What is the process for clearing the use of a cervical (c) collar?

Process for Clearing the Use of a Cervical Collar

The cervical collar should be removed after a negative high-quality CT scan of the cervical spine in obtunded adult blunt trauma patients, without the need for additional MRI imaging. 1

Patient Assessment Algorithm

For Alert Patients (GCS 15)

1. Clinical clearance can be performed if:
   • Patient is fully alert and oriented
   • No intoxicants or drugs have been consumed
   • No significant distracting injuries are present 2
   • No neck pain or tenderness
   • Full range of motion without pain

For Obtunded/Unconscious Patients

1. Obtain high-quality cervical spine CT scan with:

   • Thin slices (≤3mm)
   • Sagittal and coronal reconstructions 3, 1

2. If CT is negative:

   • Remove cervical collar without additional imaging 1
   • This approach is supported by evidence showing extremely low risk (0% in cumulative literature) of unstable injuries being missed by high-quality CT 1

3. If CT shows abnormalities:

   • Maintain immobilization
   • Consult neurosurgery or orthopedic spine specialist
   • Consider additional imaging as directed by specialist

Rationale for Early Collar Removal

The evidence strongly supports early collar removal after negative CT in obtunded patients due to:

1. Low risk of missed injuries: High-quality CT has demonstrated excellent ability to detect clinically significant cervical spine injuries 3, 1

2. Significant complications of prolonged collar use 2:

   • Pressure ulcers (increasing dramatically after 48-72 hours)
   • Elevated intracranial pressure
   • Airway management difficulties
   • Impaired central venous access
   • Poor oral hygiene leading to infection risk
   • Compromised enteral nutrition
   • Increased risk of aspiration pneumonia
   • Restricted physiotherapy
   • Increased risk of thromboembolism
   • Staffing burden for proper patient handling

3. Risk-benefit analysis: The 2.5% risk of cervical spine instability is outweighed by the much higher risks of secondary brain injury from prolonged collar use (35.8% risk of increased ICP) 4

Common Pitfalls to Avoid

1. Overreliance on MRI: While MRI is highly sensitive for soft tissue injuries, many detected abnormalities have uncertain clinical significance and lead to unnecessary prolonged immobilization 2

2. Delayed collar removal: Waiting for patients to regain consciousness for clinical clearance significantly increases complication rates 2, 5

3. Inadequate CT technique: Using older or lower quality CT protocols without proper reconstructions may miss injuries 1

4. Improper collar fit: When collars must remain in place, ensure proper sizing and regular skin inspection to prevent pressure ulcers 5

5. Assuming collars provide complete immobilization: Collars may not fully restrict movement at the craniocervical and cervicothoracic junctions, which are common injury sites 2

By following this evidence-based approach, clinicians can minimize both the risk of missed cervical spine injuries and the complications associated with prolonged cervical collar use, ultimately improving patient outcomes related to morbidity, mortality, and quality of life.