Cervical collar in trauma patients – friend or foe?

Vidya Saketharaman*

Emergency Physician, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence: vidsan169@gmail.com

Abstract

This article debates the efficacy of cervical collar in spinal immobilization of trauma patients with suspected spinal injury. The application of cervical collars has become a ritual of habit without solid scientific evidence. In last three decades, there has been mounting concern about the efficacy of cervical collars.

Keywords: Cervical collar, Trauma patients, Spinal cord injury, Spinal immobilisation

Origin of Cervical Collar

The motif of cervical collar dates back to early 1960’s during the Vietnam War. Initially rolled up towels were used to immobilize the neck. Soft foam collars made its appearance in the late 1960’s. In 1974, Glen Hare designed the first true cervical collar with medium density foam that was believed to provide greater immobilization. Semi-rigid collars of polyethylene plastic were developed during the late 1970’s and used popularly till date.

Faith in cervical collars

The yesteryear people “believed” that

  • Injured patient could have an unstable spinal injury
  • Movement can cause additional damage
  • Application of cervical collars prevents these movements
  • Immobilization procedure is “relatively harmless” and can be applied as a “failsafe method”.

How did it become a tradition?

  1. “All is fair in love and war”. The Vietnam war of military-medical revolution, which first witnessed the use of cervical collars, focused on quick implementation of the tool to save lives with no time to test the efficacy of the tool.
  2. War-related spinal cord injuries were most commonly due to gunshot wounds and explosions which are high energy injuries, most common at the thoracic level followed by lumbosacral. Gunshot injuries appear to be less associated with instability of spine when compared to blunt trauma. The cervical collars were widely used in this war related spinal cord injuries where their use could not have made a difference in the neurological outcome [1].
  3. According to Cochrane report 2001, there were 4453 studies on different immobilization methods and not a single report fitted the criteria of randomized control trial owing to the inadequate discipline of research methodology [2].
  4. Ethical consideration remains at the cynosure for the studies comparing immobilization in suspected spine injury patients where there is a theoretical potential harm to do the patients.
  5. 2–4% trauma patients have spinal injuries, of which 20% had spinal cord injuries, of which there was a risk of missing 1.3% spinal cord injuries. Fear of missing a spinal cord injury remained the rallying point of cervical collar use [3].
  6. Levi and coworkers conducted a retrospective review of 24 patients from 8 level 1 trauma centers who had adverse neurological outcome from a missed spinal cord injury “despite presence of experienced personnel and sophisticated imaging techniques” [4].
    On these grounds, NICE guidelines 2016 and American College of Surgeons and Pre-Hospital Trauma Life support 2012 guidelines recommended the use of cervical collars in suspected spine injury patients [5].
  7. “First do no harm”
    It is said 3–25% of spinal cord injuries are secondary to “inappropriate management” at prehospital care [6].This claim has several limitations

    • not easy to identify neurological decline during pre-hospital phase
    • questionable extrapolation of results at the pre hospital settings
    • several of cited studies conducted with no rigid research structure
    • besides 5% of patients with spinal cord injuries experience some degree of neurological worsening, even with good immobilization of spine [7].
  8. Malpractice lawsuits in cases of avoidable spinal cord injury are very expensive with compensations of approximately 3 million USD. In fact, the key to winning a spinal cord injury medical malpractice case lies in proving negligence by the doctor to adhere to the “standards of care” [8,9].
  9. ABC of trauma which recommends immediate C spine clearance for instability is a powerful mnemonic with strong psychological presumptions for medical action in the field.

Breaking tradition

“I struck the board and cried,” no more;

I will abroad!

What? Shall I ever sigh and pine?

My lines and life are free, free as the road,

Loose as the wind, as large as store.”

Verses from George Herbert critically acclaimed poem “The Collar”

The poem discusses the reflective sense of obedience and desperation of faith. I see it as a metaphor to the subject in discussion.

Now that we have discussed the incompetent grounds of recommending the use of cervical collars. Let’s look into the evidence supporting why the use of cervical collars has been frowned upon in the last few decades.

While the cervical collar has been traditionally claimed to immobilize the neck movements, collar efficacy on motion control has never been examined on real trauma patients to support this assertion. However, there has been a number of studies that have tested the efficacy of collars on simulated environment. The inference from these studies have been listed below.

  • Cervical collars do not restrict neck movement and allow for approximately 30 degrees of flexion/extension/rotation [10].
  • Haus Wald et all conducted a 5-year retrospective study on two hospitals that showed less than 2% chance that the immobilisation had any beneficial effect on the neurological outcome of the patients. Less than 2% chance is equal to insignificant benefit [11].
  • Ben-Galim [12] carried out a study on nine human cadavers with simulated unstable cervical injuries and found that cervical collars caused some separation between the vertebrae causing secondary spinal injuries.
  • Cervical collars caused increased intracranial pressure as evidenced by increased optic nerve sheath diameters in healthy volunteers [13].
  • Cervical collars increase the risk of aspiration, compromise airways and make intubation difficult. Mouth opening was significantly reduced when patients were wearing cervical collars and this was the main factor contributing to the increased difficulty of laryngoscopy in cervical spine immobilisation [14].
  • Cervical collars increase the mortality by compromising airway management and increasing ICP [15].
  • Significant movement of spine while applying cervical collar has been proved. It is indeed appalling to note how few of the medical professionals can apply the cervical collar the right way [16].
  • There are general deficits in the practical skill of applying cervical collars by healthcare workers [17].

Cervical collars do not serve the purpose of immobilising the neck in suspected spinal cord injuries. The evidence in support of cervical collar use is “incompetent, irrelevant and immaterial “as often quoted by famous Perry Mason in the famous court battles in the popular book series.

I rest my case, Your Honour

A new dawn

The use of cervical collars is based more on chronicles than solid scientific evidence. Over the years, there has been a lot of work suggesting better immobilization strategies. Manual in line stabilization and use of sandbags and tape have been said to be more effective in restricting neck movement in suspected spinal cord injury patients. These also need further research as to their efficacy. The Canadian C spine rule and Nexus criteria are proving to be a much broader outlook in managing these patients. The pre-hospital care must refrain from using cervical collar as a “precaution” and follow techniques with good quality evidence.

Acknowledgements

I am grateful to Dr. Venkita S Suresh for inspiring me constantly. I am thankful to Dr. Balamurali, Neurosurgeon for his guidance and inputs for this article. Last but not the least, I am indebted to Dr Aslesha, Chief and Mentor, for the opportunity.

References

  • Furlan JC, Gulasingam S, Craven BC. Epidemiology of war-related spinal cord injury among combatants: a systematic review. Global Spine J. 2019;9(5): 545–58.
  • Kwan I, Bunn F, Roberts IG. Spinal immobilisation for trauma patients. 2001.
    https://www.cochrane.org/CD002803/INJ_spinal-immobilisation-for-trauma-patients.
  • Hasler RM, Exadaktylos AK, Bouamra O, Benneker LM, Clancy M, Sieber R, et al. Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study. J Trauma Acute Care Surg. 2012;72(4):975–81.
  • Levi AD, Hurlbert RJ, Anderson P, Fehlings M, Rampersaud R, Massicotte EM, et al. Neurologic deterioration secondary to unrecognized spinal instability following trauma: a multicenter study. Spine 2006;31:451–8.
  • NICE Guideline, No. 41. Spinal injury: assessment and initial management. NICE guideline. National Clinical Guideline Centre (UK). London:National Institute for Health and Care Excellence (UK); 2016.
  • Brunette DD, Rockswold GL. Neurologic recovery following rapid spinal realignment for complete cervical spinal cord injury. J Trauma. 1987;27(4):445–7.
  • Marshall LF, Knowlton S, Garfin SR, Klauber MR, Eisenberg HM, Kopaniky D, et al. Deterioration following spinal cord injury. A multicentre study. J Neurosurg. 1987;66(3):400–4.
  • Lekovic GP, Harrington TR. Litigation of missed cervical spine injuries in patients presenting with blunt traumatic injury. Neurosurgery. 2007;60(3):516–22.
  • Graziano AF, Scheidel EA, Cline JR, Baer LJ. A radiographic comparison of prehospital cervical immobilization methods. Ann Emerg Med. 1987;16(10):1127–31.
  • Landor R, Ben-galim P, Hipp JA. Motion within the unstable cervical spine during patient manoeuvring: the neck pivot-shift phenomenon. J Trauma. 2011;70(1):247–50.
  • Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-Hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214-9.
  • Ben-Galim P. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma. 2010;69(2):447-50.
  • Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical hard collar on intracranial pressure after head injury. ANZ J Surg. 2002;72(6):389-91.
  • Heath. KJ. The effect on laryngoscopy of different cervical spine immobilization techniques. 1994.
  • Tsutsumi Y, Fukuma S, Tsuchiya A, Ikenoue T, Yamamoto Y, Shimizu S, et al. Association between spinal immobilization and survival at discharge for on-scene blunt traumatic cardiac arrest: a nationwide retrospective cohort study. Injury. 2018;49(1):124-129.
  • Prasarn ML, Conrad B, Del Rossi G, Horodyski M, Rechtine GR. Motion generated in the unstable cervical spine during the application and removal of cervical immobilisation collars. J Trauma Acute Care Surg. 2012;72(6):1609-1603.
  • Kreinest M, Goller S, Rauch G, Frank C, Gliwitzky B, Wölfl CG, et al. Application of cervical collars – an analysis of practical skills of professional emergency medical care providers. PLoS One. 2015;10(11):e0143409.

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