Morning Report: C-Spine Immobilization - A Review of the Evdence

Dr. Grock presents today’s Morning Report!

C- Spine Immobilization: A Critical Review of the Evidence

Cervical collars have been in use for over 30 years, yet, there have been no randomized, controlled trials evaluating their effectiveness. Per the most recent Cochrane review in 2009, there is no evidence for any benefit to C-Collars. Studies with healthy volunteers and cadavers report that C-collars may lead to, paradoxically, increased C-spine movement. Reviews also point out that patients with neck injuries hold their neck very still secondary to pain.

Previously, it has been estimated that 3-25% of injuries could be due to lack of c-spine immobilization. These studies were quite old and full of potential confounders. Furthermore, we now know that 5% of patients with spinal injuries will have neurological worsening even with adequate c-spine immobilization due to inflammation and edema.

C-Collars are known to increase ICP through compression of the jugular vein. As head injuries frequently coincide with neck injuries, increasing the ICP can be dangerous, though no studies have directly demonstrated harm. Studies have shown increased mortality for patients with GCS <9 who receive C-collars in the field. Most importantly, collars are well known to limit mouth opening and neck extension – two factors that are integral in accessing the trachea for intubation. Delaying transfer for repair of other injures due to C spine immobilization is also thought to negatively affect patient outcome.

For penetrating trauma, there is some good data indicating that C-spine immobilization is rarely needed. In a study from LA County hospital, no stab wound patients had a c-spine or neurologic injury. For the patients with gunshot wounds, altered patients had c-spine injuries 9.7% (3/31). Of evaluable patients with midline bony tenderness to palpation, deformity, or neurologic deficit, an incredible 46% had spinal injury. For patients without these physical exam findings, only 4.8% (3) had a spinal cord injury, none of which needed any braces or surgery. Here the physical exam for c- spine injury was 100% sensitive for clinically relevant injury. Another retrospective study reviewed almost 3,100 trauma patients and found that only 443 (1.3%) had any injury with 116 undergoing surgery and 11 receiving halos. Most interestingly, only 30 of these patients had incomplete injuries and could have potentially benefitted from a c-collar. In the end the NNT was 1,032 to potentially help one patient.

In conclusion:

There is documented harm for C-Collars with no documented benefit.
For penetrating trauma, conscious patients without midline tenderness to palpation, deformity, or a neuro deficit are very low risk for clinically relevant C-spine injury

References

1. Kwan I, Bunn F, Roberts IG. Spinal immobilisation for trauma patients. Coch Lib, Jan 2009

2. Lador R, Ben-Galim P, Hipp JA. Motion within the unstable cervical spine during patient maneuvering: the neck pivot-shift phenomenon. J Trauma. 2011 Jan;70(1):247-50

3. Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma. 2014 Mar 15;31(6):531-40

4. Inaba K, Barmparas G, Ibrahim D, Branco BC, Gruen P, Reddy S, Talving P, Demetriades D. Clinical examination is highly sensitive for detecting clinically significant spinal injuries after gunshot wounds. J Trauma. 2011 Sep;71(3):523-7.

5. Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010 Jan;68(1)