A rifleman takes a fragment through the side of his neck on a compound wall. He is awake, swearing, and moving all four limbs, and his buddy is already digging a cervical collar out of the aid bag. The wound is oozing dark blood under the edge of where that collar would sit. Every second spent sizing and fitting it is a second the team stays exposed and nobody is watching the neck swell.
Bottom line: a conscious casualty with only penetrating trauma and a normal neurologic exam does not get a collar or spinal motion restriction. Blast, blunt force, altered mental status, neck pain, or a neurologic deficit change that answer.
The 01 May 2026 TCCC Guidelines put it in one line under Tactical Field Care airway management: "Cervical spine stabilization is not necessary for casualties who have sustained only penetrating trauma" [1]. The same section tells you to let a conscious casualty assume any position that best protects the airway, including sitting up and leaning forward, and to place an unconscious casualty in the recovery position [1]. A collar and a flat litter work against both of those instructions.
The Joint Trauma System spine CPG (19 Jun 2020) is more specific. Patients with isolated penetrating cervical injury who are conscious and have no neurologic signs "should not have a cervical collar placed in the prehospital environment" [2]. The CPG then draws the boundary: penetrating neck injury from an explosive mechanism should get a collar if possible, and when a blunt mechanism is combined with a penetrating injury, the collar stays on until an unstable spine is ruled out [2].
The civilian position matches. The 2018 joint statement from the American College of Surgeons Committee on Trauma, ACEP, and NAEMSP states that there is no role for spinal motion restriction in penetrating trauma [3].
The anchor study is Haut and colleagues, a retrospective analysis of the National Trauma Data Bank (version 6.2) covering 45,284 penetrating trauma patients at US trauma centers [4]. The exposure was prehospital spine immobilization versus none, and the primary outcome was mortality. Only 4.3% were immobilized. Unadjusted mortality was 14.7% in immobilized patients versus 7.2% in those who were not, and after adjusting for demographics, mechanism, physiologic and anatomic injury severity, and other prehospital procedures, the odds ratio for death was 2.06 (95% CI 1.35 to 3.13) [4]. Subset analyses by Injury Severity Score category, mechanism (stab versus gunshot), and blood pressure showed the same direction in every group [4].
The safety side is the number that matters to a medic. Only 30 patients in the entire cohort had an incomplete spinal cord injury that went on to operative fixation, the group a collar could plausibly protect [4]. The authors calculated a number needed to treat of 1,032 to potentially benefit one patient and a number needed to harm of 66 to potentially contribute to one death [4]. This is registry data, and sicker patients were likely immobilized more often, so the odds ratio overstates harm to an unknown degree. The benefit side is small no matter how you adjust it.
The Eastern Association for the Surgery of Trauma (EAST) followed with a systematic review and meta-analysis using GRADE methodology [5]. Twenty-four studies met inclusion and 5 entered the meta-analysis. No study showed a mortality or neurologic benefit from immobilization, including for direct neck injury. Immobilization was associated with higher mortality (RR 2.4, CI 1.07 to 5.41). Neurologic deficit (RR 4.16, CI 0.56 to 30.89) and potentially reversible deficit (RR 1.19, CI 0.83 to 1.70) were not significantly different, with point estimates favoring no immobilization [5]. EAST recommends against routine spine immobilization in adults with penetrating trauma; the evidence is level III [5].
Two military series answer the question for ballistic neck wounds specifically. Ramasamy and colleagues reviewed 90 British casualties from Iraq and Afghanistan with penetrating neck injury over 5.5 years; 66 (73%) were from explosions and 24 (27%) from gunshot wounds [6]. Cervical spine fracture or cord injury was present in 20 casualties, but only 6 of those reached hospital alive, and 4 of the 6 died within 72 hours. Of the 56 casualties who survived to a surgical facility, 1 (1.8%) had an unstable cervical injury requiring surgical stabilization, and that patient died of a coexisting head injury [6].
Barkana and colleagues reviewed 44 Israel Defense Forces casualties with penetrating neck injury over 4.5 years [7]. None needed surgical stabilization of the cervical spine. Among 36 hospitalized casualties, 8 (22%) had a life-threatening sign in the neck: a large or expanding hematoma or subcutaneous emphysema [7]. Those are exactly the findings a collar covers.
Put together, the casualty with a penetrating neck wound who is alive when you reach them almost never has an unstable spine. They often have a threat to the airway or a bleeding vessel that you need to see.
The exception list is where medics get this wrong in both directions. The JTS CPG calls for a rigid collar, or another form of cervical stabilization if the tactical situation allows, after any of these mechanisms [2]:
Any casualty complaining of neck pain or showing neurologic impairment after trauma also gets stabilization until a qualified provider clears the spine [2]. For blunt mechanisms, the civilian joint statement adds acutely altered consciousness (GCS below 15 or intoxication), midline neck or back tenderness, focal numbness or weakness, spinal deformity, and distracting injuries such as long-bone fractures, large burns, or a communication barrier [3].
The practical consequence: the gunshot wound to the neck from a sniper and the fragment wound to the neck from an IED are different casualties. The second one was also thrown, and you treat the mechanism along with the hole.
When the criteria say restrict motion, do it in a way that does not hide the next problem. The JTS CPG warns that a collar can conceal other injuries and developing pathology such as an expanding hematoma [2], so look under it at every reassessment. In a casualty with suspected moderate or severe TBI, TCCC directs you to loosen any cervical collar and keep the head facing forward without rotating the neck [1].
Restriction is about alignment during movement, not a rigid board. The joint statement lists a scoop stretcher, vacuum mattress, or a cot the patient is secured to as acceptable methods and calls for minimizing board time with padding if transport is long [3]. The JTS CPG asks that the cervical spine be cleared and the collar removed within 24 hours when possible, with long-term collars substituted if it has to stay on longer [2].
Document the neurologic exam before and after every move. A deficit that appears after loading is a different patient from one that was present at the point of injury, and the next echelon needs to know which one they received.
Only when something besides the projectile is in play: blast, a fall, loss of consciousness, neck pain, or a neurologic deficit [2]. In British combat data, 1 of 56 penetrating neck casualties who reached surgery had an unstable cervical spine [6]. Leaving the neck exposed lets you see an expanding hematoma or air under the skin.
The JTS CPG lists major explosive or blast injury as a collar indication, along with loss of consciousness, falls from height, ejection, and rollovers [2]. Penetrating neck injury from an explosive mechanism should get a collar if possible, because the casualty also took blunt force [2].
No. A scoop stretcher, vacuum mattress, or secured cot all achieve motion restriction, and board time should be minimized [3]. For unstable thoracolumbar fractures in theater, the JTS CPG uses a vacuum spine board or a padded NATO litter for transport [2].
I have two jobs that put spinal precautions squarely on my desk: HEMS medical director and Army National Guard State Surgeon. Both make me responsible for protocols, and spinal precautions are the protocol habit that outlives its evidence the longest. This article gets the core argument right. The collar on an awake casualty with a penetrating neck wound is a ritual, and rituals are expensive under fire. What I would add is that the habit survives because it feels protective to the person applying it. Nobody gets blamed for putting a collar on. That asymmetry is the real enemy here, and it is why the guideline language had to become blunt. When a medic hesitates, it is usually fear of the rare spine injury rather than any doubt about the evidence. The data are about as one-sided as prehospital data get.
That being said, the blast exception is where I worry. On a modern battlefield the clean "penetrating only" casualty is less common than the rule makes it sound. A fragment wound plus a casualty who was thrown against a vehicle is a blunt-trauma patient first. I would rather a medic put a collar on the occasional casualty who did not need it after a blast than skip it on the one who did. What I will not accept is a collar that stays on while nobody looks underneath it. The exam is the safety system, and the collar is only a reminder to keep doing it. I also want medical officers to stop treating a collar as a disposition decision. Once it is on, someone owns the plan to take it off, and that plan belongs in the written handoff where the next team can read it.
If you are the medic on the ground, decide penetrating-only versus blunt-plus-penetrating out loud before you reach into the bag, and document a motor and sensory exam on both sides before the first move. If you are a medical officer or flight medic receiving the casualty, ask what the mechanism was and when the neuro exam was last done, then decide whether the collar stays. If you run training, build lanes where the right answer is leaving the collar in the bag, because medics only get credit for applying one. Grade the decision as hard as you grade the skill, and make the medic say the mechanism aloud before the evaluator says a word. A neck you can see is a neck you can treat.
— Chester Shermer, MD, FACEP | Emergency Medicine, 25+ Years Clinical Experience | State Surgeon
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Relevant Reading on Global MedOps Command:
How to Avoid Becoming an AI Casualty — Dr. Shermer's guide to navigating AI tools in clinical and operational settings without compromising judgment or patient outcomes.
Emergency Department Efficiency Playbook — Practical systems for throughput, triage optimization, and operational efficiency.
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Related simulation training: EMS-MedSim · EM-Sim · Books by Dr. Shermer