Sunday 2 July 2017

Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: Are the collars really necessary?

“Keep them still! Don’t let them move… if they turn their head an inch, they’ll be paralysed.”
-Dr Longheld Dogma

Protection of the cervical spine has been a bedrock of trauma care. This has traditionally been accomplished by strapping patients to backboards and the application of properly fitted cervical collars.

But these collars are uncomfortable, have potential harms and can make cooperative patients rather uncooperative.

Of course we can rest easy in the knowledge that  the original randomised controlled trials (RCT's) of the cervical collar took this all into account. 

What…there is no good quality evidence that the c-collars do anything?!?

Surely there must at least be a large body of observational literature to suggest they work? Heck, we’ve been using them for decades!

These authors sought to definitively answer the latter question.

They conducted a thorough literature review to find cases of neurologic deterioration in the early care of blunt spinal trauma.

In the end, they found only 41 cases from 12 papers. The quality of the evidence was “extremely low.” They conclude the following:

No reports were found of sudden, movement-provoked deterioration during the prehospital interval; this remains an unpublished phenomenon if not a medical myth. Overall, since many of these events described are consistent with the natural history of disease, it is unclear how often deterioration may be causally linked with patient movement and furthermore whether such events are preventable by motion restriction.

On the flip side, one might argue that lack of evidence does not equate to lack of efficacy. After all, these collars have not truly been studied. In addition, there may have been negative reporting bias of bad outcomes.

What should we conclude? I think you can make up your own mind… hopefully not while strapped to a collar.


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