Maintaining Cervical Spine Precautions

In recent years there has been increasing discussion around the use of spinal immobilisation both pre and in hospital, in particular the use of the rigid cervical collar and the evidence behind it (1-6).

There is no scientific evidence that any type of cervical collar used in prehospital transport or initial trauma management is effective in stabilising an acutely injured cervical spine or preventing further neurological deterioration in those with spinal cord injury (7). However, there is evidence that rigid collars can lead to significant complications and morbidity when used to secure the c-spine.

These complications include (11-13):

  • Pressure areas of the scalp and neck
  • Increased pain adversely affecting compliance with immobilisation strategies designed to protect patients from further harm
  • Impaired jugular venous return and rises in intracranial pressure both in head-injured and healthy people
  • Impaired respiratory effort and forced expiratory volume, particularly in older patients with chest injury or comorbid respiratory conditions, predisposing these patients to aspiration
  • Increased complexity of airway management
  • Increased extrication time and delay to definitive treatment

Evidence indicates that we are unable to completely immobilise the C spine in any collar and there is no data to support that any additional movement of an injured C spine causes more damage (13, 14).

After consultation with specialist clinicians across NSW and consideration of the available evidence, The Institute of Trauma and Injury Management (ITIM) and ECI have concluded that the risks of immobilisation with rigid collars outweigh the chance of benefit.

ITIM and ECI are advocating for the adoption of foam cervical collars in the initial management of injured adults and children requiring cervical spine precautions being transported by NSW Ambulance and presenting to NSW Health facilities.

For more information, please read our Position Statement on maintaining cervical spine precautions. This statement also covers application of foam collars in a variety of clinical scenarios.

Source: Curtis and Ramsden: 16.21

Source: ISLHD - How to order soft collars in NSW Health

Further References and Resources

1. Connor, D. et al. (2015) Prehospital spinal immobilisation: an initial consensus statement, Trauma. vol. 17, pp. 146-150.

2. Sundheim et al. (2006) The evidence for spinal immobilisation: an estimate of the magnitude of treatment benefit, Annals of Emergency Medicine, vol. 48, pp. 217.

3. ILCOR guidelines - draft document

4. Sundstrom, T. et al. (2014) Prehospital use of cervical collars in trauma patients: A critical review, Journal of Neurotrauma, vol. 31, no. 6, pp. 531-540.

5. Oteir, A.O. et al. (2015) Should suspected cervical spinal cord injury be immobilised? A systematic review, Injury, vol. 46, pp. 528-535.

6. Bledsoe, B. (2015) Why EMS should limit the use of rigid cervical collars, JEMS, vol. 40, no. 2.

7. Miller CP, Bible JE, Jegede KA, Whang PG, Grauer JN. Soft and rigid collars provide similar restriction in cervical range of motion during fifteen activities of daily living. Spine (1976). 2010;35(13):1271–8.

8. Cameron, P. et al. (2005) The trauma registry as a statewide quality improvement tool, Journal of Trauma, vol. 59, pp. 1469-1476.

9. Burney R. (1993) Incidence, characteristics and outcomes of spinal cord injury at trauma centres in North America, Archives of Surgery, vol. 128, pp. 596-599.

10. Stiel, I.G. et al. (2001) The Canadian C-spine rule for radiography in alert and stable trauma patients, JAMA, vol. 286, pp. 1841-1848.

11. Kwan, I. et al. (2009) Spinal immobilisation for trauma patients, review, Published in the Cochrane Library, issue 1.

12. Benger, J. et al. (2009) Why do we put cervical collars on conscious trauma patients? Commentary, Scan J of Trauma, Resus and Emerg Med, vol. 17, pp. 44.

13. Hauswald, M. et al. (2002) Out of hospital spinal immobilisation in trauma patients: is it really necessary? Curr Opin Crit Care, vol. 8, pp. 566-570.

14. Hauswald, M. et al. (1998) Out of hospital spinal immobilisation: its effect on neurologic injury, Acad Emer Med, vol. 5, pp. 214-221.

15. Blackham, J. et al. (2009) ‘Clearing’ the cervical spine in conscious trauma patients, Trauma, vol. 11, pp. 93-109.

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