What are the indications for using a cervical collar in patients with cervical spine injuries?

Indications for Cervical Collar Use in Trauma Patients

Primary Recommendation

The routine use of cervical collars in trauma patients is NOT recommended based on current evidence, as they cause documented harm (increased intracranial pressure, pressure ulcers, difficult airway management) without proven benefit in preventing secondary spinal cord injury. 1, 2

Evidence Against Routine Cervical Collar Use

The American Heart Association explicitly recommends against routine application of cervical collars by first aid providers due to growing evidence of harm and lack of proven benefit. 1, 2 This represents a significant departure from traditional trauma care practices.

Documented Harms of Cervical Collars:

• Increased intracranial pressure, particularly dangerous in patients with co-existing head trauma 1, 2
• Pressure ulcers requiring skin grafting and potentially causing sepsis, with each ulcer costing approximately $30,000 to treat 1, 2, 3
• Difficult airway management due to reduced mouth opening, increasing risk of failed intubation 4, 1
• Ventilator-associated pneumonia and delirium from prolonged immobilization 1
• Bacteremia and sepsis from poor oral care associated with collar use 1
• In one study, 38% of severe closed head injury patients developed collar-related decubiti when collars remained in place for prolonged periods 3

Lack of Efficacy Evidence:

• No high-quality evidence demonstrates clinical benefit of cervical collar use for injured patients 1
• Collars provide incomplete immobilization, particularly at craniocervical and cervicothoracic junctions 1, 5
• In cadaveric models with unstable cervical spine injuries, collars paradoxically caused greater cervical spine movement (anterior-posterior subluxation) compared to manual in-line stabilization during intubation 4, 1
• Neither one-piece nor two-piece collars effectively reduced segmental motion in unstable cervical spine cadaver models 5

Current Recommended Approach

Instead of Routine Collar Application:

Have the patient remain as still as possible while awaiting EMS arrival. 1 This approach avoids the documented harms of collars while achieving the same goal of minimizing cervical spine movement.

When Manual Stabilization May Be Considered:

• High-risk circumstances where patient movement cannot be controlled 1, 6
• During airway management procedures as an alternative to rigid collars 4, 1

Specific Clinical Scenarios

During Airway Management:

Remove at least the anterior portion of any cervical collar during intubation attempts to improve glottic exposure and reduce difficult intubation rates. 4, 1 The 2024 Difficult Airway Society guidelines provide a Grade D weak recommendation for this practice, acknowledging that collar presence significantly worsens intubation conditions. 4

• Use videolaryngoscopy over direct laryngoscopy (Grade A recommendation) 1
• Apply manual in-line stabilization during the intubation attempt 4, 1
• Have a low threshold for removing manual stabilization if difficult intubation is encountered 4

For Obtunded Patients Requiring Clearance:

Obtain high-quality cervical spine CT (axial thickness <3mm) rather than prolonged collar immobilization. 1 If CT is negative, remove the collar without requiring additional MRI or flexion-extension views. 1

• Collars should be removed by hospital day 3 rather than day 7.5 when CT is negative to minimize harm 1
• Modern CT imaging is highly sensitive for detecting unstable injuries in patients with decreased level of consciousness 1

If a Collar Must Be Used (Exceptional Circumstances):

When clinical judgment dictates collar use is absolutely necessary:

• Soft foam collars may be preferable to rigid collars in low-risk patients, causing significantly less pain (median pain score 3.0 vs 6.0, P<0.001) and less agitation (5% vs 17%, P=0.04) 7
• A retrospective study of 2,036 patients found no increased risk of secondary spinal cord injury with soft collar use compared to rigid collars 8
• However, even soft collars should be removed as soon as clinically appropriate to minimize complications 1, 2

Critical Pitfalls to Avoid

• Prolonged collar use beyond 48-72 hours when not indicated by clinical or radiographic findings—the morbidity from prolonged immobilization may exceed the risks of missed cervical spine injury 1, 2
• Delaying collar removal in patients cleared by appropriate imaging 1
• Keeping collars on during intubation attempts without removing at least the anterior portion 4, 1
• Assuming collars provide effective immobilization—they do not prevent all motion and may paradoxically increase movement at injury sites 4, 1, 5

Special Populations

Pre-hospital and Military Settings:

Given limited data in these environments, airway management should follow standard algorithms relevant to the particular clinical setting, with airway security taking priority over spinal immobilization concerns. 4 Observational data show tracheal intubation is more likely to fail with neck immobilization (odds ratio 2.53,95%CI 1.72-3.67). 4

Patients with Head Trauma:

Exercise particular caution with collar use in patients with co-existing head trauma due to increased intracranial pressure risk. 1, 2 The potential harm is magnified in this population.