Head, Neck & Spine Injuries — Lesson 7

Overview

Learning Objectives

Understand spinal anatomy and mechanisms of spine injury
Recognize when spine precautions are needed, and understand the reference criteria higher-trained rescuers use to discontinue them
Perform manual in-line stabilization and proper logroll technique
Apply spinal motion restriction (SMR) using generous padding and improvised materials
Decide when a helmet should stay on versus come off, and perform two-rescuer helmet removal without traction
Recognize and manage traumatic brain injury (TBI) including concussion
Identify signs of increased intracranial pressure (ICP) and basilar skull fractures
Understand GCS scoring and when to evacuate TBI patients

A spine injury is the one you can make permanently worse with your own hands. Move slow, think first. A simple fall can result in spinal cord injury leading to permanent paralysis. A bump to the head can cause traumatic brain injury with subtle but serious consequences. At this level of training, the rule is simple: if the mechanism or symptoms suggest possible spine injury, keep the patient still and evacuate — discontinuing spine precautions is a decision for higher-trained rescuers or medical direction.

This lesson teaches when to suspect spine injury, how to restrict spinal motion in the field, and the recognition and management of head injuries, including concussion and intracranial emergencies.

Golden Rule: When in doubt about potential spine injury, immobilize and stabilize until proven otherwise. Spinal cord damage is irreversible; conservative management is justified.

Spinal Anatomy & Injury Mechanisms

Spinal Column Regions

Region	Vertebrae	Location	Injury Patterns
Cervical (C)	C1-C7	Neck; most mobile, least protected	High-risk region; injuries often catastrophic (quadriplegia)
Thoracic (T)	T1-T12	Mid-back; protected by rib cage	Often associated with significant trauma; spinal cord injury 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 common; below about L1-2 the canal contains nerve roots (the cauda equina) rather than spinal cord — cauda equina syndrome is itself a surgical emergency
Sacral (S)	S1-S5 (fused)	Lowest spine; fused to pelvis	Part of pelvis; fractures usually from extreme trauma

Spinal Cord Anatomy

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

Cervical injury (C1-C4): Can be fatal (respirations controlled by C3-C5); causes quadriplegia (paralysis of all four limbs)
Cervical injury (C5-C8): Quadriplegia with variable arm and hand function
Thoracic injury: Paraplegia (paralysis of lower limbs)
Lumbar injury: Cauda equina syndrome (variable leg paralysis, bowel/bladder dysfunction) — a surgical emergency

Mechanisms of Spinal Injury

Axial Load (Compression): Force applied along the length of the spine. Example: diver hitting bottom, falling and landing on buttocks with legs straight, falling from height and landing on feet. Causes vertebral compression fractures.

Hyperflexion: Excessive forward bending. Example: head-on collision, being struck from behind. Can cause vertebral fractures and ligament rupture.

Hyperextension: Excessive backward bending. Example: rear-end collision, struck on forehead. Can cause fractures and spinal cord damage.

Rotation/Distraction: Twisting or pulling forces. Example: rollover accident, being twisted. High-energy; often associated with fracture-dislocations and severe cord injury.

For Reference: NEXUS Criteria

Hospital providers use the NEXUS criteria to decide who needs C-spine imaging. A patient with ANY of the following cannot be ruled out by NEXUS:

Midline cervical spine tenderness
Focal neurological deficit (weakness, numbness, paralysis)
Altered level of alertness
Intoxication
Painful distracting injury

At the WFA level, treat a concerning mechanism (significant fall, high-speed impact, axial load) OR any of the findings above as reason to keep the patient still and evacuate.

Wilderness Spine Assessment (WSA)

Who Decides to Discontinue Spine Precautions?

At the Wilderness First Aid level, you do not "clear" the spine. If the mechanism or symptoms suggest possible spine injury, keep the patient still and evacuate. The decision to discontinue spine precautions belongs to rescuers with higher-level training or medical direction.

For Reference — Wilderness Spine Assessment Criteria (used by higher-trained rescuers): Spine precautions may be discontinued only when ALL of the following are present:

Reliable patient: calm, cooperative, sober, and alert
No spine pain AND no midline tenderness on palpation
Normal motor and sensory function in all four extremities
No significantly distracting injury (an injury so painful it could mask spine symptoms)

If any criterion is not met — or the assessment cannot be completed — precautions stay in place and the patient is evacuated.

Manual In-Line Stabilization Technique

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

Rescuer holds patient's head with hands on both sides, keeping head neutral (not flexed, extended, or rotated)
Support the head in neutral alignment WITHOUT pulling — NEVER apply traction to a suspected spine injury (it can worsen an unstable injury). Stop any repositioning if you meet resistance, pain increases, or the patient reports new tingling or numbness
Do NOT allow head to move in any direction
Continue until patient is fully immobilized on stretcher

Logroll Technique

When moving a suspected spine-injured patient from ground to stretcher, use a logroll to keep the spine straight:

Logroll Requirements:

Requires MINIMUM 3 rescuers (one for head/neck, one for torso, one for legs)
4+ rescuers is ideal
One rescuer directs the movement (usually the one holding the head)
Roll patient as one unit; do not allow spine to bend or rotate
Place on stretcher in supine position

Spinal Motion Restriction (SMR)

The goal is spinal motion restriction (SMR): keep the patient still, pad generously beneath and around them, and stabilize the head with rolled blankets, clothing, or foam placed on both sides. Improvised padding that actually limits motion is the goal — comfort and generous padding also matter for the long evacuations typical of wilderness settings.

For Reference — Cervical Collars: EMS providers may apply a rigid cervical collar, but current guidance de-emphasizes rigid collars: they can cause pressure injury and do not actually immobilize the neck well. A collar alone is never sufficient — manual stabilization and padding that limits motion matter more.

Helmet Removal

On a motorcycle or rafting trip, many head and spine injuries arrive wearing a helmet. A snug helmet is not the enemy — it splints the head in much the same way your hands do during manual stabilization. The question is never "do helmets come off?" but "does THIS helmet, on THIS patient, right now, help or hurt?" That makes it primarily an airway decision.

Leave It On or Take It Off?

Leave the Helmet ON when...	Remove the Helmet when...
The patient is breathing adequately	You CANNOT assess or manage the airway through it
The airway is accessible and you can monitor it	The patient is vomiting or needs rescue breathing/CPR
The helmet fits snugly — it is splinting the head for you	Breathing is compromised, or the helmet is loose (a loose helmet stabilizes nothing)
Removing it would cause more movement than leaving it	The helmet prevents keeping the head in neutral alignment

Full-Face vs. Open-Face: A full-face motorcycle helmet usually must come off for ANY airway problem — you cannot manage an airway through a chin bar. An open-face or whitewater helmet leaves the face exposed, so a breathing patient can often keep it on while you stabilize and monitor.

Preparation First

Before anyone touches the helmet itself, set up for success:

Tell a conscious patient exactly what you are about to do
Raise the visor fully
Remove the patient's glasses or goggles
Unbuckle the chin strap — or cut it if the buckle fights you
Remove the cheek pads if the helmet design allows (many full-face helmets have pull-out pads; this creates room and reduces 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 mandible (jaw), the other hand behind the occiput (back of the skull). Rescuer 2 now owns the head — say it out loud: "I have stabilization"
Rescuer 1 removes the helmet: spread the helmet sides outward to clear the ears, then rotate it — tilting back slightly so the chin bar clears the nose, then forward to clear the back of the skull — sliding it off slowly and straight, never jerking
Rescuer 2 maintains neutral support throughout and announces immediately if anything changes — resistance, pain, or new tingling or numbness
Rescuer 1 resumes manual in-line stabilization as soon as the helmet is off
Pad under the occiput: a full-face helmet held the head elevated, so once it is off, the head will drop toward the ground unless you pad beneath it. Slide folded clothing under the back of the skull to restore neutral alignment

No Traction — Ever: At no point in helmet removal does anyone pull on the head or neck. Support the head in neutral WITHOUT pulling. If you meet resistance, pain increases, or the patient reports new tingling or numbness, STOP and reassess before continuing.

Solo Rescuer

Only remove a helmet alone if the airway demands it right now and no help is available. One person cannot stabilize the head and manipulate the helmet at the same time, so 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 remove a full-face helmet should not be on an injured friend.

Same principle for gear: a bike, pack, or PFD pinning the patient follows the same rule — move the obstacle, not the patient, when spine injury is suspected.

Traumatic Brain Injury (TBI)

Concussion Definition

A concussion is a type of TBI caused by a blow to the head or violent head movement, resulting in disruption of normal brain function. May or may not involve loss of consciousness. Recovery involves gradual return of function.

Concussion Signs & Symptoms

Headache (most common)
Confusion or disorientation ("What's my name?" or "Where am I?")
Dizziness or vertigo
Nausea or vomiting
Difficulty concentrating or memory problems
Sensitivity to light or noise
Loss of consciousness (variable; not required for diagnosis)
Amnesia for events before or after the injury

Return-to-Play Protocol

Post-concussion management starts with 24-48 hours of relative rest, followed by a gradual, symptom-limited return to activity — activity should not more-than-mildly worsen symptoms:

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

Key Rule: Activity at each stage should not more-than-mildly worsen symptoms; if symptoms worsen, drop back to the prior stage. No return to sport or other high-risk activities until cleared by a medical professional.

Overnight Monitoring in the Backcountry

Sleep is allowed — monitoring is required:

Sleep is allowed and beneficial after a concussion — do not force the patient to stay awake
Monitor for deterioration: check that the person can be roused (wakes and responds appropriately) every few hours during the first night
NEVER leave a concussed person alone in the backcountry
Worsening headache, repeated vomiting, or declining alertness = EMERGENT evacuation

Postconcussion Syndrome

In some patients, symptoms persist for weeks to months after concussion. May include persistent headache, cognitive dysfunction, mood changes. Requires longer recovery period and may benefit from specialist evaluation.

Cushing's Triad: Sign of Rising Intracranial Pressure

Cushing's Triad (Late Sign of Increased ICP):

Hypertension: Progressive, severe rise in blood pressure with a widening pulse pressure
Bradycardia: Slow heart rate (<60 bpm) despite shock from injury
Irregular Respirations: Abnormal breathing pattern (Cheyne-Stokes, gasping)

Presence of Cushing's triad indicates EMERGENT condition. Brain herniation may be imminent.

Basilar Skull Fracture Signs

A fracture at the base of the skull can be subtle on exam but is serious. Look for:

Sign	Finding	Significance
Battle's Sign	Bruising behind the ear (over mastoid bone)	Suggests basilar skull fracture
Raccoon Eyes	Bruising around both eyes (without direct eye trauma)	Suggests anterior fossa basilar fracture
CSF Rhinorrhea	Clear fluid draining from nose	CSF leak through cribriform plate fracture
CSF Otorrhea	Clear fluid draining from ear	CSF leak through temporal bone fracture
Hemotympanum	Blood behind the tympanum (ear drum)	Suggests basilar fracture

Glasgow Coma Scale (GCS)

GCS measures level of consciousness by evaluating eye opening, verbal response, and motor response. Score ranges 3-15; lower scores indicate more severe injury.

GCS Interpretation:

13-15: Mild TBI
9-12: Moderate TBI
3-8: Severe TBI (indicates inability to protect airway)

Signs of Deteriorating TBI Patient

Immediate Evacuation Indicators:

Unequal pupils (anisocoria) — suggests brain herniation
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 supine with head neutral. If patient is vomiting, logroll to side while maintaining spine alignment.

Conscious Head Injury without Spine Injury: Position upright or semi-upright to reduce intracranial pressure and prevent aspiration.

Airway Management Priority

Maintaining a patent airway is the absolute priority. If patient is unconscious or cannot protect airway:

Position in recovery position (lateral recumbent) with head tilted back to maintain airway patency, IF spine injury ruled out
If spine injury possible, maintain supine with head neutral and prepare for aggressive airway management
If vomiting occurs with suspected spine injury, logroll as unit to side to protect airway

Vomiting in Spinal Patient

A major challenge in wilderness: vomiting patient with suspected spine injury risks aspiration. Solution:

Keep patient supine with head neutral as much as possible
If vomiting occurs, logroll patient as a unit to the left side (maintains spine alignment)
Suction airway if available
Return to supine once vomiting clears

When to Move a Spine-Injured Patient

Immediate Movement Required:

Environmental danger (fire, rock fall, water)
Airway compromise requiring repositioning
Shock requiring intervention

Otherwise: Minimize movement. Keep patient still until fully immobilized on stretcher.

Evacuation Urgency

EMERGENT Evacuation:

Any unconscious patient
Deteriorating level of consciousness
ANY neurological deficit (weakness, paralysis, sensory loss)
Unreliable exam (altered mental status, intoxication, severe distracting injury)
Signs of increasing ICP (Cushing's triad, unequal pupils, vomiting)
Basilar skull fracture suspected

URGENT Evacuation:

Concussion with any symptoms
Mild TBI (GCS 13-15) with reassuring exam
Suspected spine injury with a normal, reliable exam (no deficits; calm, cooperative, sober, alert patient)

Documentation

Careful documentation is critical for TBI patients:

Mechanism of injury
Level of consciousness at arrival and throughout evacuation
GCS score
Pupils (size, equal/unequal, reactive)
Any vomiting or seizures
Vital signs and trends
Any improvement or deterioration

Clinical Scenarios

Scenario 1: Possible Cervical Spine Injury

A 40-year-old rock climber rappels down a steep descent and loses control, landing forcefully on his upper back and neck area. He's conscious, alert, and asking questions. He reports mild neck pain but no numbness or weakness. Exam: No midline tenderness, normal strength/sensation in all extremities, mechanism was significant (fall from height).

Analysis: Significant mechanism (fall from height onto the upper back and neck) with neck pain. At the WFA level, this warrants spine precautions and evacuation.

Management:

Maintain spine precautions — at the WFA level, the decision to discontinue them belongs to higher-trained rescuers or medical direction
Apply manual in-line stabilization immediately (support the head in neutral, no pulling)
Keep patient supine with head neutral; stabilize the head with rolled blankets, clothing, or padding on both sides (spinal motion restriction)
Reassess neuro function frequently (any change in strength, sensation, or symptoms?)
URGENT evacuation for imaging (X-ray or CT) to rule out fracture
Do not allow patient to walk or self-rescue

Key Point: WFA providers maintain precautions and evacuate. For reference: rescuers with higher-level training could formally assess this patient using the wilderness spine assessment criteria — he is 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 struck on the head by a falling tree branch. Initial: he's dazed, confused, complains of headache, no vomiting. You evacuate him down the mountain over 90 minutes. Partway down, you notice his headache is worsening, he's become increasingly drowsy, and one pupil appears slightly larger than the other. HR 52, BP 158/95.

Analysis: This is a deteriorating TBI patient showing signs of increased intracranial pressure: worsening headache, drowsiness (decreasing consciousness), unequal pupils (anisocoria), Cushing's triad (hypertension, bradycardia). This is a MEDICAL EMERGENCY.

Immediate Actions:

Stop the slow ground carry — escalate to the fastest available evacuation
Call for helicopter/emergency rescue immediately
Elevate head of stretcher 30° to promote venous drainage and reduce ICP
Keep patient calm and cool (minimize exertion)
Monitor airway — this patient is at risk for loss of airway
Monitor vitals and pupils constantly
Be prepared to manage airway emergency
Do NOT delay evacuation — brain herniation is imminent without hospital intervention

Critical Pearl: Unequal pupils in a head injury patient is a neurosurgical emergency. Brain herniation may occur rapidly.

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

Key Concepts to Remember:

Concerning mechanism or symptoms = keep the patient still and evacuate
Discontinuing spine precautions is a decision for higher-trained rescuers or medical direction — not a WFA skill
Logroll requires minimum 3 rescuers; roll as a unit
Spinal motion restriction (SMR) is the goal: generous padding and blanket rolls; rigid collars are de-emphasized and never sufficient alone
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 cannot manage the airway, the patient is vomiting or needs rescue breathing/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 is handed off, never dropped; no traction; pad under the occiput after a full-face helmet comes off
Cushing's triad (severe hypertension with widening pulse pressure, bradycardia, irregular respirations) indicates raised ICP emergency
Unequal pupils in TBI = neurosurgical emergency
Concussion = not about unconsciousness, but disruption of brain function
Concussion care: relative rest 24-48 hours, then gradual symptom-limited return; sleep is allowed — check arousability overnight and never leave the patient alone

Glossary of Terms

Anisocoria

Unequal pupil size; in head injury indicates possible brain herniation or increased intracranial pressure.

Basilar Skull Fracture

Fracture at the base of the skull; can be subtle but serious, indicated by Battle's sign, raccoon eyes, or CSF leakage.

Cauda Equina Syndrome

Neurological emergency from compression of the bundle of nerve roots in the lumbar spine; causes lower limb paralysis and bowel/bladder dysfunction.

Cervical Spine

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

Concussion

A type of traumatic brain injury from a blow to the head causing disruption of normal brain function; may or may not involve loss of consciousness.

Cushing's Triad

Hypertension, bradycardia, and irregular respirations — a late sign indicating dangerously increased intracranial pressure.

CSF (Cerebrospinal Fluid)

Clear fluid surrounding the brain and spinal cord; if leaking from nose or ears, indicates basilar skull fracture.

Glasgow Coma Scale (GCS)

A scoring system (3-15) measuring level of consciousness by evaluating eye opening, verbal response, and motor response.

Herniation

Shifting of brain tissue from increased intracranial pressure; can be rapidly fatal; indicated by unequal pupils.

Logroll

A technique to move a suspected spinal injury patient as one unit, keeping spine straight; requires minimum 3 rescuers.

Occiput

The back of the skull. After a full-face helmet is removed, pad under the occiput to keep the head in neutral alignment — the helmet had been holding the head elevated.

Postconcussion Syndrome

Persistent symptoms (headache, cognitive dysfunction, mood changes) lasting weeks to months after concussion.

Spinal Cord

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 using generous padding, blanket rolls, and careful handling rather than relying on rigid devices; the modern goal of field spine care.

Traumatic Brain Injury (TBI)

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

Wilderness Spine Assessment (WSA)

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