From the Guidelines
Spinal precautions and the cervical collar should be removed as soon as is feasibly possible, considering that only approximately 5% of obtunded blunt trauma patients have an actual injury, as stated in the study by 1. To medically clear a cervical collar, a thorough assessment must be performed, taking into account the patient's condition and the mechanism of injury.
- The study by 1 recommends documenting movement of limbs at first presentation and ensuring robust handover from the pre-hospital team.
- It also suggests that routine plain radiographs and dynamic flexion/extension views are not necessary, and instead, CT of the entire spine should be performed using a modern MDCT.
- Additionally, the study emphasizes the importance of getting images reported by a senior radiologist who is skilled in musculoskeletal/neuro-radiology.
- The removal of spinal precautions and the cervical collar should be done as soon as possible, while being vigilant for developing neurological signs despite a spine having been ‘cleared’, as recommended by 1.
- It is crucial to consider the implications of removing the cervical collar, including the risk of missing a potential cervical spine injury, and to weigh this against the benefits of early mobilization and minimizing unnecessary immobilization.
- The study by 1 provides strong evidence for the removal of spinal precautions and the cervical collar as soon as possible, and this approach should be prioritized in clinical practice to improve patient outcomes and reduce morbidity and mortality.
From the Research
Medically Clearing a C Collar
- The process of medically clearing a c collar involves assessing the patient's cervical spine for potential injuries and determining whether it is safe to remove the collar 2, 3, 4.
- Studies have shown that a normal computed tomography (CT) scan of the cervical spine can be used to clear the cervical spine and remove the collar in unconscious patients presenting to the emergency department 2.
- In intubated patients admitted to the trauma intensive care unit (TICU) with cervical collars in situ, the removal of the collar by intensive care physicians based on a normal CT scan of the cervical spine has been shown to be safe, provided certain quality conditions related to the CT scan are met 2.
- The incidence of missed neurological injury in patients who had their cervical collars removed by intensive care physicians based on a normal CT scan of the cervical spine was found to be nil, with a negative predictive value of 100% 2.
Cervical Collar Clearance in Specific Patient Populations
- In obtunded pediatric patients presenting without a known traumatic mechanism, the overall incidence of c-spine injury was found to be zero, suggesting that cervical collar placement and radiographic evaluation may not be necessary in this patient population 3.
- In patients with acute blunt trauma to the neck and posterior midline cervical tenderness, intravenous acetaminophen therapy has been shown to reduce the necessity of imaging in patients with probable traumatic cervical spine injury 5.
Biomechanics and Mechanisms of Injury
- The cervical spine functions to position the head while maintaining stability and protecting the spinal cord, and knowledge of the normal biomechanical anatomy of the cervical spine is imperative to understanding the biomechanics of injury to the cervical spine 6.
- There are a variety of reproducible injury patterns based on the direction and magnitude of force applied to the cervical spine, and understanding these forces can allow an understanding of the mechanical and neurologic stability of the cervical spine 6.