Clear the neck and the back separately. Then know who to call within four hours.

And the standard for all of it: “Imaging for spinal injury should be performed urgently, and the images should be interpreted immediately by a healthcare professional with training and skills in this area.”

A tool has to send every answer somewhere. In four places NG41 does not say where, and this module tells you so rather than inventing a rule.

1. The patient with no high-risk and no low-risk factor

1.4.7 covers a high-risk factor, or a low-risk factor with failed rotation. 1.4.8 covers a low-risk factor with successful rotation. A patient with neither kind of factor is in neither. What NG41 does say is that the neck's range “can only be assessed safely if the person is at low risk and there are no high‑risk factors” — so this patient cannot be cleared by the rotation test, and immobilisation stays. NG41 does not state an imaging instruction for them; that is a senior decision.

2. “Pain free”

1.4.8 removes immobilisation only if the patient has low-risk factors, “are pain free and are able to actively rotate their neck 45 degrees left and right”. So a patient who rotates fully but still has spinal pain is not cleared by NG41's wording — but nor does 1.4.7 require imaging for them. This tool keeps them immobilised and flags the decision as senior.

3. What counts as “clinical signs or symptoms” in 1.5.10

Thoracolumbar imaging is “an X-ray as the first‑line investigation” for column injury without neurology (1.5.9), and then “CT if the X‑ray is abnormal or there are clinical signs or symptoms of a spinal column injury” (1.5.10). NG41 does not define those signs. Read literally, the examination findings in 1.1.7 — midline tenderness, deformity, pain on coughing — are such signs, which would make CT first-line for most patients who get this far. Read narrowly, 1.5.9 would be pointless. Local practice varies; this tool shows both rules and does not choose.

4. The cross-reference to the head injury guideline is stale

1.5.5 and 1.5.8 send head-injured patients to “section 1.5 of the NICE guideline on head injury”. NG41 was last changed in May 2021; the current head injury guideline, NG232 (May 2023), puts the brain in section 1.5 and the cervical spine in section 1.6. The intent is clearly the cervical spine section, and that is where this module points.

5. Thoracolumbar neurology in a child

NG41's paediatric MRI recommendation is written for the cervical cord and column. For a child with thoracic or lumbar neurology it gives no specific instruction. What is clear is the destination: “Transport children with suspected spinal column injury (with or without spinal cord injury) to a major trauma centre.” Discuss imaging with paediatric radiology and the paediatric spinal team.

• Adults, stepwise: manual in-line stabilisation; an appropriately sized semi-rigid collar; reassess the airway after the collar goes on; scoop stretcher; head blocks and tape, ideally in a vacuum mattress (1.1.13).
• No collar if the airway is compromised, or with known spinal deformity such as ankylosing spondylitis — “in these cases keep the spine in the person's current position.” A collar forced onto a fused, kyphotic spine can cause the injury you are trying to prevent.
• Devices can make things worse — short or wide necks, pre-existing deformity, increased pain, worsening neurology. “In uncooperative, agitated or distressed people, including children, think about letting them find a position where they are comfortable with manual in‑line spinal immobilisation.” (1.1.12)
• Children: the same stepwise approach, and consider involving family and carers, keeping infants in their car seat if possible, and scoop with blanket rolls, vacuum mattress or splints, or a Kendrick device (1.1.14).
• The longboard is for extrication only. “Do not transport people with suspected spinal injury on a longboard or any other extrication device.” (1.1.19)

For older people specifically — where lying flat in a collar causes delirium, aspiration and pressure damage — see the silver trauma module.

From NICE NG41 — adults and children

• Call immediately. The trauma team leader contacts the on-call specialist neurosurgical or spinal surgeon — in the trauma unit or the nearest major trauma centre (1.6.1–1.6.2).
• The 4-hour call. That surgeon “should contact the linked spinal cord injury centre consultant within 4 hours of diagnosis to establish a partnership of care.” (1.6.3)
• Document the neurology properly. If cord injury is suspected in anyone over 4, complete an ASIA chart as soon as possible in the ED, and record vital capacity for anyone over 7, and the ability to cough (1.9.9).
• No neuroprotective drugs: not methylprednisolone, nimodipine or naloxone (1.7.3) — and no drugs in the acute stage to prevent chronic neuropathic pain (1.7.4).
• Destination: suspected cord injury goes to a major trauma centre irrespective of transfer time unless a life-saving intervention is needed first — not directly to a spinal cord injury centre (1.3.2–1.3.5).

From AO Spine / Praxis 2024 — 18 and over only

• Blood pressure: “We suggest the augmentation of MAP to at least 75–80mmHg but not higher than 90–95mmHg in order to optimize spinal cord perfusion in acute traumatic SCI.” For 3–7 days. Weak recommendation, very low quality evidence. This replaces the older AANS/CNS target of 85–90 mmHg for 7 days.
• Which vasopressor: the guideline declines to choose — “The decision should be left to the attending physician”.
• Surgery: “We recommend that early surgery be offered as an option for adult patients with acute SCI regardless of level.” Early means decompression within 24 hours of injury. Strong recommendation, moderate quality evidence. No recommendation could be made for “ultra-early” surgery.

Hypotension

AO Spine is explicit that low blood pressure after cord injury “may occur from a combination of hypovolemia from concomitant hemorrhage and neurogenic shock.” In a trauma patient, assume bleeding until it is excluded. Neither NG41 nor the AO Spine guideline defines neurogenic shock or gives diagnostic criteria for it, so this module does not either.

• Assess pain regularly with a scale suited to the patient's age, developmental stage and cognition, and keep using the same scale the ambulance crew used (1.2.2–1.2.3).
• “For people with spinal injury use intravenous morphine as the first‑line analgesic and adjust the dose as needed to achieve adequate pain relief.” (1.2.5)
• No IV access: consider intranasal diamorphine or ketamine — off-label when NG41 was written (1.2.6).
• Ketamine in analgesic doses as a second-line agent (1.2.7).

NG41 gives no doses, and neither does this module. Use the drug monographs for adults and the paediatric tool for children.

• Suspected cord injury, any age: major trauma centre irrespective of transfer time, unless an immediate life-saving intervention such as RSI is needed first, in which case the nearest trauma unit; never direct to a spinal cord injury centre from scene.
• Adult column injury without cord injury: nearest trauma unit, unless triage says major trauma centre.
• Child with suspected column injury, with or without cord injury: major trauma centre.

For patients being transferred from the ED, NG41 1.8.14 asks for verbal and written information: the reason, where they are going (including the linked spinal cord injury centre for cord injury), and named contacts at both ends.

• It does not decide C-spine imaging after a head injury. NG232 does, and the CT head module implements it.
• It does not cover penetrating trauma. NG41 contains no recommendation about it.
• It does not give drug doses or vasopressor choices. NG41 gives none; AO Spine leaves the vasopressor to the clinician.
• It does not extend the AO Spine recommendations below 18.
• It does not fill NG41's gaps with a rule of its own. Where the guideline is silent, the result says so and hands you the decision.

• NICE NG41. Spinal injury: assessment and initial management. Published 17 February 2016; minor change to 1.5.7 in May 2021. The full Recommendations chapter, 1.1–1.10, was parsed for this module. Applies to children and adults unless a recommendation says otherwise.
• NICE NG232. Head injury: assessment and early management, May 2023 — section 1.6, cervical spine, for head-injured patients.
• Fehlings MG, Tetreault LA, Kwon BK, Evaniew N, et al. A clinical practice guideline on the timing of surgical decompression and hemodynamic management of acute spinal cord injury… : introduction, rationale, and scope. Global Spine Journal 2024;14(3 Suppl):10S–24S. AO Spine / Praxis Spinal Cord Institute. Open access, CC BY 4.0 (PMC10964894). Adults only.

Every quotation on this page is verbatim from the source named beside it.