A Pain in the Neck by Sue Ieraci, MBBS, FACEM
Saturday, October 24, 2009 
Sue Ieraci, MBBS, FACEM Is it only me or does everyone think that cervical spine immobilisation sometimes does more harm than good? In the ED where I work, major trauma is bypassed and the ambulance service only brings people from minor motor vehicle accidents or falls. As soon as I see them arrive with yet another patient trussed up in a hard collar, I rush to clear the neck and remove the collar – generally resulting in a sigh of relief from the patient.
Usually I just have to ask the patient what happened (rear-ended, walked around at the scene), I take off the collar and the patient sits up and moves their head around in relief. If I don’t get there early and the patient slips through the system, they are likely to develop a sore neck, and often end up with an XRay. Then there are the ambulance officers who bring a person from a minor crash in a collar who doesn’t have neck pain at all – it’s “precautionary”, they tell me.
So, what evidence do we really have for cervical spine immobilisation? While it is said that the force that caused the initial injury (if present) is far greater than any movement that might occur with gentle handling, no research group is putting up their hand to test this. Largely (I think) as a result of ATLS, protecting the neck has become the holy grail and no-one wants to challenge this principle, even at risk to the patient.
Hunting around for evidence supporting immobilisation (or, more specifically, harm caused post-injury by LACK of immobilisation), most of the papers found relate to the difficulties in controlling the airway while immobilising the neck. Doesn’t this tell us something? Isn’t it more dangerous to have an uncontrolled airway than to protect a theoretically-possibly-injured neck?
I found this paper from the 2001 edition of the Journal of Neurosurgery: Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. The group tested various methods of neck immobilisation during intubation of cadavers with unstable C4-5 injuries. (The movement was assessed using fluoroscopy). They found that various methods caused more movement in one dimension and less in others. Interestingly, orotracheal intubation without stabilization had intermediate results, causing less distraction than traction, less subluxation than immobilization, but increased angulation compared with either intervention. In general they found that “little motion occurs at C4–5 during direct laryngoscopy and OTI in either the intact or posteriorly injured states, significant motion may occur in the presence of a complete ligamentous injury.”
That gives up two clear areas where cervical immobilisation may do more harm than good: (a) where there is no injury, in a well patient; and (b) where fear of moving the neck leads to delay in securing the airway. Is it time to think more logically about this process – as we try to do for other things we do?
Reader Comments (4)
I think a lot of the neck collars are put on solely to avoid lawsuit liability. No idea if they really need it or not, but by george I put one on there so if the patient is paralyzed or whatever, it's not my fault.
There is no empiric evidence that I'm aware of the cervical immobilization does anything. For many decades-and perhaps still- medics in New Zealand (and maybe Australia) put people in the "rescue position" with head turned to left side. This supposedly was to prevent vomiting and aspiration which was considered a greater risk than exacerbating a c-spine injury.
There was a case 20 years ago where the Pittsburgh medics paralyzed a guy by immobilizing him on a backboard in approved fashion. He had only trivial trauma to start with but also had ankylosing spondylitis and they broke his neck. So it's not entirely benign.
It is necessary then to have this collar form if you have this pain in the neck so as to protect you from direct or any contact which will result to further pain with your later later on.
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