Words by Mark Ward
Perhaps calling this a myth is a little harsh because evidenced based practice is meant to evolve. What used to be considered good practice, can sometimes be a contributing factor to the deterioration of our patients. Believe it or not but before bronchodilators were available, smoking cigarettes were used to treat asthma. Around the same time, heroin was the wonder cure for a cough, cocaine was the elixir that cured everything and at the turn of the 20th century, we were still treating mental health patients with a lobotomy. Smoking to cure asthma and putting holes in heads to cure mental health issues are no doubt highly questionable practices these days but ironically cocaine, despite a few side effects, worked extremely well in making people feel better. What ended up ruining it for everyone was something called, research! But research drives us forward so lets look at a paramedic practice previously NOT researched.
There is a myth that spinal immobilisation prevents secondary spinal injuries in paramedic care. Some believe it, others not so much. But before we all go ‘binning’ spinal collars, just hear me out. I am still collaring a suspected spinal injured patient but I’m now using a soft collar because hard collars are now shown to cause more damage to the C Spine than not having a collar ever will.
This may have all started with a study that compared prehospital care of spinal injuries in developed countries, with spinal injuries from less developed countries (that almost never got a collar). The result demonstrated less secondary spinal injuries in the cohort that didn’t receive collars. (1) This study is not what I would called ideal in its methodology however, it did trigger a flow on effect of studies that looked at the use of spinal immobilisation and whether collars have a place in pre-hospital care. Many studies have suggested that we got it wrong however, we do not have a double-blind randomised control trial (DBRCT) that can emphatically rule in or out the use of collars. Ethically, we may never have a DBRCT on the use of collars and that is okay. If you read into this body of research, you may end up thinking that collars are a waste of time. That however is not what I found when I read into the research.
What we do know is that secondary spinal cord injuries are caused by movement of an unstable fracture. Other causes of spinal cord injury are haematomas, oedema and inflammation of the injured area. A patient who has a very painful, unstable fracture in their neck is unlikely to want to move it around to the extent that the spinal cord will be severed. Likewise, swelling in that area is highly likely to cause pain as well. That is why many patients in less developed countries can manage their unstable fractures without the need for a collar. They can’t, nor do they want to, move their neck very much at all.
The other thing that we have to keep in mind is that the patient from the less developed country has less access to paramedics with narcotics so they are less inclined to move their neck if it hurts. Likewise, the wife, husband, partner friend, boyfriend or whoever, wants to run to the patient’s side to make sure they are OK is exactly there, on the patients side causing our highly inebriated patient to turn their head. In this particular scenario, the paramedic feel like that C Spine is being taken care of and the collar makes the patient feel like their neck has been secured but truth is, the collar does very little. The other factors such as swelling, haematomas and oedema can actually be made worse by collars, particularly the old stiff collars which is largely why we have moved to soft collars across Australia.
The fact is collars do very little to protect a patient’s C Spine. Paramedics protect the patient’s C spine. Good management of a suspected spinal fracture is not to slap a collar around their neck and juice them up on narcotics. Be smarter than that. Allow them to do some of the management themselves. There is a massive difference between taking the edge of the pain and removing the pain. Taking the edge off just might save more C Spine injuries than collars actually do. And please, please please only talk to a collared patient from directly over their head and never to the side. I think putting blinkers on our patients in the same way they put them on race horses when they are racing would prevent just as many secondary spinal cord injuries as collars do.
While a number of studies and systematic reviews all conclude that there is weak evidence to suggest that pre-hospital spinal immobilisation has much of an impact on patient outcomes, most studies, including a 2015 systematic review (2) and a 2021 critical review (3) suggest removing the use of collars would not increase secondary spinal injuries. Earlier this year, the European Journal of Trauma and Emergency Surgery reviewed nine studies, of which six concluded that collars should not be used and three were uncertain. (4) Once again, the main issue is that there is a discrepancy between common practice and what the evidence is suggesting. It is hard to change common practice. If the situation was reversed and we were looking at introducing collars into prehospital management, the evidence would never allow it.
Therefore, the question begs, do I put my patients in collars? Absolutely I do and will always do until my protocols change. The point that I am making here is that spinal cord injuries are not managed by putting a collar on and that’s it. They are certainly not managed by putting a collar on and juicing patients up to the eyeballs with narcotics. More than ever, we need to take a holistic approach to spinal care.
References
1. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214-9.
2. Oteir AO, Smith K, Stoelwinder JU, Middleton J, Jennings PA. Should suspected cervical spinal cord injury be immobilised?: a systematic review. Injury. 2015 Apr;46(4):528-35. doi: 10.1016/j.injury.2014.12.032. Epub 2015 Jan 12. PMID: 25624270.
3. Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma. 2014 Mar 15;31(6):531-40. doi: 10.1089/neu.2013.3094. Epub 2013 Nov 6. PMID: 23962031; PMCID: PMC3949434.
4. Hawkridge K, Ahmed I, Ahmed Z. Evidence for the use of spinal collars in stabilising spinal injuries in the pre-hospital setting in trauma patients: a systematic review. Eur J Trauma Emerg Surg. 2022 Feb;48(1):647-657. doi: 10.1007/s00068-020-01576-x. Epub 2020 Dec 21. PMID: 33346863; PMCID: PMC8825572.