Collar-Only Spine Immobilization?

It's been a while since the last post; if you've been ardently checking the site every day hoping for a new post (yeah, right!), I'm sorry!  The start of the semester and all the work that goes along with that, working the truck, a new four-legged fur baby (his name is Able, and he's a sweetie) all have conspired against me.  That, and I was wondering if there was anything new to say in the world of spine immobilization practices...by now, more and more people seem to be getting hip to the idea that strapping everyone to a long spine board and strangling them with a cervical collar may not be good medicine.  The National Association of EMS Physicians joined the American College of Surgeons' Committee on Trauma to publish a position paper on spine immobilization:

http://www.naemsp.org/Documents/Position%20Papers/POSITION%20EMS%20Spinal%20Precautions%20and%20the%20Use%20of%20the%20Long%20Backboard.pdf

I think this is a great step forward, but I have two main issues with it:

1)  There are no citations or evidence to support their recommendations.  I'm sure they did some research to form their conclusions, but I always like to see the strengths and weaknesses of the evidence behind them.

(Source:  one of my friend's Facebook page and www.roguemedic.com)

Around the same time period, the Wilderness Medical Society published their practice guidelines for spine immobilization in austere environments.  Even if you don't work in wilderness-y type places, it's a great review of the available literature (much of it from non-wilderness types of places) and recommendations that include levels of evidence.  If you're looking for recommendations with supporting evidence, it's a great reference:

http://wildernessmedicinemagazine.com/1041/articles/1041/Spine.pdf

2)  The NAEMSP/ACS-COT paper recommends that spine immobilization can be achieved with a rigid cervical collar and securing tightly to the EMS stretcher.

That statement worries me; I worry that, in our haste to abandon routine use of a backboard, our profession will jump in bed with a similarly unproven, possibly harmful piece of equipment!

Let's compare.....backboards;

• have not been shown to improve patient outcomes
• can impede respiratory effort
• can compromise the airway (lying supine + vomit = badness)
• can cause pressure ulcers

(All this has been discussed in many, many articles and online postings with references attached, so I won't bore you by repeating them here.  The evidence is there, and pretty easy to find with a good PubMed or Google search, depending on your preference.)

Cervical collars;

• have not been shown to improve patient outcomes
• may not actually restrict range of motion adequately (http://www.jem-journal.com/article/S0736-4679(11)00171-5/abstract)
• can compromise the airway by limiting mouth opening

(There is also a lot of literature about pressure ulcers developing from cervical collar use, but they seem to occur with prolonged application, i.e. days in an ICU, rather than the short frontcountry EMS transport times)

The literature I found demonstrated that spine immobilization as a whole impedes respiratory effort, but the studies didn't study cervical collars alone vs. collars with other devices (although they did test long boards vs. KEDs and found similar results).  So it's difficult to say whether or not a collar affects respiratory function like an LSB/KED does.

And of course, many are probably familiar with the small study published in Journal of Trauma back in 2010 that indicated that a cervical collar separates the cervical vertebrae, potentially making injuries worse.  In case you're not, however...http://www.ncbi.nlm.nih.gov/pubmed/20093981

What to make of all this?

Well, on the face of it, it seems that cervical collars, like long spine boards, have unproven benefit and pretty substantial risks.  We already have validated criteria for determining who might benefit (MIGHT being the operative word) from spine immobilization; why complicate the issue further?  Years of routine spine immobilization have ingrained half-hearted attempts (be honest....as important as padding the void spaces is, how often do you really do it?).  Now we're supposed to make choices between one unproven device and another?

Enough.

Spine immobilization, when it's indicated, should not be a half-assed procedure.  You either do it right (with a vacuum mattress, collar optional and probably not needed), or you don't.  The criteria to help you decide whether or not to perform it are valid.  Aside from a short-term way to save precious hands from manually holding the spine during something like rapid extrication, I don't think cervical collars have any place in EMS.  Unless, of course, you're a provider who likes to say "I want to play a game":

 

(Source:  images3.wikia.nocookie.net)