Does a Cervical Collar Immobilization Device Improve Patient Outcomes - Research Paper Example

?Does a cervical collar immobilization device improve patient outcomes? During any accident, in the prehospital stage, spinal immobilization is considered to be an effective strategy to prevent further injury to the spine and spinal cord when the patient is being shifted to the hospital for further management. Especially the cervical spine is prone for further injury because of movements of the head and the most common practice is to immobilize cervical spine is using a cervical collar. Though several devices and techniques are being developed for cervical immobilization, it is yet unclear whether use of cervical collar during resuscitation and transport improves patient outcomes. One of the reasons for such uncertainty is the lack of effective measure to evaluate and ascertain the extent of injury to the patient in the prehospital stage in the emergency scenario. Another reason is the lack of proper definition for immobilization. While some experts recommend immobilization as a routine protocol in all resuscitation protocols, a few of them question the very application of cervical immobilization arguing that it has very little impact on the outcomes of the patient. In many hospital protocols, selective spinal immobilization has been employed and the emergency medical personnel decide whether cervical immobilization, cervical collar or long spine board is necessary for the patient. It is a well known fact that early management of an individual with suspected or potential cervical spine injury begins at the accident scene. This is because of the chief concern that impairment of the neurologic function can ensue due to pathologic motion of the vertebrae that are injured. It has been estimated that 3- 25 percent of spinal cord injuries occur after the traumatic insult during early treatment or transit. Mishandling of cervical spine results in poor outcomes. Thus, spinal immobilization has become an integral part of prehospital spinal care until injury to the spine is rules out. A cervical collar, also known as neck brace, is a medical equipment which is used to support the cervical spinal cord of the patient. The collar mainly stabilizes the cervical vertebrae C1-C7. The exact definition of cervical spinal immobilization is yet unclear. In a retrospective study by Jin et al (p.401), the researchers examined the sensitivity of a prehospital protocol in which there are 5 criteria for immobilization of spine and they are presence of any neurological deficit, decreased awareness in terms of time, person and place, presence of intoxication, pain on palpation of the spine and age of atleast 65 years. This study included 238 victims of trauma. Of these, atleast 236 individuals had atleast one of the five criteria and thus received immobilization. Of the 2 cases who has no positive findings and hence did not receive any immobilization, one had a small fissure in the arch of C2 and the other had fracture of the transverse process of L3. Both the patients were discharged within 24 hours. Thus, it can be said that hospital protocols for spinal immobilization can be sensitive upto 99.2 percent. The effectiveness and benefits of immobilization of the spine depends on the perfection in application of the immobilization technique. Generally, immobilization of spine consists of a cervical collar that supports either side of the head, and the long and short back boards which have straps attached to them to immobilize the rest of the body. Mozalewski (cited in AANS, p.6) opined that unless the motion of trunk also was minimized along with motion of head, spine immobilization was ineffective. The literature review by AANS (p.6) drew some implications about spine immobilization practices in an emergency setting. The review opines that studies pertaining to spinal immobilization are limited because none of the studies actually evaluate the full range of available devices. However, from whatever results are available, it appears that a combination of cervical collar immobilization with supportive straps on a rigid long spinal backboard to secure the whole body including the trunk is superior to cervical collar immobilization alone. Chandler et al (p.1185) conducted a study to evaluate the effectiveness of immobilization of cervical-spine using a rigid cervical extrication collar and an Ammerman halo orthosis with and without spine boards. Their study included 20 normal men and the measurements used to examine were photographic measurement of head and neck during maximal movements and radiological measurement during flexion-extension. From the results of the study, it was evident that immobilization was much better with spine board and a rigid cervical collar rather than cervical collar alone. Similar opinion was provided by Hauswald et al (AANS, p.6) who also reported in their prospective study that vacuum splint device was much faster to apply than the spine boards and that it was much better in immobilizing head. In yet another study, Hamilton et al (AANS, p.6) reported that vacuum splint device had similar advantages and disadvantages compared to backboard-collar combination. According to Webber-Jones (p.19), rigid cervical collar is one of the good additions for successful treatment of injuries related to cervical spine. However, they are fraught with several disadvantages like providing a false sense of security in terms of complete prevention of further spinal damage. The increased length of wear of collar causes development of skin pressure points leading to pressure ulcers. The ulcers delay weaning from ventilators and increase the risk of exposure to blood borne diseases. In yet another study by Gennis (p.568), the researchers conducted a randomized controlled trial in an emergency department in an urban setting. Adult patients with neck pain following automobile involved road traffic accidents, but without obvious cervical spine injury like focal neurologic deficits, cervical spine fractures, cervical spine subluxation and major distraction injuries were assigned to receive soft cervical collar or no collar based on random assignment. The patients were evaluated after 6 weeks in terms of pain based on the visual analogue scale. From the results of the study it was evident that there was no difference between the study group and control group in terms of recovery, improvement or deterioration. The authors opined that soft collar application has no role in the improvement of pain in those with whiplash injury. After the introduction of immobilization of spine a routine in the protocols of all emergency medical services, the rates of complications related to cervical cord damage have been significantly reduced (AANS, p.3). However a study by Hauswald et al (cited in AANS, p.7) disputed this fact. In their study, they found that outcomes were similar in those who were immobilized with cervical collar and those who were not, in patients who suffered from road traffic blunt injury. In fact, they noted that those who did not receive cervical collar immobilization had less neurological consequences that those who were immobilized. The authors theorized that when the initial injury itself is of tremendous force, subsequent immobilization with collar is insufficient to cause further injury48. But this study has been challenged and several flaws have been identified like died patients excluded from the study and lack of matching of injuries based on the severity of neurological injuries. It is not possible to execute a clinical trial to ascertain the benefits of cervical spine immobilization owing to ethical and legal issues. The consensus opinion in articles reviewed is that from an biomechanical and anatomic perspective and also from time-tested clinical perspective, in patients with established or potential cervical spine injuries, spinal column immobilization must be done until definitive management or exclusion of injury. Following Hauswald's report, several experts have opined that cervical immobilization must be executed only in those with high risk for cervical injury. The benefits of a such a protocol was studied by Domier et al (p.332). These researchers studied 6500 trauma patients in which they immobilized patients base don clinical criteria like focal neurologic deficit, altered mental status, intoxication, spinal tenderness, spinal pain and suspected extremity fracture.,the authors opined that clinical criteria is a better tool to ascertain and predict the need for cervical immobilization rather than the mechanism of injury. In a major study by Podolsky et al (p.77), the researchers evaluated the efficacy of the immobilization techniques of cervical spine through goniometric measures. From the results of the study, it was evident that cervical collars alone are not useful for cervical spine immobilization and that sand bags taped in proper position are also essential. In another study by Cline (1985) (p.18), the researchers opined that short boards were superior to cervical collar for immobilization of cervical spine. Application of cervical collar is fraught with certain disadvantages. According to Chan et al (16), those whose cervical spine was immobilized suffered from pain and discomfort and other symptoms like sacral pain, mandibular pain, lumbar pain and occipital head ache. Cervical collars are also associated with elevations in the intracranial pressure and risks of aspiration. (AANS, p.10). In conclusion, it can be inferred that cervical collars in trauma patients are generally effective for limiting the motion of the cervical spine, but are associated with modest morbidity. They should be used for safe extrication and transit, but must be removed as soon as possible. Works Cited Page AANS.Prehospital immobilisation following trauma September 2001. 25th April 2011. Web Chan D, Goldberg R, et al. "Backboard versus mattress splint immobilization: a comparison of symptoms generated." J Emergency Med. 1996, 14:293-298. Chandler, DR., Nemejc, C, Adkins, RH., and Waters, RL. “Emergency cervical-spine immobilization.” Ann Emerg Med., 1992, 21(10), 1185-8. Cline JR, Scheidel E, et al. "A comparison of methods of cervical immobilization used in patient extrication and transport." J Trauma, 1985, 25:649-653. Domeier RM, Evans RW, et al. "The reliability of pre-hospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury." Pre-Hospital Emergency Care, 1999, 3:332-337. Gennis P, Miller L, Gallagher EJ, Giglio J, Carter W, Nathanson N. "The effect of soft cervical collars on persistent neck pain in patients with whiplash injury." Acad Emerg Med., 1996, 3(6):568-73. Jin P, Goslings J, Luitse J, & Ponsen K. "A retrospective study of five clinical criteria and one age criterion for selective prehospital spinal immobilization." European Journal of Trauma & Emergency Surgery, 2007, 33(4), 401-406. Krock, N. "Immobilizing the cervical spine using a collar. Complications and nursing management." Axone, 1997, 18(3), 52-5. Podolsky S, Hoffman, JR, et al. "Neurologic complications following immobilization of cervical spine fracture in a patient with ankylosing spondylitis." Ann Emerg Med, 1983, 12:578-580. Schnabel, M, Ferrari, R, Vassiliou, T, and Kaluza, G. "Randomised, controlled outcome study of active mobilisation compared with collar therapy for whiplash injury." Emerg Med J., 2004, 21, 306–310. Webber-Jones JE, Thomas CA, Bordeaux RE Jr." The management and prevention of rigid cervical collar complications." Orthop Nurs. 2002 Jul-Aug;21(4):19-25 Read More