Summary pREPARED by: Nate Smith, ph.D., wemt & Judie FLEYSHGAKKER, RN, CCRN, WFR

Focused Spine Assessment Overview:

The Focused Spine Assessment (FSA) is a tool utilized in the wilderness medicine education course series. Wilderness medicine is defined as pre-hospital care provided when 1 hour or more from definitive medical resources (e.g. ambulance, air-ambulance, hospital, etc.). It has been utilized for 10+ years and is supported by multiple wilderness medicine course providers including Mountain Education & Development LLC (MED).

The FSA is taught at the Wilderness First Aid – 16 training hours (WFA), Wilderness Advanced First Aid – 32 training hours (WAFA) and Wilderness First Responder – 72 training hours (WFR) course level. During these courses, trainees are taught to utilize the FSA as a decision making tool at the conclusion of a complete patient assessment. In such a situation, the patient presents with a supporting mechanism of injury for a suspected head, neck or back injury. Spinal precautions are considered and administered throughout the regular patient assessment. Findings during the complete patient assessment contradict the original spinal precaution decision. If such a situation exists, the rescuer may utilize the FSA as an additional decision making tool of whether or not to maintain spinal precautions in the field and during evacuation.

Spinal immobilization can be difficult to achieve in remote wilderness settings. Access to appropriate equipment, diverse landscapes and extended response times all contribute to the complexity of wilderness medical emergencies. The FSA is a useful and practical tool for wilderness medicine practitioners. Immobilizing a patient in any situation, especially a wilderness context, can contribute to challenging patient care, discomfort and even secondary injury.

If a patient fails the FSA, then the rescuer makes every effort to maintain spinal precautions. If a patient passes the FSA, a rescuer is able to make an informed decision to release spinal precautions during their pre-hospital care.


Overall, the FSA has the potential to improve patient care and efficiency—benefits that would be helpful in any pre-hospital first response situation.

Urban Findings related to Spinal Immobilization:

Emergency Departments

  • U.S. Emergency Departments treat over 13 million patients each year with risk for cervical spine injury (Eyre, 2006; Stiell, et al., 2003; Stiell, et al., 2009).  Approximately 0.3% of these patient actually have significant c-spine injuries (Eyre, 2006).
  • Over 98% of c-spine radiographs prove to be negative for injury (Stiell, et al., 2009), all those unnecessary images cost the U.S over $180,000,000 annually (Eyre, 2006).  


  • In EMS, the dollar amounts to be saved are not as apparent--however, time is money.  The amount of time that could be saved by utilizing a tool that might allow first responders to make an informed decision to not immobilize patients is substantial.  

The Tools:


The National Emergency X-Radiography Utilization Study (NEXUS) was the first documented evaluation of a decision making tool which examines the likelihood of a cervical spine injury. In 1992, over 34,000 patients were in enrolled in NEXUS. Of which 818 were found to have injuries--NEXUS missed only 8, and only 2 of which were deemed clinically significant. (Grossheim, Polglaze, & Smith, 2009)


Of note, the study included patient ages 1 to 101 (Runde, 2015) and further review of the data showed that the NEXUS low-risk criteria was 100% effective in study participants who were either pediatric patients or elderly patients defined as over 80 years old (Eyre, 2006). There is also some debate as to how easily interpreted the criteria are, and various sources caution clinicians to read the fine print.  While NEXUS is certainly imperfect, it has become the foundation on which new tools have been based and developed out of (Eyre, 2006).


Almost a decade later, in 2001 Canadian researchers came out with the Canadian C-Spine Rule (CCR) and published a study of nearly 9,000 patients which found that this tool was more accurate and effective than the previously developed NEXUS (Stiell, et al., 2003).   


Since the initial CCR study, additional literature reviews found possible flaws in the process by which the researchers found their tool to be superior. Among these is the patient exclusion criteria. This included patients if they were under 16 years of age, had a Glasgow Coma Scale (GCS) less than 15, and/or if their vital signs were unstable. It has been discussed that the results of this initial study may be skewed in the favor of the CCR because of the exclusion criteria. (Eyre, 2006)

It has also been found that clinicians are more reluctant to use this tool, likely due to it’s complexity--which may contribute to why the CCR had a slightly higher rate of misinterpretation (Eyre, 2006).

Additionally, the CCR could release an intoxicated individual provided they were still alert and oriented (Runde, 2015). 

Maine EMS Spine Assessment Protocol

Around that same time, Maine’s EMS took this idea to the streets.  They took NEXUS, gave it a makeover--because as we said, it is certainly not perfect--and in 13 years, they have not changed it their spine assessment protocol (Maine EMS, 2015).



NEXUS, the Maine EMS Spine Assessment Protocol, and the FSA are remarkably similar. NEXUS preceded the other two by a decade and is a less conservative tool, while the other two are essentially identical, but used by different providers.  

The CCR, on the other hand, is a completely different assessment, being utilized in hospitals to decrease the use of imaging tests in the emergency department.  It has proved to be a useful and reliable tool.


The above information was prepared in part by referencing these sources. This summary was utilized as a presentation ("Focused Spine Assessment") during the 2015 St. Alphonsus Ski & Mountain Trauma Conference. 

Eyre, A. (2006).  Overview and Comparison of NEXUS and Canadian C-Spine Rules.  American Journal of Clinical Medicine, 3 (4), 12-15.

Grossheim, L. F., Polglaze, K., & Smith, R., (2009).  Cervical Spine Injury:  An Evidence-Based Evaluation of the Patient with Blunt Cervical Trauma.  Emergency Medicine Practice, 11 (4).

Hong, R., Meenan, M., Prince, E., Murphy, R., Tambussi, C., Rohrbach, R., & Baumann, B. M. (2014). Comparison of Three Prehospital Cervical Spine Protocols for Missed Injuries. Western Journal Of Emergency Medicine: Integrating Emergency Care With Population Health, 15(4), 471-479 9p. doi:10.5811/westjem.2014.2.19244

Maine EMS, (2015).  Maine EMS Prehospital Treatment Protocols Effective July 1, 2015.  61. Retrieved from

Runde, D., (2015). Canadian C-Spine Rule.  Retrieved from

Runde, D., (2015). NEXUS Criteria for C-Spine Imaging.  Retrieved from

Stiell, I., Clement, C., Grimshaw, J., Brison, R., Rowe, B., Schull, M., & ... Lesiuk, H. (2009). Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. BMJ: British Medical Journal (Overseas & Retired Doctors Edition), 339(7729), b4146-b4146 1p. doi:10.1136/bmj.b4146

Stiell, I. G., Clement, C. M., McKnight, D., Brison, R., Schull, M. J., Rowe, B. H., … Wells, G.A. (2003). The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. The New England Journal of Medicine, 349, 2510-2518. DOI: 10.1056/NEJMoa031375