Cervical Spine Collars & Immobilisation

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C-spine Immobilisation and Clearance

Cervical collars have been used since the Vietnam War and after their implementation in the ATLS guidelines they have been considered the benchmark in trauma patients when there were any concerns about the C-Spine stability.

Studies about the real utility of these devices to date haven’t shown a clear benefit, mostly of them have been poorly conducted with a limited number of patients due to the potential catastrophic consequences of secondary spinal injuries. Subsequently the pre-hospital and intra-hospital management hasn’t changed for years.

So, collars have been introduced to prevent secondary injury to the spinal cord but what does the literature say about this practice? Are they really game-changing?

In a recent review by OTO (2015), the authors reviewed the published literature from 1979 till 2013 and they concluded that the cause of deterioration of the 24 c-spine injuries in a total of 12 different studies, were non specific and more importantly not care related.

They identified 3 categories of high- risk patients for secondary deterioration after c-spine trauma:

  • altered mental status
  • ankylosing spondylitis
  • iatrogenic manipulation.

And their conclusion about Secondary injury was mostly linked to:

  • thrombosis
  • hypotension
  • hypoxia
  • but NOT care related.

So, we don’t have a clear demonstration of their utility but what about their potential harm?

What we know so far……

  • increased intracranial pressure by reducing the venous drainage ( up to 4.5 mmHg)
  • aspiration/ respiratory compromise
  • limiting mouth opening. More difficult airway management.
  • pain from local ischaemia
  • hiding other injuries
  • claustrophobia
  • delays in transport

In this review by Benger (2009), the authors discuss the drawbacks associated with collars and immobilisation devices and suggest not to use them in co-operative patients even if an underlying cervical spine fracture is suspected for these reasons:

  1. Unstable C-spine injuries in awake and co-operative patients are rare (UK 10-15 per million per year spinal cord trauma. Half of them are cervical #).
  2. Unlikely, in awake patients, further movement will cause more harm than the initial force which created an unstable injury.
  3. Often cervical collars are poorly applied and even if well fitted, they don’t avoid neck movements (30 degrees flexion and extension are still permitted).
  4. Potential harms discussed previously.

Moreover in patient with a penetrating cervical trauma we already know the harms caused by general immobilisation hence the cervical collar must be avoided. Once of the most representative studies about this topic was published by Haut (2010). A retrospective analysis of penetrating trauma patients.

Primary outcome: mortality. Calculated NNT and NNH for spine immobilisation.

Total of 45,284 pts.

4.3% underwent spinal immobilisation. Overall mortality 8.1%

OR of death 2.06 if immobilised (95% CI: 1.35-3.13)

NNT 1.032

NNH 66

Evidence Surround C-Spine Clearance

In 2000 Hoffman et al published the NEXUS study (overall 34 069 blunt trauma patients).

Briefly, if patients meet all the 5 criteria, no imagining is needed and the C-spine can be cleared……..

Screen Shot 2015-12-03 at 20.20.37

Sensitivity 99%

Specificity 12.9%

NPV 99.8%

PPV 2.7%

In 2001, Stiell et al published a study which became famous as the Canadian C-Spine rule (CCR). (in total 8924 awake blunt trauma patients)……

Screen Shot 2015-12-17 at 21.44.53

In 2003 Stiell et al compared NEXUS vs CCR in a prospective cohort study (8283 patients) (12)

Results:

With CCR: 1 missed injury;

Nexus 16 missed injuries, 4 of which unstable

CCR was statistically more sensitive than the NEXUS in the detection of significant cervical spine injury.

C-spine Clearance and Guidelines

In 2009 the Eastern Association for surgery of trauma (EAST) published their guidelines about the management of cervical spine clearance in the traumatically injured patient.

The first edition can be easily summarised with these 4 points:

  • In awake, non symptomatic patients the c-spine can be cleared following the NEXUS criteria.
  • MDCT scan has got Class I Level I evidence of being superior to cervical x-ray.
  • In obtunded patients or awake but symptomatic a MRI should be done
  • Hard collar should be removed within 72 hrs and avoid prolonged immobilisation

There has been a long debate about the superiority of MRI towards CT.

Several studies and meta-analysis failed to highlight any superiority of the former.

Finally, BADHIVALA (2015) completed a systematic review of 28 observational studies (3627 patients with blunt trauma and obtunded) 20 retrospective cohort and 8 prospective (0% significant injuries missed if CT negative).

The conclusion was: WELL-INTERPRETED AND HIGH-QUALITY SCAN can avoid prologued collar use and routine adjust images

Primary outcome: clinically significant (mechanical instability) c-spine injuries missed by CT scan and detected with other tests.

Limits: retrospective studies. Only in English. No paeds.

Morevoer, CCT requires less time to complete the exam and there is an all in all reduction of costs!

In September 2015, EAST published the updated guidelines for C-spine clearance in obtunded patients. The conditional recommendation is to clear the c-spine in the obtunded patient who sustained blunt trauma after a negative MDCT alone. (conditional due to the very low-quality evidence).

They based their suggestion on a Systematic Review. The lack of RCT and complete cohort study designs was stressed out

Of 52 studies identified, only 12 were included in the qualitative synthesis and data extraction. Of 5 articles with a total follow-up of 1,017 patients none reported changes after collar removal. Of 11 studies with a total of 1,718 patients, no unstable c-spine fracture missed.

NPP MDCT 100% for unstable injury

91% any stable injury.

Their primary outcomes were new neurologic changes after cervical clearance and identification of an unstable injury.

Secondary ones: stable C-spine injury and their treatment, post-clearance imaging, false-negative CT, pressure ulcers and time to cervical removal

strenghts: multilevel systematic dual-review of the literature

limitations: low quality data and bias. Possible type II error (underpowered studies). Non homogeneous interpretation of the term obtunded.

In conclusion

If all the NEXUS criteria are met or the CCS is negative: clear the c-spine

If MDCT is negative, c-spine can be cleared even in the obtunded patients without requiring any other imaging.

Further information in February 2016 when NICE will publish the “Spinal Injury Assessment”guidelines.

Erika

References

  1.  American College of Surgeons Committee on Trauma. ATLS–9th Edition 2012, American College of Surgeons, Chicago.

2.         Hauswald, M., and Braude, D. Spinal immobilization in trauma patients: is it really necessary? Curr. Opin. Crit. Care 2002 8; 566–57

3.       Oto B, Corey DJ, Oswald J et al. Early secondary neurologic deterioration after blunt spinal trauma: a review of the literature. Academic emergency Medicine. 2015; 22: 1200-1212.

4.     Abram, S., and Bulstrode, C. Routine spinal immobilization in trauma patients: what are the advantages and disadvantages? Surgeon 2010 8; 218–222

5.     Hunt, K., Hallworth, S., and Smith, M. The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia 2001 56; 511–513

6.     Goutcher, C.M., and Lochhead, V. Reduction in mouth opening with semi-rigid cervical collars. Br. J. Anaesth. 2005 95; 344–348

7.     Benger, J., and Blackham, J. Why do we put cervical collars on conscious trauma patients? Scand. J. Trauma Resusc. Emerg. Med. 2009 17; 44-48

8.   Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm than good? J Trauma 2010;68:115–20.

9. HoffmanJR,WolfsonAB,ToddKH,MowerWR.Selectivecervicalspine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998;32:461-9

10. Hoffman JR, Mower WR, Wolfosn AB. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. NEJM 2000; 343 (2): 94-99

11. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286:1841–8.

12. Stiell IG, Clement CM, McKnight RD The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003; 349:2510–2518

13. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma 2009;67:651Y659.

14. Panczykowski DM, Tomycz ND, Okonkwo DO. Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma. J Neurosurg. 2011;115:541-9.

15. Badhiwala JH, Chung KL, Alhazzani W. Cervical Spine clearance in obtunded patients after blunt traumatic injury. Ann Int Med 2015; 162: 429-437.

16. Patel MB, Humble SS, Cullinane DC et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. Trauma Acute Care Surg. 2015; 78(2): 430-441

7 thoughts on “Cervical Spine Collars & Immobilisation

  1. Minh Le Cong says:

    Hi there! great over view of issue on hard neck collars so thanks.
    I would suggest you also look at the Norwegian and Queensland publications on this issue in recent years as they have gone further to advocate for no hard neck collar use at all.

    In my state of Queensland in 2015 the state ambulance service removed all hard collar neck use and have published their SOP including evidence base review on their website ( I have linked their references on my PHARM website)

    Your review goes to the point of saying we have no good evidence of benefit for hard neck collars in trauma patients but then you dont come to any recommendation nor conclusions about what to do about this dilemma, apart from saying lets wait for 2016 NICE guideline.

    Just wanted to point out other countries literature and guidelines on this issue that you did not mention .
    thanks again for the excellent podcast summary

  2. sl says:

    Hi Minh

    Thanks for listening and getting in touch. As mentioned on twitter last night we it’s a fine balance between sparking further debate and interest in the topic and standing strong and stating that a change needs to happen. It’s the fine line between the early adopters causing havoc to those who haven’t investigated the topic and being too slow to adopt the belief that you hold.

    We may have fallen down on the noncommittal side here this time so thanks for the feedback

    Take care and a I hope you have a great Xmas

    Simon

  3. Erika says:

    Hi Minh,
    Thanks for your comment and your precious suggestions!
    Hard collars have been an uncontested device for the latest 40 years but ,luckily, in the past 5 years something seems to have changed in our perception of this tool and its real benefits.
    I hope 2016 is “the” year for this change and that the UK and the rest of Europe as well will follow Norway and Queensland example.

  4. Sue Ieraci says:

    Hi, All. Thanks for addressing this issue – a real bugbear of mine. It seems that we can intelligently approach severe sepsis or STEMI, but we lose our nerve when logically approaching cervical spine injury and the practice of immobilisation. We remain worried that we will “make the person paralysed” – even though there is a wealth of evidence that this is not true.

    We also make the mistake of applying a process that makes sense for the unconscious multi-trauma patient to the awake person with minor injury, with or without sore neck.

    For the unconscious major trauma patient, let’s just CT all the necks, unless going to the CT will jeopardise control of oxygenation or perfusion.

    For the awake and rational, let’s do history and examination, just like we normally do. There is no good evidence that hard collars do anything for these people except make their pain worse, which then leads to more imaging. Let’s watch the people for a while, give analgesics, see whether the neck pain gets better, if not, image. Like we do with other injuries, we can advise the person that initial diagnosis isn;t perfect, and that, if pain persists, they should seek follow-up and perhaps delayed imaging. The nature of any neck injury that does not manifest on initial careful clinical screening does not suddenly lead to cord injury. For every terrifying anecdote of the “missed” cervial spine injury, it’s likely that there are many future thyroid cancers in the “cautiously”tested with low risk of fracture.

    It’s time to reclaim our clinical skills.

  5. Brandon O says:

    Well said, Sue. I think that’s a reasonable approach.

    As lead author of the first piece cited, I wrote a quick follow-up that walks through some of the alternate approaches we might select even if we explode the old paradigm of the “sudden mysterious deterioration in an unstable spine.” Might be of interest: http://emsbasics.com/2015/10/12/life-without-the-boogeyman-alternate-models-of-emergency-spinal-care/

  6. Erika says:

    Hi Brandon, thank you so much for listening to our podcast and sharing your latest article about this tricky topic.
    You analysed and summarised the current state of the art about spinal immobilisation and in my view, the “hard collar dogma” will be over in the next few years.
    As Sue pointed out we need to start again reclaiming our clinical skills!

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