From the Guidelines
The application of a cervical collar (C-collar) in the emergency department is indicated for patients with suspected cervical spine injury until such injury can be ruled out, following assessment using validated clinical decision rules such as the NEXUS criteria or Canadian C-Spine Rule, as recommended by the most recent study 1. The criteria for applying a C-collar include:
- Trauma patients with neck pain or tenderness
- Altered mental status or intoxication that prevents reliable examination
- Neurological deficits suggesting spinal cord injury
- High-energy trauma mechanisms such as motor vehicle accidents, falls from height, or diving accidents
- Patients with distracting injuries that may mask cervical spine pain C-collars should also be applied in patients with known cervical spine fractures or instability awaiting definitive management. Proper sizing and application are essential, ensuring neutral alignment of the cervical spine while providing adequate immobilization, as emphasized in the study 1. C-collars should be maintained until cervical spine injury is excluded through appropriate imaging and clinical assessment, with CT preferred to radiographs for initial assessment of spine trauma, as stated in the study 1. The rationale for C-collar use is to prevent secondary injury to the spinal cord by limiting movement of potentially unstable cervical vertebrae, as undetected cervical spine injuries could lead to permanent neurological damage if the spine is manipulated inappropriately, a concern highlighted in the study 1. However, the potential benefits of applying a cervical collar must be weighed against the potential harms, such as increased intracranial pressure, as discussed in the study 1. In clinical practice, the decision to apply a C-collar should be made with caution, considering the individual patient's risk factors and the potential consequences of unnecessary neck movement, as noted in the study 1.
From the Research
Criteria for Applying a Cervical Collar (C-collar) In-Hospital
The application of a cervical collar (C-collar) in the emergency department is guided by specific criteria to ensure proper immobilization and clearance of the cervical spine. The following points outline the criteria:
- Cervical collars should be removed as soon as feasible, according to the guidelines for identification of cervical spine injuries following trauma 2.
- Clinical clearance remains the standard in awake, alert patients with trauma without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion 2.
- Computed tomography (CT) of the cervical spine is the primary screening modality in patients who require imaging, and it facilitates the removal of immobilization collars in patients who are neurologically intact 3, 2.
- For patients with impaired mental status, the management remains controversial, but CT scans can help identify traumatic injuries and expedite rigid collar removal 3.
- In alert, stable, and co-operative trauma patients, the application of a semi-rigid cervical collar may not be necessary unless their conscious level deteriorates or they find the short-term support of a cervical collar helpful 4.
- A post-computed tomography scan out-of-collar lateral radiograph may be useful in diagnosing cervical spine instability, particularly in patients without neurological deficits 5.
- Clinical cervical spine clearance in trauma patients can be safely performed using a structured algorithm in either the prehospital or emergency department setting, with few missed injuries or poor outcomes 6.
Key Considerations
- The use of cervical collars should be limited to patients who require immobilization, and they should be removed as soon as possible to avoid potential harm 2, 6.
- Imaging modalities, such as CT scans and magnetic resonance imaging (MRI), play a crucial role in evaluating trauma patients and guiding management decisions 3, 2, 5.
- Clinical clearance protocols should be used to evaluate patients and determine the need for cervical collar application or removal 2, 6.