Suspect cervical spine injury and apply precautions from the first moment in:
- High-energy mechanisms: road traffic crashes, falls from height (rooftops, trees), diving into shallow water, heavy objects falling on the head.
- Any trauma patient who is unconscious or intoxicated — they cannot report neck pain.
- Neck pain or tenderness, weakness, numbness or tingling in the limbs.
- Significant injury above the clavicles.
A patient who is fully alert, not intoxicated, with no neck pain or midline tenderness, no neurological symptoms and no painful distracting injury is very unlikely to have an unstable injury — this is the basis of standard clearance rules. When in doubt, keep precautions and refer; adapt clearance decisions to local policy and imaging availability.