Head, Neck & Spine Injuries — Lesson 7

Overview

Learning Objectives

Know the basic anatomy of the spine and how spine injuries happen
Recognize when spine precautions are needed, and know the reference criteria higher-trained rescuers use to discontinue them
Do manual in-line stabilization and a proper logroll
Apply spinal motion restriction (SMR) with generous padding and improvised materials
Decide when a helmet stays on and when it comes off, and do a two-rescuer helmet removal without traction
Recognize and manage traumatic brain injury (TBI), including concussion
Spot the signs of increased intracranial pressure (ICP) and of a basilar skull fracture
Track level of consciousness with AVPU and know when a TBI patient needs to evacuate

A spine injury is the one you can make permanently worse with your own hands, so move slow and think first. A simple fall can injure the spinal cord and leave someone paralyzed for life. A bump on the head can cause a traumatic brain injury whose signs are subtle and still serious. At this level of training the rule is simple. If the mechanism or the symptoms suggest a possible spine injury, keep the patient still and evacuate. Deciding to discontinue spine precautions is left to higher-trained rescuers or medical direction.

So you have two jobs. With a possible spine injury, you restrict motion. With a head injury, whether it's a concussion or pressure building inside the skull, you watch for decline.

When in doubt, keep it still. If a spine injury is possible, immobilize and stabilize until someone proves otherwise. Spinal cord damage is permanent, so you err on the conservative side.

Spinal Anatomy & Injury Mechanisms

Spinal column regions

Region	Vertebrae	Location	Injury Patterns
Cervical (C)	C1-C7	Neck; the most mobile and least protected	High-risk region; injuries are often catastrophic (quadriplegia)
Thoracic (T)	T1-T12	Mid-back; protected by the rib cage	Often comes with significant trauma; spinal cord injury is common
Lumbar (L)	L1-L5	Lower back; large, weight-bearing vertebrae (the thoracic spine, braced by the rib cage, is the most rigid region)	Fractures are common. Below about L1-2 the canal holds nerve roots (the cauda equina) instead of spinal cord, and cauda equina syndrome is a surgical emergency in its own right.
Sacral (S)	S1-S5 (fused)	Lowest spine; fused to the pelvis	Part of the pelvis; fractures usually take extreme trauma

Spinal cord anatomy

The spinal cord is a bundle of nerves running through the vertebral column from the brainstem to about L1. Nerve roots branch off at each level to supply the body. Damage the cord at any level and you disrupt function below that level:

Cervical injury (C1-C4): can be fatal, because C3-C5 control breathing. Causes quadriplegia (paralysis of all four limbs).
Lower cervical injury (C5 and below): quadriplegia, with variable arm and hand function
Thoracic injury: paraplegia (paralysis of the legs)
Lumbar injury: cauda equina syndrome (variable leg paralysis, bowel and bladder dysfunction), a surgical emergency

Mechanisms of spinal injury

Axial load (compression): Force driven along the length of the spine. Examples: a diver hitting the bottom, a fall onto the buttocks with the legs straight, a fall from height landing on the feet. It causes vertebral compression fractures.

Hyperflexion: The spine bent too far forward. Examples: a head-on collision, a blow to the back of the head. It can fracture vertebrae and rupture ligaments.

Hyperextension: The spine bent too far backward. Examples: a rear-end collision, a blow to the forehead. It can cause fractures and spinal cord damage.

Rotation/distraction: Twisting or pulling forces. Examples: a rollover, a body being twisted. These are high-energy injuries, and they often come with fracture-dislocations and severe cord injury.

For reference: NEXUS criteria

Hospitals use the NEXUS criteria to decide who needs C-spine imaging. NEXUS can't rule out an injury in a patient with any of these:

Midline cervical spine tenderness
A focal neurological deficit (weakness, numbness, paralysis)
An altered level of alertness
Intoxication
A painful distracting injury

At the WFA level, a concerning mechanism (a fall of more than about 10 feet, roughly one story or about twice their height, and lower for older adults or anyone who lands on their head; a high-speed impact; an axial load) or any of the findings above is reason to keep the patient still and evacuate. If you're not sure the fall was high energy, treat it as high energy.

Wilderness Spine Assessment (WSA)

Who decides to discontinue spine precautions?

At the Wilderness First Aid level, you don't rule out a spine injury in the field. If the mechanism or the symptoms suggest a possible spine injury, keep the patient still and evacuate. Watch for a distracting injury. A broken leg or a dislocated shoulder can hurt enough to hide neck or back pain, and when they have one, their "my neck's fine" isn't reliable. Stay conservative. The decision to discontinue spine precautions belongs to rescuers with higher-level training, or to medical direction.

For reference: the Wilderness Spine Assessment criteria, used by higher-trained rescuers. Spine precautions can be discontinued only when all of these are true:

A reliable patient: calm, cooperative, sober, and alert
No spine pain and no midline tenderness when you press on it
Normal motor and sensory function in all four limbs
No significant distracting injury (one painful enough to mask spine symptoms)

If any one of them fails, or you can't finish the assessment, precautions stay on and the patient evacuates.

Manual in-line stabilization

If a spine injury is possible, stabilize the head and neck:

Hold the patient's head with a hand on each side, keeping it neutral: not bent forward, bent back, or turned (flexed, extended, or rotated)
Support the head in neutral alignment without pulling. Never apply traction to a suspected spine injury; it can make an unstable injury worse. Stop any repositioning if you meet resistance, the pain increases, or the patient reports new tingling or numbness.
Don't let the head move in any direction
Keep holding until the patient is fully immobilized on a stretcher

Logroll technique

To get a patient with a suspected spine injury from the ground onto a stretcher, logroll them so the spine stays straight.

What a logroll takes:

At least 3 rescuers: one on the head and neck, one on the torso, one on the legs
4 or more is ideal
One rescuer directs the move, usually the one holding the head. Nobody rolls until that person calls it.
Roll the patient as one unit. Don't let the spine bend or twist.
Lay them on the stretcher on their back (supine)

Spinal motion restriction (SMR)

The goal is spinal motion restriction (SMR): keep the patient still, pad generously under and around them, and stabilize the head with rolled blankets, clothing, or foam on both sides. Improvised padding is fine as long as it actually limits motion. Wilderness evacuations run long, so build in comfort and pad generously.

For reference: cervical collars. EMS may apply a rigid cervical collar, but rigid collars are de-emphasized now. They can cause pressure injuries, and they don't immobilize the neck well. A collar alone is never enough. Your hands and padding that limits motion do more than any collar.

Helmet Removal

On a motorcycle or rafting trip, a lot of head and spine injuries arrive wearing a helmet. A snug helmet splints the head much the way your hands do during manual stabilization, so there's no blanket rule about taking it off. Ask whether this helmet, on this patient, right now, helps or hurts. Mostly that comes down to the airway.

Leave it on or take it off?

Leave the helmet on when...	Take the helmet off when...
The patient is breathing adequately	You can't assess or manage the airway through it
The airway is accessible and you can monitor it	The patient is vomiting or needs rescue breathing or CPR
The helmet fits snugly and is splinting the head for you	Breathing is compromised, or the helmet is loose (a loose helmet stabilizes nothing)
Taking it off would cause more movement than leaving it on	The helmet keeps you from holding the head in neutral alignment

Full-face vs. open-face. A full-face motorcycle helmet usually has to come off for any airway problem. You can't manage an airway through a chin bar. An open-face or whitewater helmet leaves the face exposed, so a patient who's breathing can often keep it on while you stabilize and monitor. For an alert patient whose airway is open and staying open, removal is optional either way. Leave a snug helmet on, or take it off with two rescuers if it's getting in the way of care on a long carry.

Preparation first

Before the helmet moves, set up. One rescuer holds the head still through all of it:

Tell a conscious patient exactly what you're about to do
Raise the visor all the way
Take off the patient's glasses or goggles
Unbuckle the chin strap, or cut it if the buckle fights you
Remove the cheek pads if the design allows. Many full-face helmets have pull-out pads, and taking them out makes room and cuts down on movement.

Two-rescuer removal technique

Rescuer 1 stabilizes from above: kneeling at the top of the head, hands on both sides of the helmet, fingertips on the patient's jaw.
Rescuer 2 takes over stabilization from below: kneeling at the patient's side, one hand cupping the jaw (mandible), the other behind the back of the skull (occiput). Rescuer 2 now owns the head and says so out loud: "I have stabilization."
Rescuer 1 removes the helmet: spread the sides outward to clear the ears, then rotate it. Tilt it back slightly so the chin bar clears the nose, then forward to clear the back of the skull. Slide it off slowly and straight. Never jerk it.
Rescuer 2 keeps neutral support the whole time and calls out immediately if anything changes: resistance, pain, or new tingling or numbness.
Rescuer 1 takes back manual in-line stabilization as soon as the helmet is off.
Pad under the occiput: a full-face helmet held the head up, so once it's off, the head will drop toward the ground unless there's padding under it. Slide folded clothing under the back of the skull to bring it back to neutral alignment.

No traction, ever. At no point in a helmet removal does anyone pull on the head or neck. Support the head in neutral without pulling. If you meet resistance, the pain increases, or the patient reports new tingling or numbness, stop and reassess before you go on.

Solo rescuer

Take a helmet off alone only if the airway needs it right now and no help is available. One person can't stabilize the head and work the helmet at the same time, so a solo removal always costs more movement. If the patient is breathing, stabilize the head, monitor, and wait for a second rescuer.

Riders: practice this with your group before the trip. The first time you take off a full-face helmet shouldn't be on an injured friend.

Gear works the same way. If a bike, pack, or PFD is pinning the patient and you suspect a spine injury, move the gear and leave the patient where they are.

Traumatic Brain Injury (TBI)

What a concussion is

A concussion is a type of TBI. A blow to the head or a violent head movement disrupts normal brain function. They may or may not lose consciousness. Function comes back gradually.

Concussion signs and symptoms

Headache (the most common)
Confusion or disorientation ("What's my name?" "Where am I?")
Dizziness or vertigo
Nausea or vomiting
Trouble concentrating, or memory problems
Sensitivity to light or noise
Loss of consciousness (it varies, and it isn't required for the diagnosis)
Amnesia for events before or after the injury

Return-to-play protocol

Care after a concussion starts with 24-48 hours of relative rest. After that, they work back up gradually, limited by symptoms. Activity shouldn't make symptoms more than mildly worse.

Stage	Activity Level	Duration
1	Relative rest (limit screens and exertion; normal daily activities as tolerated)	24-48 hours
2	Light aerobic activity (walking, stationary bike)	As tolerated, 24+ hours at stage
3	Sport-specific exercise	As tolerated, 24+ hours at stage
4	Non-contact training	As tolerated, 24+ hours at stage
5	Full-contact practice	As tolerated, 24+ hours at stage
6	Return to competition	Full return

At every stage, activity shouldn't make symptoms more than mildly worse. If symptoms get worse, drop back to the previous stage. No return to sport or other high-risk activities until a medical professional gives the go-ahead.

Overnight monitoring in the backcountry

Let them sleep. Keep checking on them.

Sleep is allowed after a concussion, and it helps. Don't force the patient to stay awake.
Watch for deterioration. Every few hours during the first night, check that you can rouse them and that they respond appropriately.
Never leave a concussed person alone in the backcountry
A worsening headache, repeated vomiting, or declining alertness means an emergent evacuation

Postconcussion syndrome

In some patients, symptoms hang on for weeks to months after a concussion. They can include persistent headache, trouble thinking (cognitive dysfunction), and mood changes. Recovery takes longer, and a specialist evaluation may help.

Cushing's triad: a sign of rising intracranial pressure

Cushing's triad is a late sign of increased ICP:

High blood pressure (hypertension): a progressive, severe rise, with a widening pulse pressure
Slow heart rate (bradycardia): often under 60 bpm, when you'd expect an injured patient's pulse to be fast
Irregular breathing: an abnormal pattern (Cheyne-Stokes, gasping)

If you see Cushing's triad, you have an emergency. Brain herniation may be imminent.

Basilar skull fracture signs

A fracture at the base of the skull is serious and easy to miss on exam. Look for these:

Sign	Finding	Significance
Battle's Sign	Bruising behind the ear (over the mastoid bone)	Suggests a basilar skull fracture
Raccoon Eyes	Bruising around both eyes (with no direct trauma to the eyes)	Suggests a basilar fracture of the anterior fossa (the front of the skull base)
CSF Rhinorrhea	Clear fluid draining from the nose	CSF leaking through a fracture of the cribriform plate
CSF Otorrhea	Clear fluid draining from the ear	CSF leaking through a temporal bone fracture
Hemotympanum	Blood behind the eardrum (tympanum)	Suggests a basilar fracture

Level of consciousness: AVPU

AVPU (Alert, Verbal, Pain, Unresponsive, from Lesson 2) is your tool for tracking a head injury. Write it down with the time, every time you check. You may hear EMS and hospitals use the Glasgow Coma Scale (GCS), a 3-to-15 score. You don't need it out here.

Reading AVPU after a head injury:

A: alert and oriented. Keep checking; a TBI can get worse hours later.
V: responds only to your voice, or is confused. That's altered mental status.
P or U: responds only to pain, or not at all. They can't protect their own airway.
Any slide down the scale (A to V, V to P) means the brain injury is getting worse

Signs a TBI patient is getting worse

Any of these means immediate evacuation:

Unequal pupils (anisocoria), which suggest brain herniation
A worsening headache or mental status
Vomiting, especially projectile
Loss of consciousness
Seizures
Cushing's triad (hypertension, bradycardia, irregular respirations)

Field Management of Head & Spine Injuries

Positioning

Suspected spine injury: Keep them on their back (supine) with the head neutral. If they vomit, logroll them to their side, keeping the spine aligned.

Conscious head injury with no suspected spine injury: Sit them upright or semi-upright to reduce intracranial pressure and prevent aspiration.

Airway management priority

Airway beats everything except severe bleeding. Stop that first, then keep the airway open. If the patient is unconscious or can't protect their airway:

If there's no suspected spine injury, put them in the recovery position (on their side, lateral recumbent) with the head tilted back to keep the airway open
If a spine injury is possible, keep them on their back with the head neutral and open the airway with a jaw thrust. Snoring or gurgling means it's blocked. Be ready to logroll them.
If they vomit with a suspected spine injury, logroll them as a unit to their side to protect the airway
Alone with an unresponsive, breathing spine patient? Hold the head and keep the jaw thrust going if you can stay. If you have to leave them, you can't keep the airway open, or they vomit and there's nobody to help you logroll, roll them onto their side yourself, keeping the head and body in line as best you can. The airway wins.

Vomiting in a spine patient

A vomiting patient with a suspected spine injury is a hard problem in the wilderness, because they can aspirate. Here's how to handle it:

Keep them on their back with the head neutral as much as you can
If they vomit, logroll them as a unit onto their side (either side). That keeps the spine aligned.
Suction the airway if you have suction
Roll them back onto their back once the vomiting stops

When to move a spine-injured patient

Move them right away for:

An environmental danger (fire, rockfall, water)
Airway compromise that needs repositioning
Shock that needs treatment

Otherwise, move them as little as possible, and keep them still until they're fully immobilized on a stretcher.

Evacuation urgency

Emergent evacuation:

Any unconscious patient
A declining level of consciousness
Any neurological deficit (weakness, paralysis, loss of sensation)
Altered mental status that your fix doesn't fully and quickly reverse
Signs of rising ICP (Cushing's triad, unequal pupils, vomiting)
A suspected basilar skull fracture

Urgent evacuation:

A concussion with any symptoms
Mild TBI (Alert on AVPU) with a reassuring exam
A spine mechanism with an unreliable exam (intoxication, a severe distracting injury) but no deficits
A suspected spine injury with a normal, reliable exam (no deficits; a calm, cooperative, sober, alert patient)

Documentation

Write everything down for a TBI patient. By the end of a long carry, you won't remember the details.

Mechanism of injury
Level of consciousness on arrival and throughout the evacuation
AVPU level, with the time of each check
Pupils: size, equal or unequal, reactive or not
Any vomiting or seizures
Vital signs and their trends
Any improvement or deterioration

Clinical Scenarios

Scenario 1: Possible Cervical Spine Injury

A 40-year-old rock climber loses control rappelling down a steep descent and lands hard on his upper back and neck. He's conscious, alert, and asking questions. He has mild neck pain but no numbness or weakness. Exam: no midline tenderness and normal strength and sensation in all four limbs. The mechanism was significant (a fall from height).

What's going on: He fell from height onto his upper back and neck, and his neck hurts. At the WFA level, that's spine precautions and evacuation.

What you do:

Keep spine precautions in place. At the WFA level, the decision to discontinue them belongs to higher-trained rescuers or medical direction.
Start manual in-line stabilization immediately (support the head in neutral, no pulling).
Keep him on his back with the head neutral, and stabilize the head with rolled blankets, clothing, or padding on both sides (spinal motion restriction).
Recheck his neuro function often. Any change in strength, sensation, or symptoms?
Urgent evacuation for imaging (X-ray or CT) to rule out a fracture.
Don't let him walk out or self-rescue.

Precautions stay on. At your level, you keep them in place and evacuate. For reference, a rescuer with higher-level training could run him through the wilderness spine assessment criteria. He's calm, alert, and sober, but his neck pain alone would keep precautions in place.

Scenario 2: Traumatic Brain Injury with Deterioration

A 32-year-old hiker is hit on the head by a falling tree branch. At first he's dazed and confused, with a headache and no vomiting. You start evacuating him down the mountain, a 90-minute trip. Partway down, you notice his headache is getting worse, he's more and more drowsy, and one pupil looks slightly larger than the other. HR 52, BP 158/95.

What's going on: A deteriorating TBI with signs of increased intracranial pressure: a worsening headache, drowsiness (a falling level of consciousness), unequal pupils (anisocoria), and two parts of Cushing's triad (hypertension, bradycardia). Watch his breathing pattern for the third.

What you do now:

Stop the slow ground carry and escalate to the fastest evacuation available.
Call for a helicopter or emergency rescue immediately.
A branch heavy enough to do this can hurt the neck too, so keep his head, neck, and body in line. Tilt the whole stretcher so his head sits about 30° higher than his feet. That helps blood drain from the head and lowers ICP without bending his spine.
Keep him calm, keep him from overheating or getting cold, and keep his exertion to a minimum.
Watch his airway. He's at risk of losing it.
Monitor his vitals and pupils constantly.
Be ready to manage an airway emergency.
Do not delay the evacuation. Without hospital care, brain herniation is imminent.

Unequal pupils after a head injury are a neurosurgical emergency. Brain herniation can happen fast.

Knowledge Check

12 questions. Pick an answer to get immediate feedback. Answer order is shuffled each attempt, and your best score is saved on this device.

Summary & Key Takeaways

The short version:

A concerning mechanism or symptoms means you keep the patient still and evacuate.
Discontinuing spine precautions is a decision for higher-trained rescuers or medical direction. It isn't a WFA skill.
A logroll takes at least 3 rescuers, and the patient rolls as one unit.
The goal is spinal motion restriction (SMR): generous padding and blanket rolls. Rigid collars are de-emphasized and never enough on their own.
Never apply traction to a suspected spine injury. Support the head in neutral without pulling.
Helmet on if breathing is adequate, the airway is accessible, and the fit is snug. Helmet off if you can't manage the airway, the patient is vomiting or needs rescue breathing or CPR, or the helmet is loose or blocks neutral alignment. A full-face chin bar blocks all airway management.
Helmet removal is a two-rescuer job. Stabilization gets handed off, never dropped. No traction. Pad under the occiput once a full-face helmet comes off.
Cushing's triad (severe hypertension with a widening pulse pressure, bradycardia, irregular respirations) means a raised-ICP emergency.
Unequal pupils after a TBI are a neurosurgical emergency.
A concussion disrupts brain function. They don't have to be knocked out to have one.
Concussion care: relative rest for 24-48 hours, then a gradual, symptom-limited return. Sleep is allowed. If a night out comes before the trailhead, check that they can be roused, and never leave them alone.

Glossary of Terms

Anisocoria

Unequal pupil size. After a head injury, it can mean brain herniation or increased intracranial pressure.

Basilar Skull Fracture

A fracture at the base of the skull. It can be subtle, but it's serious. Signs include Battle's sign, raccoon eyes, and leaking CSF.

Cauda Equina Syndrome

A neurological emergency from compression of the bundle of nerve roots in the lumbar spine. It causes leg paralysis and bowel and bladder dysfunction.

Cervical Spine

The neck part of the spine (C1-C7). The most mobile and least stable region, and injuries here are often catastrophic.

Concussion

A type of traumatic brain injury in which a blow to the head disrupts normal brain function. There may or may not be a loss of consciousness.

Cushing's Triad

Hypertension, bradycardia, and irregular respirations. A late sign of dangerously increased intracranial pressure.

CSF (Cerebrospinal Fluid)

The clear fluid around the brain and spinal cord. If it's leaking from the nose or ears, that indicates a basilar skull fracture.

Glasgow Coma Scale (GCS)

A 3-to-15 score for level of consciousness, based on eye opening, verbal response, and motor response.

Herniation

Brain tissue shifting under increased intracranial pressure. It can kill quickly, and unequal pupils are the sign.

Logroll

Moving a patient with a suspected spinal injury as one unit, with the spine kept straight. Takes at least 3 rescuers.

Occiput

The back of the skull. After a full-face helmet comes off, pad under the occiput to keep the head in neutral alignment, because the helmet had been holding the head up.

Postconcussion Syndrome

Symptoms (headache, cognitive dysfunction, mood changes) that last weeks to months after a concussion.

Spinal Cord

The bundle of nerves running through the vertebral column. Damage at any level causes loss of function below that level.

Spinal Motion Restriction (SMR)

Keeping the spine still with generous padding, blanket rolls, and careful handling, instead of relying on rigid devices. It's the modern goal of field spine care.

Traumatic Brain Injury (TBI)

Injury to the brain from a blow or a violent movement. It ranges from mild (concussion) to severe (unconsciousness, permanent disability).

Wilderness Spine Assessment (WSA)

Reference criteria higher-trained rescuers use to decide whether spine precautions can be discontinued in the field. At the WFA level, keep the patient still and evacuate.