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

Two rules sharing one guideline

NG41 clears the neck and the back by different logic. Treating them as one decision is the commonest structural mistake.

NG41 is not a single spinal-clearance rule. It contains the Canadian C-spine rule for the cervical spine (1.1.5) and a separate list of factors for the thoracic and lumbosacral spine (1.1.7). They were built from different evidence, they have different thresholds, and they hand you to different imaging. A cleared neck tells you nothing about the back, and vice versa — which is why the decision tool reports the two regions in separate boxes and never lets one clear the other.

Both sit downstream of a gate that comes first: recommendation 1.1.3. If the patient has a distracting injury, is intoxicated, is confused or has a reduced level of consciousness, is neurologically abnormal, has spinal pain or has past spinal problems — or if you simply cannot do the assessment — then “carry out or maintain full in-line spinal immobilisation.” NG41 1.4.4 No clearance rule can be used to talk yourself out of immobilising a patient you cannot examine. The rules in steps 3 and 4 decide imaging; they do not decide whether the collar stays on when a 1.1.3 factor is present.

The neck rule, and why the order is fixed

High-risk factor first. Low-risk factor second. Rotation last — and only if the first two allow it.

The Canadian C-spine rule asks three questions in a strict order. One: is there a high-risk factor that mandates imaging — age 65 or over, a dangerous mechanism, or paraesthesia in the limbs? If yes, image; do not test rotation. Two: is there a low-risk factor that makes it safe to assess movement — a simple rear-end collision, comfortable sitting, ambulatory since injury, delayed onset of neck pain, or absence of midline tenderness? A low-risk factor is what permits the rotation test; it does not clear anything on its own. Three: only then, can the patient actively rotate their neck 45° to the left and right?

The order is the whole safety mechanism. NG41 puts it plainly: the neck’s range of movement “can only be assessed safely if the person is at low risk and there are no high-risk factors.” Ask someone aged 65 with a dangerous mechanism to turn their head and you have done a dangerous test on a high-risk neck. The tool disables the rotation control until the rule allows it, and tells you which condition is blocking it.

Two further NG41 subtleties the tool surfaces rather than smooths over. The rotation test is active — the patient turns their own head; you never rotate it for them. And clearance under 1.4.8 requires the patient to be “pain free” as well as able to rotate — so a patient who turns fully but still has neck pain is not cleared by NG41’s wording, even though 1.4.7 does not mandate imaging for them either. That is a genuine gap; the tool flags it as a senior decision instead of inventing a rule.

The back — a different list, on purpose

The thoracolumbar factors are not the cervical ones with the spine swapped in. The thresholds differ.

The thoracic and lumbosacral list (1.1.7) has a different dangerous-fall height and a different age rule. The dangerous fall for the neck is more than 1 metre or 5 steps; for the back it is more than 3 metres, with landing on the feet or buttocks named specifically because axial load transmits up the column. Age 65 is a high-risk factor for the neck on its own; for the back it counts only when there is thoracic or lumbosacral pain as well.

The list also includes a mobilisation test — sit, stand, step, assess walking — which is done only if nothing else on the list applies, and stopped the moment it produces pain or neurological symptoms. And there is a deliberate ambiguity the tool will not resolve: 1.5.9 makes plain X-ray the first-line thoracolumbar study without neurology, then 1.5.10 says do CT “if the X-ray is abnormal or there are clinical signs or symptoms of a spinal column injury.” NG41 never defines 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 reach this step. Local practice varies; the tool shows both rules and does not choose.

The collar is not a free intervention

Immobilisation is a treatment with harms, and NG41 says so more clearly than most people remember.

The semi-rigid collar is often applied reflexively and left on for hours. NG41 is explicit that it can do harm: devices “could be counterproductive (for example increasing pain, worsening neurological signs and symptoms)” (1.1.12), and there are patients who should not get a collar at all. If the airway is compromised, or there is a known spinal deformity such as ankylosing spondylitis, do not force a collar — “keep the spine in the person’s current position” (1.1.13). A fused, ankylosed spine fractures with trivial force and a collar can lever it into a dangerous position.

For the agitated or distressed patient — including children — NG41 says “think about letting them find a position where they are comfortable with manual in-line spinal immobilisation” rather than fighting them into a collar (1.1.12). And 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). In older people the harms of prolonged immobilisation are amplified — see the silver trauma module.

Where NG41 stops and hands the decision away

Two common patients are not cleared by this page at all — and pretending otherwise is the error.

Head injury. If the patient also has a head injury, cervical spine imaging is decided by NICE NG232, not NG41 — and NG41 says so itself at 1.5.5 and 1.5.8. This is a whole-decision handoff, not just a change of modality: the CCR is not applied by this page to a head-injured neck; NG232 section 1.6 governs whether and how to image. When an upstream guideline defers a decision, it defers all of it — so the tool sends these patients to the CT head & C-spine module and keeps only the immobilisation advice.

There is a stale cross-reference worth knowing about: 1.5.5 and 1.5.8 cite “section 1.5 of the NICE guideline on head injury.” NG41 last changed in May 2021; the current head injury guideline NG232 (May 2023) puts the brain in 1.5 and the cervical spine in 1.6. The intent is clearly the C-spine section, and that is where the module points.

Penetrating injury. NG41 contains no recommendation about penetrating trauma — its Canadian C-spine pathway was derived in blunt injury. So the collar and clearance logic here do not apply to a stab or gunshot to the neck; see the penetrating neck module, where “no routine collar” is EAST/PHTLS guidance and explicitly not NICE.

The cord — the first hours

Once neurology suggests the cord, the pathway is about calls, perfusion, timing and what not to give.

Neurology that could be cord is treated as cord until MRI says otherwise. Image: in adults, MRI after CT “regardless of whether or not the abnormality is evident on CT” (1.5.7) — CT shows the bones, MRI shows the cord. Call: the trauma team leader contacts the on-call neurosurgical or spinal surgeon immediately (1.6.1–1.6.2); that surgeon then “should contact the linked spinal cord injury centre consultant within 4 hours of diagnosis to establish a partnership of care” (1.6.3). Document: complete an ASIA chart as soon as possible for anyone over 4, record vital capacity for anyone over 7, and note whether they can cough (1.9.9).

Do not give neuroprotective drugs: not methylprednisolone, nimodipine or naloxone (1.7.3). The apparent case for steroids rests on a single post-hoc subgroup in NASCIS II that never replicated and came at the cost of infection and other harms — see the Evidence tab. And destination: suspected cord injury goes to a major trauma centre irrespective of transfer time unless a life-saving intervention is needed first, never directly to a spinal cord injury centre from scene (1.3.2–1.3.5).

What AO Spine 2024 adds — for adults 18 and over only

Two recommendations from the AO Spine / Praxis guideline, both of which the module confines to 18+ because the guideline lists “SCI in children or adolescents (i.e., those under 18 years of age)” among the conditions it does not cover:

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

Two kinds of shock, and why the order matters

Spinal shock and neurogenic shock are different things, and confusing them is dangerous in a trauma patient.

Spinal shock is a neurological phenomenon: transient areflexia and flaccid paralysis below the level immediately after injury. It mimics a complete injury, so completeness (the AIS grade) cannot be assigned while it lasts — its resolution is marked by the return of the bulbocavernosus reflex. Do not label an injury “complete” in the ED during spinal shock.

Neurogenic shock is a haemodynamic phenomenon: hypotension with bradycardia from loss of sympathetic tone, in injuries at roughly T6 and above. The trap is that it looks like a reason to stop worrying about bleeding. AO Spine is explicit that hypotension after cord injury “may occur from a combination of hypovolemia from concomitant hemorrhage and neurogenic shock.” In a trauma patient, treat hypotension as bleeding until proven otherwise — neurogenic shock is a diagnosis of exclusion. Neither NG41 nor AO Spine defines neurogenic shock or gives diagnostic criteria, so the module does not either.