Cervical Collars Deemed Redundant or Worse

A new critical review discusses the pros and cons of using a rigid cervical collar in trauma patients, due to a growing body of evidence and opinion against their use.

Researchers at Haukeland University Hospital (Bergen, Norway) are proposing a new standard operating procedure (SOP) for prehospital spinal immobilization that does not include routine use of cervical collars. The SOP has already been implemented by the Bergen Hospital Emergency Medical Service (HEMS), due to the fact that despite long standing use, there has not been any proven benefit from their use in trauma patients, but rather increasing evidence of possible harm and unwanted effects.

These effects include evidence that the cervical collar can lead to increased movement in the upper parts of the neck; evidence that in patients with trauma affecting the spine, larger neurological deficits were detected in areas where the cervical collar is routine use, compared to areas where they are not in use; evidence that the cervical collar increases intracranial pressure (ICP) due to decreased venous return resulting from venous compression of the neck; that cervical collars hamper airway management; and evidence that cervical collars lead to increased risk of aspiration.

The review also details specific treatment scenarios. Awake patients can stabilize their own neck and do not need a cervical collar, including during vehicle extrication. Unconscious, nonintubated patients should be transported in the lateral trauma position, focusing on keeping the spine straight by using blankets under the head, between the legs and under the abdominal area. If intubated and lying on their backs, a standard pillow can be used to lightly stabilize the neck and keep it in a more natural position. For handling or moving the patient, the EMS team will have to keep the spine stabilized.

The only indications left in the SOP for use of a cervical collar is during difficult vehicle extrication of unconscious patients, where the EMS personnel cannot get in position to stabilize the patient’s head adequately, and for stabilizing the neck during stretcher carrying in difficult terrain. However, once the extraction from the difficult terrain has been completed, the cervical collar should be removed for transport. The review and new suggested SOP were published on March 15, 2014, in the Journal of Neurotrauma.

“Due to the cervical collar use being cemented by advanced trauma life support and introduced to the trauma patient with the A in ABC, this is sure to spark some controversy,” said lead author Helge Asbjørnsen, MD, of the HEMS department. “However, when there is no good evidence supporting the use of cervical collars, but some (although weak) evidence against its use, the only rationale is to abandon it.”

A cervical collar (or neck brace) is an orthopedic device used to stabilize the top seven vertebrae (C1 through C7). Cervical collars are also used therapeutically to help realign the spinal cord and relieve pain; another use of the cervical collar is for strains, sprains, or whiplash. A patient may also need a cervical collar to support the neck during recovery after neck surgery, such as following cervical spinal fusion.

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Haukeland University Hospital