-COT), American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP) introduced the term “spinal motion restriction” (SMR) instead of PSI. Both terms refer to the same con- cept, but SMR emphasizes the goal of the procedure, i.e., to mini- mize unwanted movement of the potentially injured spine. SMR can be realized using a scoop stretcher, vacuum splint, ambulance cot, or another similar device to which a patient is safely secured. Indications for SMR following blunt trauma include an acutely alte- red level of consciousness (e.g., GCS < 15, evidence of intoxica- tion); midline neck or back pain and/or tenderness; focal neurologi- cal signs or symptoms (numbness or motor weakness); anatomic deformity of the spine; distracting circumstances or injuries that impair the patient’s ability to contribute to a reliable examination. High-energy trauma is no longer a criterion for spinal immobiliza- tion in the adult population.18 The current evidence base for traditional techniques used during pre-hospital extrication of trauma patients is poor and more based on pragmatism than evidence-based research. Dixon et al. demonstrated that conventional extrication techniques record up to Emergency Care Journal 2024; volume 20:12745 [Emergency Care Journal 2024; 20:12745] [page 62] Do not move! Spinal immobilization or spinal motor restriction: the long-lasting debate from the Napoleonic Wars to 2024 SIMEU policy statement Sossio Serra,1* Erika Poggiali,2* Mario Rugna,3 Fabio De Iaco,4 Lorenzo Ghiadoni5 1Emergency Department, Maurizio Bufalini Hospital, Cesena; 2Emergency Medicine Unit, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, Milan; 3Dipartimento Emergenza, Struttura Operativa Complessa 118 Firenze-Prato, Azienda USL Toscana Centro, Firenze; 4S.C. Medicina di Emergenza-Urgenza, Ospedale Maria Vittoria, ASL Città di Torino, Turin; 5Emergency Medicine Department, Pisa University Hospital; Department of Clinical and Experimental Medicine, University of Pisa, Italy *contributed equally to the work Correspondence: Sossio Serra, Emergency Department, Maurizio Bufalini Hospital, Cesena, Italy. E-mail: sossio.serra@gmail.com Key words: spinal immobilization, pre-hospital, spinal injury, trau- ma, trauma management, PHTLS, ATLS. Contributions: SS and EP drafted the manuscript. MR, FD and LG critically revised the work. All the authors approved the final version. Conflicts of interest: all the authors are members of the editorial board of Emergency Care Journal. The authors declare no potential conflict of interest, and all authors confirm accuracy. Availability of data and materials: all data underlying the findings are fully available upon reasonable request to Sossio Serra, sossio.serra@gmail.com Ethics approval and consent to participate: not applicable. Informed consent: not applicable. Received: 24 June 2024. Accepted: 24 June 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Emergency Care Journal 2024; 20:12745 doi:10.4081/ecj.2024.12745 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Non -co mmerc ial us e o nly four times more cervical spine movement during extrication than controlled self-extrication.19 Guided self-extrication is the best pri- mary route of egress from a vehicle unless it is clearly impractica- ble or unachievable20 for patients of all ages.21 For those patients who cannot self-extricate, a minimally invasive extrication appro- ach should be employed to minimize entrapment time. The correct approach should balance the benefits and risks/burdens of SMR, and all the interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provi- der safety) rather than technique-oriented (immobilization).22 In light of the new evidence, the Italian Society of Emergency Medicine (SIMEU) produced a policy statement on extrication and spinal motion restriction in trauma patients (in press. Available from July 2024 at https://www.simeu.it/w/articoli/leggi Articolo/ 302/dir). Here is a brief summary of the SIMEU recommendations: i) indications for SMR following blunt trauma include an acutely altered level of consciousness; midline neck or back pain and/or tenderness; focal neurologic signs and/or symptoms; anatomic deformity of the spine; distracting circumstances or injury or any similar injury that impairs the patient’s ability to contribute to a reliable examination; ii) penetrating trauma not requiring SMR; iii) the high energy mechanism of injury criterion alone is not an indi- cation for SMR in an adult traumatized patient; iv) the long spinal board is intended just as an extrication device and not for the trans- port of patients. It should be removed if an adequate number of trained personnel are present before the pre-hospital transport phase; v) SMR should be maintained by ensuring that the patient remains securely positioned on the ambulance cot with a cervical collar in place and ambulance bed immobilization straps; vi) a vacuum mattress with head fixation and neck support can represent a valid alternative to the rigid cervical collar; vii) in cases of into- lerance to the cervical collar or in the presence of pre-existing neck deformities (e.g., degenerative deformities in elderly patients), the SMR can be guaranteed by transport in a comfortable position using soft materials and padding in association with a head immo- bilizer and tape systems; viii) “standing take down” practice should be avoided; ix) self-extrication or minimally assisted extri- cation should be pursued as a first-line strategy in all trauma patients, except in cases of the inability of the patient to understand or follow rescuers’ instructions and injuries or conditions, acute or pre-existing, that prevent the patient from assuming or maintaining an upright position (pelvic fractures, unstable fractures of the lower limbs, etc.); x) hospitals should be prepared and equipped to carefully and quickly remove patients from a long backboard, scoop stretcher, or vacuum mattress as soon as possible after arri- val at the hospital. Safe transfer from ambulance stretcher to hos- pital bed may require the use of a slider board or similar device in order to maintain SMR during patient movement; similarly, patients can be moved safely for radiological diagnostics in the emergency room. We are aware that the process of transforming the rules of extrication and SMR will not be quick and simple because it involves altering long-standing practices. We need to remember that the management of these patients extends beyond the pre-hos- pital environment to the emergency room, where the new SMR rules offer a safe and effective strategy to avoid prolonged, useless, and potentially harmful immobilization. As a consequence, it will be essential to provide trauma patient care training not just to emergency physicians and nurses, but also to volunteer ambulance personnel who administer first aid as well as personnel from diag- nostic and imaging services. References 1. Stuke LE, Pons PT, Guy JS, et al. Pre-hospital spine immobi- lization for penetrating trauma— review and recommendations from the pre-hospital trauma life support executive committee. J Trauma 2011;71:763–9. 2. American Academy of Orthopaedic Surgeons. Committee on injuries. Emergency care and transportation of the sick and injured. Chicago, IL: The Academy; 1971. 3. Ten Brinke JG, Groen SR, Dehnad M, et al. Pre-hospital care of spinal injuries: a historical quest for reasoning and evidence. Eur Spine J 2018;27:2999-3006. 4. Kwan I, Bunn F. Effects of pre-hospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Prehosp Disaster Med 2005;20:47-53. 5. Oosterwold JT, Sagel DC, Van Grunsven PM, et al The char- acteristics and pre-hospital management of blunt trauma patients with suspected spinal column injuries: a retrospective observational study. Eur J Trauma Emerg Surg 2017;43:513– 24 6. Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury 1996;27:647-9. 7. Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia 2001;56:511-3. 8. Cordell WH, Hollingsworth JC, Olinger ML, et al. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med 1995;26:31-6. 9. Ham W, Schoonhoven L, Schuurmans MJ, Leenen LP. Pressure ulcers from spinal immobilization in trauma patients: a systematic review. J Trauma Acute Care Surg 2014;76:1131- 41. 10. Totten VY, Sugarman DB. Respiratory effects of spinal immo- bilization. Prehosp Emerg Care 1999;3:347-52. 11. Liao S, Schneider NRE, Hüttlin P, et al. Motion and dural sac compression in the upper cervical spine during the application of a cervical collar in case of unstable craniocervical junction- A study in two new cadaveric trauma models. PLoS One 2018;13:e0195215. 12. Ms R, Riffelmann M, Kunze-Szikszay N, et al. Vacuum mat- tress or long spine board: which method of spinal stabilisation in trauma patients is more time consuming? A simulation study. Scand J Trauma Resusc Emerg Med 2021;29:46. 13. Stuby L, Thurre D. Time performance of scoop stretcher ver- sus vacuum mattress for pre-hospital spinal stabilization: open- label simulation-based randomized controlled trial. Emerg Care J 2024;20:12226 14. Hawkridge K, Ahmed I, Ahmed Z. Evidence for the use of spinal collars in stabilising spinal injuries in the pre-hospital setting in trauma patients: a systematic review. Eur J Trauma Emerg Surg 2022;48:647-57. 15. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm than good? J Trauma 2010;68:115-20; discussion 120-1. 16. Castro-Marin F, Gaither JB, Rice AD, et al. Pre-hospital proto- cols reducing long spinal board use are not associated with a change in incidence of spinal cord injury. Prehosp Emerg Care 2020;24:401-10. 17. Underbrink L, Dalton AT, Leonard J, et al. New immobiliza- tion guidelines change EMS critical thinking in older adults with spine trauma. Prehosp Emerg Care 2018;22:637-44. 18. Fischer PE, Perina DG, Delbridge TR, et al. Spinal motion Editorial [page 63] [Emergency Care Journal 2024; 20:12745] Non -co mmerc ial us e o nly restriction in the trauma patient - a joint position statement. Prehosp Emerg Care 2018;22:659-61. 19. Dixon M, O'Halloran J, Cummins NM. Biomechanical analy- sis of spinal immobilization during pre-hospital extrication: a proof of concept study. Emerg Med J 2014;31:745-9. 20. Häske D, Schier L, Weerts JON, et al. An explorative, biome- chanical analysis of spine motion during out-of-hospital extri- cation procedures. Injury 2020;51:185-92. 21. Nutbeam T, Kehoe A, Fenwick R, et al. Do entrapment, injuries, outcomes and potential for self-extrication vary with age? A pre-specified analysis of the UK trauma registry (TARN). Scand J Trauma Resusc Emerg Med 2022;30:14. 22. Hawkins SC, Williams J, Bennett BL, et al. Wilderness medi- cal society clinical practice guidelines for spinal cord protec- tion: 2024 update. Wilderness Environ Med 2024;35:78S-93S. Editorial [Emergency Care Journal 2024; 20:12745] [page 64] Non -co mmerc ial us e o nly