Use Of Cervical Collar Research Articles

Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review.

Cervical spine clearance protocols are controversial for unconscious patients after blunt traumatic injury and negative findings on computed tomography (CT). To review evidence about the utility of different cervical spine clearance protocols in excluding significant cervical spine injury after negative CT results in obtunded adults with blunt traumatic injury. MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library were searched from January 2000 through November 2014. English-language studies that examined patients with negative CT results having confirmatory routine testing with magnetic resonance imaging (MRI), dynamic radiography, or clinical examination and that reported outcome measures of missed cervical spine injury, need for operative stabilization, or prolonged use of cervical collars. Independent reviewers evaluated the quality of studies and abstracted the data according to a predefined protocol. Of 28 observational studies (3627 patients) that met eligibility criteria, 7 were prospective studies (1686 patients) with low risk of bias and well-interpreted, high-quality CT scans. These 7 studies showed that 0% of significant injuries were missed after negative CT results. The overall studies using confirmatory routine testing with MRI showed incidence rates of 0% to 1.5% for cervical spine instability (16 studies; 1799 patients), 0% to 7.3% for need for operative fixation (17 studies; 1555 patients), and 0% to 29.5% for prolonged collar use (16 studies; 1453 patients). Most studies were retrospective. Approaches to management of soft tissue changes with collars varied markedly. Cervical spine clearance in obtunded adults after blunt traumatic injury with negative results from a well-interpreted, high-quality CT scan is probably a safe and efficient practice. None.

Can focused trauma education initiatives reduce mortality or improve resource utilization in a low-resource setting?

Over 90% of injury deaths occur in low-income countries. Evaluating the impact of focused trauma courses in these settings is challenging. We hypothesized that implementation of a focused trauma education initiative in a low-income country would result in measurable differences in injury-related outcomes and resource utilization. Two 3-day trauma education courses were conducted in the Rwandan capital over a one-month period (October-November, 2011). An ATLS provider demonstration course was delivered to 24 faculty surgeons and 15 Rwandan trauma nurse auditors, and a Canadian Network for International Surgery Trauma Team Training (TTT) course was delivered to 25 faculty, residents, and nurses. Trauma registry data over the 6 months prior to the courses were compared to the 6 months afterward with emergency department (ED) mortality as the primary endpoint. Secondary endpoints included radiology utilization and early procedural interventions. Univariate analyses were conducted using χ(2) and Fisher's exact test. A total of 798 and 575 patients were prospectively studied during the pre-intervention and post-intervention periods, respectively. Overall mortality of injured patients decreased after education implementation from 8.8 to 6.3%, but was not statistically significant (p = 0.09). Patients with an initial Glasgow Coma Score (GCS) of 3-8 had the highest injury-related mortality, which significantly decreased from 58.5% (n = 55) to 37.1% (n = 23), (p = 0.009, OR 0.42, 95% CI 0.22-0.81). There was no statistical difference in the rates of early intubation, cervical collar use, imaging studies, or transfusion in the overall cohort or the head injury subset. When further stratified by GCS, patients with an initial GCS of 3-5 in the post-intervention period had higher utilization of head CT scans and chest X-rays. The mortality of severely injured patients decreased after initiation of focused trauma education courses, but no significant increase in resource utilization was observed. The explanation may be complex and multi-factorial. Long-term multidisciplinary efforts that pair training with changes in resources and mentorship may be needed to produce broad and lasting changes in the overall care system.

Are there any differences in medical emergency team interventions between rural and urban areas? A single-centre cohort study

To compare interventions of medical emergency teams in urban and rural areas with particular emphasis on response time and on-site medical rescue activities. A retrospective analysis of ambulance call reports from two emergency medical service substations: one in the city and the other in a rural area. Two emergency medical service substations: one in the city and the other in a rural area. Medical emergency teams. Interventions in the city were associated with a substantially shorter response time in comparison to rural areas. In the city, the distances were generally less than 10 km. In the rural area, however, such short distances accounted for only 7.2% of events, while 33.8% were over 30 km. Medical emergency teams more often acted exclusively on-site or ceased any interventions in rural areas. Compared with the city, actions in the rural setting were associated with significantly increased use of cervical collars and decreased use of intravenous access. The presence of a physician in the team raised the probability of pharmacotherapy. The relationship between medical emergency teams activities and the location of intervention shows the real diversity of the functioning of emergency medical service within a city and rural areas. Further research should aim to improve the generalisability of these findings.

The measurement of tissue interface pressures and changes in jugular venous parameters associated with cervical immobilisation devices: a systematic review

Cervical immobilisation is commonly applied following trauma, particularly blunt head injury, but current methods of immobilisation are associated with significant complications. Semi-rigid disposable cervical collars are known to cause pressure ulcers, and impede effective airway management. These collars may also exacerbate a head injury by increasing intracranial pressure as a result of external compression of the jugular veins. There is a clear imperative to find ways of effectively immobilising the cervical spine whilst minimising complications, and any assessment of existing or new devices should include a standardized approach to the measurement of tissue interface pressures and their effect on jugular venous drainage from the brain. This systematic review summarises the research methods and technologies that have been used to measure tissue interface pressure and assess the jugular vein in the context of cervical immobilisation devices. 27 papers were included and assessed for quality. Laboratory investigations and biomechanical studies have gradually given way to methods that more accurately reflect clinical care. There are numerous accounts of skin ulceration associated with cervical collars, but no standardised approach to measuring tissue interface pressure. It is therefore difficult to compare studies and devices, but a pressure of less than 30 mmHg appears desirable. Cervical collars have been shown to have a compressive effect on the jugular veins, but it is not yet certain that this is the cause of the increased intracranial pressure observed in association with cervical collar use. This is the first review of its type. It will help guide further research in this area of trauma care, and the development and testing of new cervical immobilisation devices.

Prehospital use of cervical collars in trauma patients: a critical review.

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

Is there a need for cervical collar usage post anterior cervical decompression and fusion using interbody cages? A randomized controlled pilot trial

Anterior cervical discectomy and fusion (ACDF) is a common surgical intervention for radiculopathy resulting from degenerative cervical spine conditions. Post-surgical cervical collar use is believed to reduce post-operative pain, provide the patient with a sense of security during activities of daily living and even reduce rates of non-fusion. This prospective randomized controlled pilot trial investigates trial design feasibility in relation to prospective physical, functional, and quality of life-related outcomes of patients undergoing ACDF with interbody cage, with (n = 17) and without (n = 16) post-operative cervical collar usage. Results show that the sample provides sufficient statistical power to show that the use of a rigid cervical collar during 6 post-operative weeks is associated with significantly lower levels of neck disability index after 6 weeks and significantly lower levels of prospective neck pain. To investigate causal quality of life or fusion rate outcomes, sample size needs to be increased at least fourfold and optimally sixfold when accounting for data loss in prospective follow-up. The study suggests that post-surgical cervical collar usage may help certain patients cope with initial post-operative pain and disability.

A re-conceptualisation of acute spinal care

The emergency care of patients who may have spinal injuries has become highly ritualised. There is little scientific support for many of the recommended interventions and there is evidence that...

Pressure ulcers in cervical spine immobilisation: a retrospective analysis

To determine the incidence of pressure ulceration in patients treated with cervical spine immobilisation. A retrospective case note analysis was conducted of all patients presenting with cervical spine injuries, who were treated with cervical spine immobilisation. Ninety consecutive patients were analysed retrospectively. Multiple level injuries were the most common reported injury and mean time until definitive treatment was 7.4 days. Halo immobilisation was used most frequently, with the mean time in halo vest immobilisation being 74 days. One patient was reported to have a pressure ulcer to the scapula relating to the use of halo immobilisation. No pressure ulcers were reported in patients immobilised with the use of cervical collar or occipito-cervico-thoracic immobilisation devices. Patients with cervical spine immobilisation have an increased risk of developing pressure ulcers. All patients with cervical immobilisation devices require close monitoring to monitor the risk of developing pressure ulcers as well as the overall management of the medical condition.

Value of a rigid collar: in need of more research and better devices

The use of cervical collar, head blocks and tape on a stable surface (such as a long spine board or hospital trolley) has long been accepted as the standard of...

Impact of Cervical Spine Management Brain Injury on Functional Survival Outcomes in Comatose, Blunt Trauma Patients with Extremity Movement and Negative Cervical Spine CT: Application of the Monte Carlo Simulation

Cervical spine (CS) magnetic resonance imaging (MRI) and collar use may prevent quadriplegia, yet create brain injury. We developed a computer model to assess the effect of CS management strategies on outcomes in comatose, blunt trauma patients with extremity movement and a negative CS CT scan. Strategies include early collar removal (ECR), ECR & MRI, late collar removal (LCR), and LCR & MRI. MRI risks include hypoxia, hypotension, increased intracranial pressure (↑ICP), and ventilator-associated pneumonia (VAP). LCR risks include ↑ICP, VAP, and delirium. Model elements include Quadriplegia and Primary, Secondary, LCR, and MRI Brain Injury. The Monte Carlo simulation determines health outcomes (Functional Survival versus Quadriplegia, Severe Brain Disability, or Dead). Utility values are Functional Survival 0.90, Quadriplegia 0.20, Severe Brain Disability 0.10, and Dead 0.00. Years of life expectancy are Functional Survival 39.5, Quadriplegia 20.0, Severe Brain Disability 20.0, and Dead 0.0. Unstable CS rate 2.5%: Functional Survival/1,000: Unstable Patients: ECR 384, LCR 350, LCR & MRI 332, ECR & MRI 331; High-Risk Patients: ECR 161, LCR 151, LCR & MRI 140, ECR & MRI 153; Stable Patients: ECR 596, LCR 587, LCR & MRI 573, ECR & MRI 595. Quality-Adjusted Life Months for Unstable, High-Risk, and Stable Patients are greater with ECR; Stable Patient ECR and ECR & MRI are similar. Unstable CS rate 0.5%: Functional Survival/1000: Unstable Patients: ECR 394, LCR 352, LCR & MRI 332, ECR & MRI 332; High-Risk Patients: ECR 164, LCR 151, LCR & MRI 140, ECR & MRI 152; Stable Patients: ECR 611, LCR 592, LCR & MRI 576, ECR & MRI 598. Quality-Adjusted Life Months for Unstable, High-Risk, and Stable Patients are greater with ECR. LCR and MRI brain injury results in losses of functional survivorship that exceed those from quadriplegia. Model results suggest that early collar removal without cervical spine MRI is a reasonable, and likely the preferable, cervical spine management strategy for comatose, blunt trauma patients with extremity movement and a negative cervical spine CT scan.

The Rodeo Athlete

A previous instalment to this review focused on the sport science for rodeo, the history behind the sport and what is currently known about the physical and physiological status, coronary risk profile, strength and power levels, event-specific kinesiological and biomechanical aspects, nutritional habits and psychological indices associated with the rodeo athlete. In regards to injury, rodeo is well known for its high-velocity, high-impact atmosphere where athletes compete against the clock and uncooperative livestock. Considered by many to be a dangerous sport with high vulnerability towards trauma and frequent injuries, animal/human contact events comprise ∼80% of reported injuries. Severe trauma includes fractures, dislocations, subluxations, concussions, ligament ruptures, pneumothorax and various neurapraxias. Head and neck trauma account for 10-29% of total trauma and up to 63% of upper body injuries, with concussion incidence rates of 3.4 per 1000 competitive exposures. The incidence of thoracic, back and abdominal injuries comprise 11-84% of trauma, while shoulder injuries, involving anterior/posterior arthralgia, inflammation, instability and increasing weakness, account for 8-15% of upper extremity cases. Lower extremity trauma accounts for 26-34% of cases, with the majority involving the knee. Many believe that the incidence of trauma is underestimated, with studies hampered by numerous limitations such as a lack of injury awareness, missing data, poor injury recall, an array of reporting sources, delays in subject response and treatment, no uniform definition of injury or reporting system and predisposing factors prior to injury. Primary mechanisms of injuries are attributed to physical immaturity, fatigue, age and experience, behaviour, the violent nature of the sport and lack of adequate medical intervention. Although there is limited adherence to organized conditioning programmes, when properly planned, sport-specific conditioning may enhance athletic potential, minimize predisposition to injury and enhance recovery. Education in care and rehabilitation should be spearheaded by the medical community to reduce injury, as several studies have linked trauma to poor technique, inexperience and poor judgement. Medical services should encompass emergency medical oversight for trauma at all levels and press toward preventive care. Competitors should also be cognizant of the signs and symptoms of overtraining, a condition exacerbated by overuse and minimal recovery. The use of helmets, taping, bracing, protective vests, cervical collars and mouthpieces is gaining popularity but has not been thoroughly studied. Guidelines requiring padding of chutes, gates or equipment essential for performance may also avert trauma. Whether increases in knowledge, education and technology are able to reduce predisposition to injury among this population, remains to be seen. As with all high-risk sports, the answer may lie in increased wisdom and responsibility of coaches and athletes to ensure an adequate level of ability, self-control and common sense as they compete in this sport.

No Evidence Supports Use of Cervical Collar

No Evidence Supports Use of Cervical Collar

Use of Cervical Collar After Single-Level Anterior Cervical Fusion With Plate

Randomized clinical trial. This study is evaluates whether the use of a cervical collar after single-level anterior cervical fusion with plating increases the fusion rate and improved clinical outcomes. Plates limit motion between the graft and the vertebra in anterior cervical fusion. Still, the use of cervical collars after instrumented anterior cervical fusion is widely practiced. Patients enrolled in an FDA-regulated, multicenter trial in 32 centers treated with single-level decompression and arthrodesis using allograft and an anterior cervical plate were included in the analysis. Patients were divided into Braced and Nonbraced groups regardless of type of brace. SF-36, Neck Disability Index (NDI), Numerical Rating Scales (0-100) for neck and arm pain were determined before surgery, 1.5, 3, 6, 12, and 24 months after surgery. Fusion was assessed by independent radiologists at 6, 12, and 24 months after surgery using upright AP, lateral, and flexion-extension views. Fusion success was defined as the presence of bridging trabecular bone, angulation of less than or equal 4 degrees on flexion-extension radiographs; and absence of radiolucencies. Two hundred fifty-seven patients were included in the analysis, 149 were braced and 108 were not. Demographic characteristics and baseline outcome measures of both groups were similar. There was also no statistically significant difference in any of the clinical measures at baseline except for SF-36 Physical Component Summary score. The SF-36 Physical Component Summary, NDI, neck, and arm pain scores were similar in both groups at all time intervals and showed statistically significant improvement when compared with preoperative scores. There was no difference in the proportion of patients working at any time point between the Braced and Nonbraced group. Independent radiologists reported higher rates of fusion in the Nonbraced group over all time intervals, none of which were statistically significant. Our results show that the use of a cervical brace does not improve the fusion rate or the clinical outcomes of patients undergoing single-level anterior cervical fusion with plating.

Computed Tomography Alone for Cervical Spine Clearance in the Unreliable Patient—Are We There Yet?

Injuries to the cervical spine (CS) occur in 2% to 6.6% of blunt trauma patients. Studies have suggested that computed tomography (CT) alone is sufficient for CS clearance in unreliable patients based on follow-up magnetic resonance (MR) imaging not altering management. We hypothesized that an admission cervical spine CT with no acute injury-using new CT technology-is not sufficient for CS clearance in an unreliable patient. The trauma registry was used to identify all patients with blunt trauma who had CS imaging with a CT and MR between August 2004 and December 2005. During this time period, a clinical guideline was in place whereby patients who had persistently unreliable examinations had MR despite a normal admission CT. Medical records were reviewed for demographics, Glasgow Coma Scale (GCS) score at time of MR, and injury specific data. Seven hundred thirty-four patients in total were identified. Two hundred three patients without obvious neurologic deficits but unreliable clinical examination, defined by a GCS score of </=14, had an initial cervical spine CT read by an attending trauma radiologist as having no acute injury. Mean age was 42.3 years (+/-20.4 years) and mean Injury Severity Score was 29.1 (+/-11.8). There were 135 (66.5%) men. Mechanism of injury included motor vehicle or motorcycle collision (48.8%), falls (25.4%), pedestrians struck (10.2%), assault (7.8%), and other (7.8%). One hundred eighty-four (90.6%) patients had a negative MR and collars were subsequently removed. After collar removal, no patient developed new neurologic deficit. Eighteen (8.9%) patients had an abnormal MR, 2 of which required operative repair and 14 required extended cervical collar use. Two patients had collars removed at the discretion of the attending surgeon. One patient had a suboptimal MR and was discharged in a collar with scheduled follow-up. Newer generation CT continues to miss CS injuries in unreliable patients. MR changed the management in 7.9% of patients having had an admission CT with no acute injury. Thus, we recommend continued use of MR for CS clearance in the unreliable patient and ongoing evaluation as the quality of CT imaging continues to evolve.

Risks associated with magnetic resonance imaging and cervical collar in comatose, blunt trauma patients with negative comprehensive cervical spine computed tomography and no apparent spinal deficit

IntroductionIn blunt trauma, comatose patients (Glasgow Coma Scale score 3 to 8) with a negative comprehensive cervical spine (CS) computed tomography assessment and no apparent spinal deficit, CS clearance strategies (magnetic resonance imaging [MRI] and prolonged cervical collar use) are controversial.MethodsWe conducted a literature review to delineate risks for coma, CS instability, prolonged cervical collar use, and CS MRI.ResultsBased on our search of the literature, the numbers of functional survivor patients among those who had sustained blunt trauma were as follows: 350 per 1,000 comatose unstable patients (increased intracranial pressure [ICP], hypotension, hypoxia, or early ventilator-associated pneumonia); 150 per 1,000 comatose high-risk patients (age > 45 years or Glasgow Coma Scale score 3 to 5); and 600 per 1,000 comatose stable patients (not unstable or high risk). Risk probabilities for adverse events among unstable, high-risk, and stable patients were as follows: 2.5% for CS instability; 26.2% for increased intensive care unit complications with prolonged cervical collar use; 9.3% to 14.6% for secondary brain injury with MRI transportation; and 20.6% for aspiration during MRI scanning (supine position). Additional risk probabilities for adverse events among unstable patients were as follows: 35.8% for increased ICP with cervical collar; and 72.1% for increased ICP during MRI scan (supine position).ConclusionBlunt trauma coma functional survivor (independent living) rates are alarming. When a comprehensive CS computed tomography evaluation is negative and there is no apparent spinal deficit, CS instability is unlikely (2.5%). Secondary brain injury from the cervical collar or MRI is more probable than CS instability and jeopardizes cerebral recovery. Brain injury severity, probability of CS instability, cervical collar risk, and MRI risk assessments are essential when deciding whether CS MRI is appropriate and for determining the timing of cervical collar removal.

When should a cervical collar be used to treat neck pain?

Neck pain is one of the most prevalent and costly health problems in the United States. It remains a complex, subjective experience with a variety of musculoskeletal causes. Although, cervical collars are a seemingly benign intervention, they can have adverse effects, especially when used for longer periods of time. It is feared that a long period of immobilization, can result in atrophy-related secondary damage. Many physicians cite anecdotal evidence of their clinical utility and soft cervical collars are often prescribed by convention for patients complaining of neck pain. The use of cervical collars to treat neck pain is an area of controversy. This review article examines the current evidence and studies related to recommending cervical collars for neck pain of a variety of etiologies.

The Incidence of Skin Breakdown Associated With Use of Cervical Collars

The most common adverse complication associated with cervical immobilization is skin breakdown. The purpose of this prospective, descriptive study was to assess the incidence of tissue breakdown associated with cervical immobilization. In this convenience sample of 484 patients, skin breakdown was noted in 33 (6.8%) patients. All cases of documented skin breakdown were stage I or II, with only 2 (0.4%) patients having stage III breakdown. Days in the cervical collar is a significant predictor of skin breakdown, along with presence of edema. Results from this study demonstrate that there is a very low incidence of complications of skin breakdown associated with the use of Aspen cervical collars. The collars are safe and effective to use in patients with actual or suspected head or spine injuries.

Evaluation of prehospital emergency care in the field and during the ambulance drive to the hospital

This study was conducted to evaluate the appropriateness of ambulance procedures and interventions in the management of patients dispatched to 2 emergency departments (EDs) of urban hospitals in Izmir. Use of trauma boards and cervical collars, airway patency, breathing, and circulation problems were recorded in both EDs. Eighty-one patients with a mean age of 47.54 +/- 2.36 years (range, 4-89) brought into the ED via ambulances were enrolled in the study. Airway maneuvers were performed in patients with airway and breathing problems. There was no significant relationship between administration of IV fluids and the presence of circulatory impairment (P=.053). A trauma board was used in 9 of 30 trauma cases (30%) and a cervical collar in 6 of 30 (20%). It was concluded that basic procedures used in the management of patients brought into the ED via ambulances were inadequate.

Insult after Injury

Nonexperimental-Descriptive. The inclusion criteria were trauma patients, ages 15 and older, who were hospitalized for > 2 days, and who did not have preexisting skin breakdown. A total of 148 consecutive trauma patients admitted to the study institution meeting the inclusion criteria were prospectively enrolled. Patients were assessed every 3 days for skin breakdown. Information on the patient's bed type, therapies, medical devices, and nutrition was collected. The Braden Scale for predicting pressure ulcer risk was completed at each assessment. Of the 148 patients enrolled, 30 developed at least one area of skin breakdown for a prevalence of 20.3% in patients hospitalized more than 2 days. The most common cause of breakdown was positional pressure (47.4%). Cervical collars were the second leading cause at 23.7%, followed by tracheostomy/endotracheal tubes at 10.5%. The mobility subscale of the Braden Pressure Ulcer Risk Assessment tool was significantly predictive of skin breakdown (p < .001). Skin breakdown is a significant problem in trauma patients who are hospitalized for more than 2 days. Aggressive protocols on positioning, cervical collar use, and airway adjuncts, as well as additional active nursing interventions for immobile patients, may be ways to decrease the skin breakdown prevalence in this population.

Outcome Analysis of Noninstrumented Anterior Cervical Discectomy and Interbody Fusion in 348 Patients

Twenty-one outcome and outcome-relevant variables (fusion and patient satisfaction) were evaluated in a subset of 348 of 514 patients operated on by one surgeon during a 22-year period, using Cloward's anterior cervical discectomy and dowel interbody fusion. Minimum patient follow-up was 2 years; average length of follow-up was 5.2 years. This retrospective analysis is accompanied by a comprehensive review of the literature (1975-1996) of noninstrumented anterior cervical fusions, excluding fibular grafts alone in the interbody space. To provide data on outcome (with regard to patient satisfaction and radiologically supported fusion) and risks of noninstrumented anterior cervical discectomy and fusion for intractable cervical nerve root and spinal cord compression symptoms at single or multiple levels, using the results from a single surgeon. Three experienced spine radiologists determined fusion rates in one to five levels in 348 patients on the basis of the results of plain film analysis. Patient self-assessment was used to determine degree of patient satisfaction and other related variables. From a comprehensive review of the literature, 43 clinical reports meeting requirements for comparison of findings with those in the current study were selected from more than 1600 reports. The mean fusion rate for 348 patients in the current study ranged from 75% (multilevel) to 88% (one level; n = 202). The overall fusion rate was 83%. The persistent complication rate was 0.1%, and patient self-assessments showed that 78% were satisfied with the outcome and that 83% returned to work. The overall fusion rate for 2037 patients evaluated in the comprehensive literature review is 92%. Results of this study indicate that better outcome in noninstrumented anterior cervical discectomy and fusion is associated with solid fusion, fewer fused levels, nonsmoking patients, higher education levels, and absence of secondary economic gain. There was no correlation between fusion status and bone graft source or use of cervical collar.