Imagine this.  You are the first responder on a ski patrol team.  You are called to the scene of a patient who has collided with a tree.  You determine that he has significant enough risk for spinal injury that you would like to put him in a c-collar and on a spinal board for extrication and transport.  The patient is wearing a helmet.  Should you remove it?

A recent paper published in WEMJ attempted to answer this question.  Classic teaching has been to remove the helmet in order to properly assess, board, and collar the patient.  However, Murray and Rust (see references) recently used 28 healthy volunteers to determine the level of spinal movement that occurs with helmet removal.  They found that “both the application of a cervical collar as well as the removal of the ski helmet led to small but statistically significant changes in the static alignment of the cervical spine in the sagittal plane.”  This information is interesting and not unexpected.  Based on this finding, the study authors concluded “our study strongly supports the practice of not removing the helmet of an injured skier/snowboarder with a suspected spine injury unless there are superseding factors.”  They also acknowledge that, based on the degree of cervical extension imposed by c-collar application, routine use should be avoided unless high suspicion of injury.


I have several critiques of this paper.

First, the statistical findings were not correlated with any clinical results.  Perhaps removing a helmet and putting on a collar changes the static alignment of the spine, but does that correlate with any meaningful clinical outcomes?  It is not accurate to draw these practice recommendations based on this evidence.

Secondly, head injuries in a helmet are not always obvious or visible during initial assessment.  If the helmet is not removed and a significant head injury is missed (i.e.: depressed skull fracture), the patient may decompensate during transport.  This would then require helmet removal and access to the airway, which would be much more difficult during ground or air transport when there is often only a single patient attendant.

Third, the helmet has to be removed eventually.  I can understand wanting to refrain if there are no providers trained in C-spine immobilization, but this is rare in most ski patrol and front country scenarios.  Also, any paramedic or physician is going to remove the helmet so unless there is some other reason to keep the helmet on during transport (warmth, ongoing hazards, high angle rescue, etc.), then removing it and doing a complete and accurate assessment of the injury is warranted.

Fourth, these recommendations seem to be geared towards ski patrollers with fast access to higher level medical care where someone with more training can be the one to remove the helmet.  It cannot be extrapolated to the backcountry or low resource environments with more limited resources and long transport times.


Ultimately, one must consider many factors when deciding to remove a helmet from an injured patient, including environmental, medical, transport, and patient factors.  The tables provided in this paper are a good starting point in terms of factors to consider when making that decision.  However, one should be skeptical about the conclusions drawn based on the results of this study and providers should remember that each case needs to be evaluated individually.


Alana Hawley, MD, FAWM, DiMM

Wilderness Medicine Fellowship, University of Utah

PGY-5 Emergency Medicine, McMaster University


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Cervical Spine Alignment in Helmeted Skiers and Snowboarders with Suspected Head and Neck Injuries: Comparison of Lateral C-spine Radiographs Before and After Helmet Removal and Implications for Ski Patrol Transport.

Wilderness Environ Med. 2017 Jul 3. doi: 10.1016/j.wem.2017.03.009.