Do cervical collars (cervical orthoses) cause more harm than good in patients with suspected cervical spine injury?

Cervical Collars: Evidence of Harm Outweighs Unproven Benefits

Cervical collars cause documented harm without proven clinical benefit in preventing secondary spinal cord injury, and current evidence supports minimizing their use, particularly avoiding prolonged immobilization beyond 48-72 hours. 1, 2, 3

The Core Problem: Documented Harms vs. Absent Evidence of Benefit

The fundamental issue is asymmetric evidence quality:

• No high-quality evidence demonstrates clinical benefit of cervical collar use for injured patients 2, 3
• Multiple well-documented harms exist with strong supporting evidence 1, 2, 3
• The American Heart Association now recommends against routine cervical collar application by first aid providers due to this unfavorable risk-benefit profile 2, 3

Specific Documented Harms

Immediate Physiological Complications

• Increased intracranial pressure, particularly dangerous in patients with co-existing head trauma 2, 3
• Difficult airway management due to reduced mouth opening, increasing failed intubation risk 4, 2, 3
• Paradoxical cervical spine distraction: In cadaveric models with unstable injuries, collars caused 7.3 mm ± 4.0 mm of abnormal separation between C1-C2, and greater cervical spine movement compared to manual stabilization 5, 2

Complications from Prolonged Use (>48-72 hours)

• Pressure ulcers requiring skin grafting and causing sepsis (38% incidence in one study, costing ~$30,000 per ulcer to treat) 6, 1, 2
• Ventilator-associated pneumonia and delirium 1, 2
• Bacteremia and sepsis from poor oral care 2, 3
• Failed enteral nutrition 1

The American College of Surgeons states that prolonged immobilization beyond 48-72 hours causes significant morbidity, with documented harms often exceeding the risks of the injury itself when definitive stabilization is not performed 1.

Why Collars Don't Work as Intended

Incomplete Immobilization

• Cervical collars provide incomplete immobilization, particularly at the craniocervical and cervicothoracic junctions where many unstable injuries occur 1, 2, 3
• The American Academy of Orthopaedic Surgeons reports that collars paradoxically may not effectively restrict movement of unstable cervical injuries 1

Worse Than Manual Stabilization

• In cadaveric models with unstable injuries, collars caused greater cervical spine movement (anterior-posterior subluxation) compared to manual in-line stabilization during laryngoscopy 2, 5

Clinical Algorithm for Collar Management

During Airway Management

Remove at least the anterior portion of the collar during intubation attempts (Grade D recommendation from 2024 Difficult Airway Society guidelines) 4, 2, 3

• Use videolaryngoscopy (Grade A recommendation - the strongest in these guidelines) 4, 2
• Apply manual in-line stabilization during the procedure 4, 3
• Consider using a stylet or bougie as adjunct 4, 2

Time-Based Removal Protocol

• For obtunded patients with negative high-quality CT (axial thickness <3 mm): Remove collar by hospital day 3 without additional MRI or flexion-extension views 2
• Never keep patients in collars beyond 72 hours without definitive surgical planning, as complications accumulate rapidly 1

Alternative to Collar Use

• Have patients remain as still as possible while awaiting EMS arrival rather than applying collars 2, 3
• Use manual stabilization in high-risk circumstances where patient movement cannot be controlled 3

Emerging Evidence: Soft Collars as Harm Reduction

Recent research suggests soft foam collars may mitigate some complications while maintaining similar safety:

• No adverse neurological events in 2,036 patients managed with soft collars 7
• Significantly lower pain scores (median 3.0 vs 6.0, P<0.001) and less agitation (5% vs 17%, P=0.04) compared to rigid collars 8
• No pressure injuries recorded in 136 patients wearing soft collars 9
• Patients report soft collars as supportive and well-tolerated with good adherence 9

However, these studies are smaller and more recent, so if a collar must be used temporarily, soft collars appear safer than rigid collars for low-risk patients 9, 7, 8.

Critical Pitfalls to Avoid

• Prolonged collar use when not indicated by clinical or radiographic findings 2, 3
• Delaying collar removal in patients cleared by appropriate imaging 2, 3
• Keeping collars on during intubation without removing at least the anterior portion 4, 3
• Assuming collars provide effective immobilization at the craniocervical junction where atlanto-occipital dislocation occurs 1
• Failing to recognize that risks of prolonged immobilization may exceed risks of a missed cervical spine injury in many cases 2

Special Consideration: Head Trauma

Exercise particular caution with collar use in patients with head trauma due to increased intracranial pressure risk 2, 3. The combination of head and cervical spine injury creates a scenario where collar-induced ICP elevation poses immediate danger.