Does a patient with a cervical spine fracture, eligible for non-surgical (non-operative) management, need to wear a cervical collar at all times, including while in bed?

Cervical Collar Use During Bed Rest for Non-Operative Cervical Spine Fractures

For patients with stable cervical spine fractures managed non-operatively, the collar can and should be removed while in bed to minimize the serious complications of prolonged immobilization, which often exceed the risks of the injury itself.

The Critical Problem with Continuous Collar Use

The evidence strongly demonstrates that prolonged immobilization beyond 48-72 hours causes significant morbidity that may exceed the risks of a missed cervical spine injury 1. The complications escalate rapidly after this timeframe and include:

Major Complications of Continuous Collar Wear

• Pressure sores develop commonly after 48-72 hours, may require skin grafting, and serve as sources of sepsis and infected cervical prostheses after operative fixation 1
• Each pressure ulcer costs approximately $30,000 to treat and requires prolonged healing time 1
• Increased intracranial pressure worsens outcomes in patients with co-existing head injury (present in up to one-third of trauma cases) 1, 2
• Airway complications can be life-threatening and are likely underreported 1
• Ventilator-associated pneumonia and delirium increase with prolonged collar use, both associated with increased mortality 1, 2
• Failed enteral nutrition requiring parenteral nutrition 1
• Gastrostasis, reflux, and aspiration promoted by static supine positioning 1
• Among elderly patients with cervical spine injuries, 26.8% died during treatment, principally from respiratory complications 1

The Paradox of Collar "Protection"

Rigid collars do not effectively restrict displacement of unstable cervical injuries 1. In fact:

• Paradoxical movement of adjacent vertebrae may occur, particularly at the craniocervical and cervicothoracic junctions—ironically the two most common injury sites 1
• Cadaveric studies demonstrate that collars are insufficient for immobilizing unstable cervical spine injuries 3
• Neither one-piece nor two-piece collars significantly reduce segmental motion in stable or unstable conditions 3

Evidence-Based Approach to Collar Use

For Stable Fractures Managed Non-Operatively:

Remove the collar while the patient is in bed and at rest 1. The rationale:

• Studies demonstrate that clearing the cervical spine based on CT imaging was associated with less delirium and less ventilator-associated pneumonia 1
• Morbidity increases with increasing duration of collar application 1
• In one protocol, cervical collars were removed on hospital day 3 compared with hospital day 7.5 in previous protocols, with only one patient (0.5%) developing a grade 1 submental decubitus ulceration 1

When to Wear the Collar:

• During mobilization and upright activities when gravitational and movement forces are greatest
• During transfers when positioning changes occur
• The collar serves primarily to remind the patient to limit neck motion rather than providing true mechanical stability 1

Clinical Decision Algorithm

1. Confirm stability through appropriate imaging (high-resolution CT at 1.5-2mm collimation) 1
2. If fracture is stable and non-operative management chosen:
   • Remove collar during bed rest
   • Apply collar for mobilization and transfers
   • Monitor for skin breakdown at every shift
3. Duration of collar use: Typically 4-6 weeks for stable injuries managed conservatively 1

Critical Caveats

• The risks of prolonged immobilization beyond 48-72 hours are poorly appreciated and exceed those of a serious missed cervical spine injury 1
• Strategies with high sensitivity but low specificity result in liberal collar application and prolonged immobilization, the risks of which must be balanced against the risks of missed injuries 1
• Ventilator-associated pneumonia may have an attributable mortality (6%) approaching that of the incidence of unstable spine injury itself (5%) 1

Common Pitfall to Avoid

The most dangerous pitfall is continuing collar use 24/7 based on tradition rather than evidence, subjecting over 90% of patients with stable cervical spines to unnecessary immobilization 1. The collar should be viewed as a reminder device during activity, not as definitive mechanical stabilization requiring continuous application 1.