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. Introduction C ervical collars are considered important measures in modern prehospital trauma care. The recommended practice of routine application of collars in trauma patients has largely been unchanged for more than 30 years. It is featured as a prioritized procedure in the Advanced Trauma Life Support (ATLS) guidelines from the American College of Surgeons (ACS) and the Prehospital Trauma Life Support (PHTLS) guidelines from the National Association of Emergency Medical Technicians (NAEMT).

These guidelines dominate the field of prehospital trauma care, and ATLS and PHTLS are implemented in 50–60 countries., The use of collars is, in fact, regarded as so important that it is highlighted in the well-known ABCs of major trauma as a first measure, together with establishment of free airways. Collars were introduced to prevent secondary injury to the spinal cord by immobilizing a potentially unstable spine. Many years have passed since, and this practice has evolved into a hallmark of modern state-of-the-art prehospital care., Millions of trauma patients are currently fitted with a collar every year. However, as evaluated in a Cochrane review in 2001 (updated in 2007), the documented evidence for our ongoing practice is rather limited: Randomized, controlled trials (RCTs) are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Moreover, and perhaps more concerning, there is a growing body of evidence and opinion against the use of collars. Improving prehospital management has a substantial effect on society as a whole and is a high-priority research area.

In this review, we argue that it is time to reconsider the unjustified dogma of collar use in prehospital trauma care. Methods We performed a literature search in the Medline database using a combination of relevant medical subject headings (MeSHs) and text words: (“cervical vertebrae”MeSH or “neck”MeSH or cervicaltext word) and (“braces”MeSH or collar.text words or “immobilization”MeSH) and (“wounds and injuries”MeSH or “emergency medical services”MeSH). This search was limited to human studies in English available by April 2013.

All authors contributed to the search strategy development. We found 1018 publications, of which 88 titles were considered relevant by one or two independent authors (T.S.

Borderline titles were included. These publications underwent full review by the author group, and 50 articles were found relevant to prehospital use of collars in trauma patients by more than one author. These articles are included here. Finally, we searched the reference lists of retrieved articles and contacted experts in the field to identify pertinent studies. Articles published over the last 10–15 years were prioritized. Current Recommendations The American Association for Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) Joint Guidelines Committee recently published a comprehensive update of the Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injury. These guidelines provide 112 evidence-based diagnostic and treatment recommendations (77 level III, 16 level II, and 19 level I recommendations).

The vast majority of treatment recommendations are level III, and all surgical recommendations, except one level II for type II odontoid fractures, are level III recommendations. In the prehospital setting, the AANS/CNS recommends spinal immobilization of all trauma patients with a known or suspected CSI or SCI; however, experienced personnel should evaluate the need for immobilization during transport (level II).

Fully awake and communicable patients that are not intoxicated, without neck pain or tenderness, neurologically intact, and without distracting injuries should not be immobilized (level II). The preferred method of immobilization is the combination of a rigid collar and supportive blocks on a spine board with straps (level III). Sandbags and tape alone should not be used, and spinal immobilization in patients with penetrating trauma is not recommended (level III). The AANS/CNS guidelines are generally in line with the ATLS and PHTLS guidelines as well as other reviews and management guidelines for CSIs, and they all state that collars are effective in limiting motion of the cervical spine and should therefore be used until the patient is properly assessed and the cervical spine is cleared.

Why Do We Use Cervical Collars? Looking Outside the Guidelines CSIs are feared because of the inherent risk of permanent SCI with potential life-threatening and -changing consequences for patients. Moreover, there are important concerns about medicolegal liability, although not yet prevalent in Scandinavia; malpractice lawsuits in cases of avoidable SCI are very expensive, with compensations of approximately $3 million USD. Further, collars are generally regarded as safe and effective, and few question their use in daily trauma practice; it makes good sense to stabilize an unstable injury.

Collars have essentially become a symbol of high-quality trauma care, and in many EMS systems protocolized paramedics never deliver patients without a collar to the emergency department (ED). Besides, the ABCs of major trauma is a powerful mnemonic and a strong psychological premise for medical action in the field. Finally, and essential in this regard, it is better to have a protocol than no protocol, and it is better and cheaper to advocate an easy, uniform practice than a difficult, individualized one.

How Effective Are Cervical Collars? It has been postulated that 3–25% of SCIs are secondary, occurring either during prehospital or early hospital care, and are the result of “inappropriate management,” such as lack of spinal immobilization (as frequently cited previously,). This claim has, however, a number of limitations. First, it is not easy to identify a neurological decline throughout the prehospital phase.

Second, extrapolation of results obtained in a hospital setting to the prehospital arena is questionable. Third, several of the cited studies were conducted many years ago with other treatment standards and available resources, so it is not always clear which factors really contributed to the clinical worsening, and there are significant concerns as to the evidence-based value of case series. Moreover, it is essential to understand that approximately 5% of patients with spinal injuries experience some degree of neurological worsening, even with good immobilization of the spine. This clinical deterioration can be the result of well-known mechanisms, such as hematomas, edema, hypotension, hypoxemia, or inflammation. The collar should, in theory, protect patients from secondary spinal cord traumas by restricting inadvertent movements of unstable CSIs. However, we will probably never know how many secondary SCIs collars have prevented. Collar efficacy on motion control has never been examined in real trauma patients.

There are also no RCTs that address the effect of collars on outcomes after CSI and probably never will be. Conversely, a number of studies have examined spine movement in simulated environments (e.g., cadavers with or without rigor mortis or healthy volunteers) using a wide range of devices and assessment criteria, and the results of these studies are somewhat contradictory and confusing. Specific Pediatric Concerns The numerous concerns regarding collars in adult patients are mostly transferable to the pediatric population. Moreover, most of the foundation for prehospital treatment of children with CSIs is based on adult studies, and the evidence favoring current management strategies is therefore even weaker than in adults., Pediatric collars are adapted to the size and anatomy of children, whereas undesirable neck flexion on spine boards should be avoided by individual modifications.

No studies have been identified that compare spinal stabilization with or without collars in children. CSI in pediatric blunt trauma victims is rare and occurs in approximately 1–2% of patients, although more frequent with concomitant head injury. Conscious patients Cervical spine clearance in awake and alert patients is easier and better documented than in unconscious or obtunded patients.

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There are several clinical approaches available to substantiate whether or not awake patients have a significant CSI and thus are in need of radiological examinations and/or specific treatment. One of the best validated algorithms is the Canadian C-spine Rule (CCR). This was originally published in 2001 as a tool to decide whether or not patients require radiology in the hospital setting. In 2011, a revised edition was published for the prehospital setting, but now as a tool to decide whether patients require cervical spine immobilization or not. High-quality studies have shown that physicians in the ED can safely use the CCR as well as the NEXUS (National Emergency X-Radiography Utilization Study) criteria to rule out CSI., Studies have also shown that the CCR is more sensitive and specific than the NEXUS criteria, and that using the CCR results in lower rates of radiological examinations. Further, the CCR can be used with similar accuracy and reliability by triage nurses in the ED and paramedics in the prehospital setting.

Education of prehospital personnel in clinical clearance of the cervical spine has a large potential for improving management, with an estimated 40% reduction in cervical spine immobilization (and subsequent radiological examinations)., Radiological investigations are often deemed unnecessary for conscious patients without symptoms, neurological deficits, or distracting injuries and that have a full range of motion upon functional examination. Evidence also suggests that this straightforward clearance approach can be simplified even further by ignoring distracting injuries, perhaps except for injuries in the upper chest region. Altogether, there is a wide range of algorithms based on different clinical criteria for clearance of the cervical spine in the prehospital setting. Conclusion The existing evidence for using collars is weak, and our practice is mainly a result of the historical influence of poor evidence. More significant and concerning, there is a well of less-appreciated documentation of harmful effects from collars. A practice change seems warranted based on a critical evaluation of the pros and cons of prehospital collar use in trauma patients.

With this perspective, we propose a safe, effective immobilization strategy that will not require any new equipment and should be easy to implement; the main difference from current protocols is the omission of routine collar application., Few patients are in need of spinal immobilization, and clearance protocols should be optimized to identify these high-risk patients. These patients should not be fitted with a collar, but immobilized on spine boards with head blocks and straps. Temporary use of a rigid collar is an option during extrication procedures from, for example, cars. Unconscious, nonintubated trauma patients should be transported in a modified lateral recovery position that maintains near neutral spine alignment and airway patency. Finally, prehospital management should, by no means, delay transportation of critically injured patients to definitive care. Future efforts should also aim to discontinue the use of rigid spine boards in favor of vacuum mattresses or other softer boards that are more comfortable and adaptable to the individual variations in body composition.

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