Not Yet Time to Abandon Cervical Collars in Blunt Trauma

In the evidence-based summary by Serigano and Riscinti1 published in this issue of Academic Emergency Medicine under the Brass Tacks series, the authors critically appraise the evidence for the longstanding practice of prehospital and emergency department cervical spinal motion restriction (SMR) in blunt trauma patients. They highlight the absence of class I data demonstrating a benefit and describe some of the potentially harmful side effects of cervical collars. The authors were unable to calculate the number needed to treat (NNT) since the only quantitative evidence of an estimated NNT was based on a non–peer-reviewed summary of three old case series. Similarly, the number needed to harm (NNH) could not be calculated due to the absence of high-quality studies assessing harms associated with SMR. Citing “common sense and general principles of causal inference” and using “TheNNT.com” evidence rating system,2 the authors assign a color recommendation of yellow (unclear if benefits) to SMR in blunt trauma. A few considerations should be highlighted regarding the clinical implications of the findings of this evidence-based review. Does the absence of randomized controlled trials warrant abandonment of cervical stabilization? SMR to prevent secondary harms from a potentially unstable cervical spine injury has been the standard of care for decades. Class II evidence coupled with expert opinion has resulted in multidisciplinary support for cervical stabilization from professional societies in the prehospital setting,3 emergency medicine,3, 4 trauma surgery,3, 5, 6 and neurosurgery.7 No new compelling studies disputing current practice have been published. Studies reporting adverse effects associated with SMR, such as the ones cited in this evidence-based summary, are of low quality or nonclinical (e.g., simulation studies), where only theoretical harms from cervical collars could be implied. In addition, there is no direct evidence to suggest that SMR applied during the acute phase of injury is deleterious; certainly not for short EMS transport times. Some have suggested thorough clinical evaluation and decisions regarding SMR be delegated to prehospital personnel. The prehospital environment is, by definition, chaotic. In this setting, care is provided by a myriad of personnel with widely divergent training, experience, and expertise. While SMR techniques can burn valuable prehospital time, so does clinical evaluation of the spine. Data in the past have demonstrated poor correlation of even something as straightforward as calculating Glasgow Coma Scale scores in the prehospital environment.8 One must ask if this is a wise strategy. All would agree that cervical collars should be removed as soon as feasible after trauma. NEXUS9 criteria and the Canadian C-spine10 decision rules guide clinicians in determining which patients can avoid radiologic imaging and prolonged SMR. Readily available high-resolution CT scans can rapidly evaluate for vertebral injuries and the need for prolonged spinal stabilization. Review of existing evidence and questioning routine practice are important steps in optimizing guidelines and improving patient care. However, change in standard practice must be balanced not only with supporting evidence but also with potential for deleterious effects that could result when deviating from existing guidelines. The overall incidence of spinal injury in blunt trauma patients is low but when present can be potentially devastating. One must question how many patients with neurologic deterioration due to inadequate SMR are acceptable? Many would argue that the only acceptable number of patients is zero. Given concerns of a neurologic injury in patients without appropriate SMR, it is unlikely a future randomized controlled trial will be performed. Rather than abandoning SMR, it may be best to focus on additional effective mechanisms of reducing cervical motion during transport and consider subsets of patients, such as morbidly obese, who might benefit from SMR by means other than poorly fitting rigid cervical collars. The paucity of robust evidence demonstrating a clear benefit to SMR is consistent with the authors’ NNT color recommendation of yellow. However, this should not be misinterpreted as a recommendation to change established practice. The application of SMR as part of the initial algorithm in blunt trauma is a safe, sensible approach in the evaluation of spinal injuries. Rapid clinical and radiologic assessment with early discontinuation of SMR, when appropriate, is the goal.

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