Cervical Collars: Helpful or just a pain in the neck?

When to suspect cervical spine injury:

• High energy mechanisms of injury (motor vehicle collisions, high falls)

• head/facial injuries

• high risk concomitant injuries (scapular fractures, sternal fractures, pelvic fractures, etc.)

• Older age

When to CT scan the neck?

1. NEXUS Criteria (SPINE mnemonic) (Hoffman et al)

• Spinal tenderness (midline)

• Painful distracting injury

• Intoxication

• Neurologic deficits

• Encephalopathy/AMS

1. Canadian C-spine Rule (Stiell et al)

   1. High risk features: Yes to any, order CT spine

• Age >65yo

• Paresthesia

• Dangerous Mechanism (fall >3ft/5 stairs, high speed MVC/rollover/ejection, bicycle accident)

  1. Low risk features: No to any, order CT spine

• Simple rear end MVC

• sitting position in ED

• ambulatory at any time

• delayed onset of neck pain

• Absence of Midline C-spine tenderness

  1. Able to rotate neck 45 degrees in both directions: if unable, order CT spine

Do cervical collars benefit cervical injuries?

• Theory behind C-collars

  • Reduces/minimizes neck motion

  • Prevents further damage/cord injuries

  • Prevents partially unstable fractures from becoming unstable

  • Prevents partial spinal cord injury into complete transection

• No robust evidence indicating normal neck movements worsen cervical injuries

  • Cadaveric studies reveal force required to cause ligamentous or bony injuries range from 645 - 7,439 Newtons of Force. This amount of force can only be created by another mechanism of injury, not normal anatomical range of motion (Mainman et al)

• Multiple studies show increased neck motion with cervical collars vs. without cervical collars

  • Collars create pivot points with increased motion at C1, C2 joints and C6, C7 joints (Lador et al)

• Evidence revealing less disability is seen in non-immobilized patients compared to immobilized patients

  • Retrospective study comparing immobilized (USA) to non-immobilized (Malaysia) reveals less disability (Hauswald et al)

  • Cochrane Review reveals no studies of sufficient quality to support or refute traditional spinal immobilization practices

• Multiple downsides to using cervical collars

  • Increased ICP

    • Decreased venous return and dilated internal jugular vein by 37% noted with cervical collar use (Stone et al)

    • Increased opening pressures during LP in patients with cervical collars applied (Kolb et al)

    • Increased motion in pivot points previously stated

    • Increased rate of failed airways especially in prehospital settings (Gaither et al)

Adam Resnick, MD

References

• Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998;32(4):461-469. doi:10.1016/s0196-0644(98)70176-3

• Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848. doi:10.1001/jama.286.15.1841

• Maiman DJ, Sances A, Jr., Myklebust JB, et al. Compression injuries of the cervical spine: a biomechanical analysis. Neurosurgery. 1983;13(3):254-260.

• Lador R, Ben-Galim P, Hipp JA. Motion within the unstable cervical spine during patient maneuvering: the neck pivot-shift phenomenon. J Trauma. 2011;70(1):247-251. doi:10.1097/TA.0b013e3181fd0ebf

• Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214-219. doi:10.1111/j.1553-2712.1998.tb02615.x

• Stone MB, Tubridy CM, Curran R. The effect of rigid cervical collars on internal jugular vein dimensions. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine. 2010;17(1):100-102.

• Kolb JC, Summers RL, Galli RL. Cervical collar-induced changes in intracranial pressure. The American journal of emergency medicine. 1999;17(2):135-137.

• Gaither JB, Spaite DW, Stolz U, Ennis J, Mosier J, Sakles JJ. Prevalence of difficult airway predictors in cases of failed prehospital endotracheal intubation. J Emerg Med. 2014;47(3):294-300. doi:10.1016/j.jemermed.2014.04.021

• Orman R, Colwell C. Do we still need the C-collar: Emergency Medicine Reviews and Perspectives. February 2016. Accessed January 7, 2024. https://www.emrap.org/episode/feb2016emrap/dowestillneed.

• Bucher J, Joseph J. Cervical collars for C-spine trauma: The facts. emDOCs.net - Emergency Medicine Education. July 2016. Accessed January 7, 2024. http://www.emdocs.net/cervical-collars-for-c-spine-trauma-the-facts/.