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• W3123354208 abstract "We would like to commend the contribution of Asha et al., who have attempted to address a long-standing knowledge gap with their publication entitled ‘Neurologic outcomes following the introduction of a policy for using soft cervical collars in suspected traumatic cervical spine injury: a retrospective chart review’.1 Spinal immobilisation has been a continual point of conjecture, with current practice dominated by legacy ideologies and perpetual dogma. The routine application of semi-rigid cervical collars has long been a mainstay of contemporary practice, despite no definitive evidence demonstrating its efficacy in preventing secondary spinal cord damage. Semi-rigid collars may be variably fitted and, or, tolerated. The utilisation of this inflexible immobilisation adjunct is not a benevolent procedure and has been shown to induce a myriad of adverse effects including: (i) tissue ulceration; (ii) impairment of respirations; (iii) increased intracranial pressure; (iv) unnecessary discomfort; and (v) exacerbation of spinal displacement. While variably more effective than soft collars, semi-rigid collars do not fully immobilise the cervical spine. As the choruses of discontent regarding the utility of semi-rigid collars continue, clinicians must question whether applying this device results in more harm than good? The Queensland Ambulance Service (QAS) is the sole ambulance provider in Queensland, providing more than 1 300 000 emergency responses annually. In 2015, following a review of contemporary evidence and in collaboration with our trauma networks, soft cervical collars were introduced for use by our responding paramedics (Fig. 1). This introduction resulted from a collaborative approach across all relevant disciplines, including spinal surgeons and spinal injury service specialists. Soft malleable collars were a readily available substitute that could be applied to patients presenting with potential cervical injury. Rather than physically attempting to immobilise the wearer, they act as a prompt to restrict voluntary movement and maintain their spinal alignment. Unlike semi-rigid collars, these devices have not been reported to incur harm and due to their pliable design, are associated with increased patient compliance. Our own experience is that greater than 95% of cases had a Glasgow Coma Scale (GCS) of 13 or above, with many of these patients being intoxicated with alcohol or agitated. It is highly unlikely any patient with a high GCS would move their neck such as to worsen a bony or ligamentous injury. In addition, even well fitted semi-rigid collars are often poorly tolerated. In the setting of patients with intoxication or agitation, our experience is that soft collars are immensely better tolerated, with a potential benefit of reduced occupational violence towards paramedics. For patients with a GCS 12 or less, our current practice is to provide lateral neck support in addition to the soft collar. Unlike Asha et al., the QAS does not change its approach for unconscious patients or those patients suffering overt spinal cord injury. This is because the collar, no matter whether semi-rigid or soft, is not the sole intervention required. These patients require holistic spinal care, of which cervical collar application is just part of a broader care bundle. Changing from a semi-rigid collar to a soft collar allowed us to redefine and reinforce the concepts of full spinal care, rather than being seen as a downgrading of treatment. This introduction was complimented by a whole of organisation educational programme. The ostensible superiority of semi-rigid collars in comparison with soft collars is currently based upon biological plausibility rather than literature supporting subsequent clinical outcomes. This has been somewhat addressed in the work of Asha et al., who have demonstrated in their well-constructed observational study that the utilisation of soft collars does not increase the risk of developing a secondary spinal cord injury. In the past 5 years the QAS has applied approximately 130 000 soft collars. During this time, no patients suffering a worsening of their injury have been identified via our own clinical governance processes, the state-wide health system safety reporting programme, various tiered trauma audit committees or directly from Queensland's sole spinal injuries unit. Despite limited numbers, the study by Asha et al. reported secondary injury occurring regardless of the immobilisation collar type used. This is not surprising, as overwhelmingly it is the initial injury insult that causes the bony, ligamentous and cord injury. In almost all cases, further neurological deterioration is a result of spinal cord haemorrhage or progressive oedema rather than from structural instability. With an ageing population, it is also important to consider the ramifications of the application of a semi-rigid collar to the degenerative cervical spine. These anatomical changes are not well suited to a semi-rigid device, with greater propensity for both pain and potential secondary injury. Given the ever-increasing numbers of falls from standing height in this patient cohort, it can be expected that large numbers of elderly patients will present with spinal immobilisation devices in situ. This is but another reason to consider soft collar application prior to formal assessment at hospital. The findings of the present study are strengthened by its multi-centre design, enrolling 2036 consecutive patients that were assessed for a traumatic cervical spinal injury. The logistics and collaboration required to undertake the present study across seven EDs is laudable and we praise the potential implications their results will have for future practice. As outlined in their published work, larger prospective studies are required to reinforce these findings; however, considering the infrequency of this injury complication, the sheer numbers required to power such a study would be near impossible to achieve. We encourage future publications exploring this topic but, in their absence, we would encourage local trauma networks and ambulance services to examine their practice to develop pragmatic approaches to acute spinal immobilisation and care. None declared." @default.
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• W3123354208 date "2021-01-25" @default.
• W3123354208 modified "2023-10-04" @default.
• W3123354208 title "Is it finally time we stick our neck out?" @default.
• W3123354208 cites W3092596088 @default.
• W3123354208 doi "https://doi.org/10.1111/1742-6723.13705" @default.
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