How effective is the Newport/Aspen collar? A prospective radiographic evaluation in healthy adult volunteers

Unintended consequences of using collars with occipital extensions in neck support - Snapshot assessment at the largest tertiary spinal referral centre in the UK

INTRODUCTION

Upper cervical spine fractures are commonplace in the elderly following low energy trauma. These injuries carry high mortality rates, similar to patients sustaining hip fractures. A key aspect affecting clinical outcome is effective management in the first 12 weeks following injury. This study aims to assess the understanding of healthcare staff that may be required to care for such patients.

MATERIALS AND METHODS

A survey was carried out over a single day at the UK's largest Spine Specialist referral centre (Salford Royal Foundation Trust, SRFT) assessing the understanding of healthcare staff of the term, 'Collar with occipital extension', by asking staff to identify the safe position of the neck when looking at clinical images of a model in a collar in various different neck positions. The participants demographics were then taken, including profession, grade, spinal/post graduate experience, if English is their first language and their understanding of the term 'Collar with occipital extension'.

RESULTS

102 participants were interviewed and the results showed almost half (45.1%) of participants selecting an incorrect hyperextended neck to be a safe position for conservative treatment and only 37.3% selecting the neutral position as satisfactory. The only positive predictors identified for those selective the neutral safe cervical spine alignment was if participants had >5 years of previous spinal experience (p = 0.0006) or if they understood the term 'Collar with occipital extension' to be describing the collar component (p = 0.000013) and not neck position.

CONCLUSION

Management of spinal injuries are classically poorly managed in non-spinal centres, possibly due to the lack of training and understanding within the spinal speciality. This study shows the importance of clearly communicating with referring hospitals exactly how to conservatively manage patients with high cervical injuries to best improve clinical outcome.

The Effects of Cervical Orthoses on Head and Intervertebral Range of Motion

STUDY DESIGN

Prospective Cohort.

OBJECTIVE

Quantify and compare the effectiveness of cervical orthoses in restricting intervertebral kinematics during multiplanar motions.

SUMMARY OF BACKGROUND DATA

Previous studies evaluating the efficacy of cervical orthoses measured global head motion and did not evaluate individual cervical motion segment mobility. Prior studies focused only on the flexion/extension motion.

METHODS

Twenty adults without neck pain participated. Vertebral motion from the occiput through T1 was imaged using dynamic biplane radiography. Intervertebral motion was measured using an automated registration process with validated accuracy better than 1 degree. Participants performed independent trials of maximal flexion/extension, axial rotation, and lateral bending in a randomized order of unbraced, soft collar (foam), hard collar (Aspen), and cervical thoracic orthosis (CTO) (Aspen) conditions. Repeated-measures ANOVA was used to identify differences in the range of motion (ROM) among brace conditions for each motion.

RESULTS

Compared with no collar, the soft collar reduced flexion/extension ROM from occiput/C1 through C4/C5, and reduced axial rotation ROM at C1/C2 and from C3/C4 through C5/C6. The soft collar did not reduce motion at any motion segment during lateral bending. Compared with the soft collar, the hard collar reduced intervertebral motion at every motion segment during all motions, except for occiput/C1 during axial rotation and C1/C2 during lateral bending. The CTO reduced motion compared with the hard collar only at C6/C7 during flexion/extension and lateral bending.

CONCLUSIONS

The soft collar was ineffective as a restraint to intervertebral motion during lateral bending, but it did reduce intervertebral motion during flexion/extension and axial rotation. The hard collar reduced intervertebral motion compared with the soft collar across all motion directions. The CTO provided a minimal reduction in intervertebral motion compared with the hard collar. The utility in using a CTO rather than a hard collar is questionable, given the cost and little or no additional motion restriction.

Restriction of Cervical Intervertebral Movement With Different Types of External Immobilizers: A Cadaveric 3D Analysis Study

STUDY DESIGN

Cadaveric radiostereometric analysis study.

OBJECTIVE

To quantify the ability of five commonly used immobilizers to restrict cervical spine movement, including intervertebral movement, in three directions.

SUMMARY OF BACKGROUND DATA

Evidence about the ability of many clinically used cervical immobilizers to restrict cervical movement is limited. Furthermore, their effect on intervertebral movement is unknown.

METHODS

Radiographic inert beads were implanted in the cervical vertebral bodies of five fresh-frozen human cadavers. After application of different immobilizers (Stifneck, Sternal Occipital Mandibular Immobilizer (SOMI), halo-traction, spineboard, halo-vest) and controlled flexion-extension, lateral bending, and rotation torques, radiostereometric analysis was used to determine the overall and intervertebral three-dimensional movement of each vertebral level. Restriction of cervical movement was described as a mean restriction percentage (MRP) and classified on an arbitrary basis (poor: <20%, fair: 20%-40%, moderate: 40%-60%, substantial: 60%-80%, nearly complete: >80%).

RESULTS

Most of the restriction of flexion/extension was observed at C0-C1, while most rotational restriction was seen at C1-C2. Lateral bending was restricted at C1 to C7.The Stifneck provided the least immobilization with a moderate restriction of flexion-extension (MRP: 41%, SD: 14%), fair restriction of lateral bending (MRP: 29%, SD: 13%), and substantial restriction of rotation (MRP: 64%, SD: 15%). The halo-vest was the most restrictive immobilizer and reduced movement of the cervical spine substantially for flexion-extension (MRP: 70%, SD: 11%), substantially for lateral bending (MRP: 77%, SD: 14%), and nearly complete for rotation (MRP: 92%, SD: 3%).

CONCLUSION

The restriction of movement from lowest to highest was: Stifneck, SOMI, halo-traction, head blocks on a spine board, and halo-vest. Notably, the standard deviations of the restrictions were smaller for the cranio-thoracic devices than for the cervico thoracic devices. With this new knowledge of external immobilizers and their ability to restrict intervertebral cervical movement, their indication and application in clinical practice can be improved for all patients with (suspected) cervical injury.

LEVEL OF EVIDENCE

N/A.

Evaluation of the efficiency of cervical orthoses on cervical fracture: A review of literature

Background:

Various methods have been used to stabilize the vertebra in cervical fractures, including the use of various orthoses and surgery. However, it is not cleared which type of orthosis is more suitable for the subjects with cervical fractures to best immobilize the vertebra and to decrease the associated side effects. Therefore, the aim of this study was to evaluate the efficiency of various orthoses based on the available literature.

Materials and Methods:

A search was done in some databases include PubMed, ISI Web of Knowledge, EBSCO, Embasco, and Google Scholar. The search was done with some key words such as: Cervical spine injuries; odontoid fractures; hangman's fractures; axis fracture; axis, atlas, cervical fractures; trauma; neck fracture; neck injury in combination with cervical orthoses. The quality of the studies was evaluated by use of Downs and Black assessment and Assessment of Multiple Systematic Reviews (AMSTAR) for original research and review articles, respectively.

Results:

Based on the aforementioned key words, 25 papers were selected. The quality of the studies varies 10-24. Most of the studies were on the use of the halo vest orthosis, its side effects and also on complications associated with various orthoses.

Discussion:

Halo orthoses provide a high degree of restriction and immobilization; however, there are some side effects associated with this orthosis, including swallowing, pin loosening, and infection. It should be emphasized that other types of orthoses fewer complications, with reasonable outputs on motion restrictions.

Effectiveness of Adjustable Cervical Orthoses and Modular Cervical Thoracic Orthoses in Restricting Neck Motion: A Comparative In vivo Biomechanical Study

STUDY DESIGN

In vivo biomechanical study.

OBJECTIVE

To compare the effectiveness of adjustable cervical orthoses (COs) and modular cervical thoracic orthoses (CTOs) with standard devices in restricting neck motion in all 3 anatomical planes.

SUMMARY OF BACKGROUND DATA

No literature is available regarding the effectiveness of adjustable COs and modular CTOs in restricting neck motion, and existing in vivo evaluation methodologies lack consistency and objectivity.

METHODS

The effectiveness of adjustable COs (Vista collar and Vista multipost collar) and modular CTOs (Vista TS, Vista TS with multipost, and Vista TS4 with multipost) in comparison with standard devices (Aspen collar [AC] and Aspen cervical thoracic orthosis) in restricting neck motion across 3 anatomical planes was studied in vivo in 27 healthy participants across prescribed loading levels ranging from 0.5 to 2.0 N·m. Neck range of motion allowed was compared between devices using Tukey post hoc test. The compliance of devices in restricting flexion and extension was obtained via a linear regression model.

RESULTS

When compared with modular CTOs, Aspen CTO was significantly more effective at motion restriction in both sagittal and frontal planes under loading level higher than 1.5 N·m. Modular CTOs outperformed adjustable COs in most of the cases but were fairly comparable with the standard CO (i.e., AC). Adjustable COs were just as effective as standard COs. The compliances of devices in restricting neck flexion ranked in ascending order were 0.83 (Aspen CTO), 1.53 (Vista TS with multipost), 1.60 (Vista TS4 with multipost), 1.77 (Vista multipost collar), 1.78 (AC), 1.99 (Vista TS), and 2.43 (Vista Collar) degrees per N·m.

CONCLUSION

Overall, modular CTOs had poorer performance in neck restriction than their standard counterpart (ACTO), whereas adjustable COs showed overall comparable performance to their standard counterpart (AC). The outcomes may assist clinicians in selecting appropriate devices.

LEVEL OF EVIDENCE

N/A.

Is external cervical orthotic bracing necessary after posterior atlantoaxial fusion with modern instrumentation: meta-analysis and review of literature

BACKGROUND

No guidelines exist regarding external cervical orthoses (ECO) after atlantoaxial fusion. We reviewed published series describing C1-2 posterior instrumented fusions with screw-rod constructs (SRC) or transarticular screws (TAS) and compared rates of fusion with and without postoperative ECO.

METHODS

Online databases were searched for English-language articles between 1986 and April 2011 describing ECO use after posterior atlantoaxial instrumentation with SRC or TAS. Eighteen studies describing 947 patients who had SRC (± ECO: 254 of 693 patients), and 33 studies describing 1424 patients with TAS (± ECO: 525 of 899 patients) met inclusion criteria. Meta-analysis techniques were applied to estimate rates of fusion with and without ECO use.

RESULTS

All studies provided class III evidence, and no studies directly compared outcomes with or without ECO use. There was no significant difference in the proportion of patients who achieved successful fusion between patients treated with ECO and without ECO for SRC or TAS patients. Point estimates and 95% confidence intervals (CI) for rates of fusion ± ECO were 97.4% (CI: 95.2% to 98.6%) versus 97.9% (CI: 93.6% to 99.3%) for SRC and 93.6% (CI: 90.7% to 95.6%) versus 95.3% (CI: 90.8% to 97.7%) for TAS. There was no correlation between duration of ECO treatment and fusion (dose effect).

CONCLUSIONS

After C1-2 fusion with modern instrumentation, ECO may be unnecessary (class III). Some centers recommend ECO use with patients with softer bone quality (class IV). Prospective, randomized studies with validated radiographic and clinical outcome metrics are necessary to determine the utility of ECO after C1-2 fusion and its impact on patient comfort and cost.

The role of flexion and extension computed tomography with reconstruction in clearing the cervical spine in trauma patients: a pilot study

OBJECT

As a result of spinal trauma, approximately 12,000 individuals become quadriplegic or paraplegic each year in the US. The cervical spine is the most frequently injured part of the spinal column, and approximately 60% of spinal cord injuries involve the cervical region. The cervical collar remains the best method of prehospital spinal stabilization. Following trauma, difficulty securing an airway, the shielding of life-threatening injuries, and pressure ulcers are just a few of the serious problems that may be encountered in patients placed in cervical collars. The authors' goal was to develop an efficient method of clearing the cervical spine, by incorporating flexion and extension CT scanning with reconstruction (FECTR) into a trauma protocol.

METHODS

This prospective study reviewed consecutive patients evaluated by the neurosurgery and trauma services who underwent FECTR. Imaging studies were reviewed using the Picture Activating and Communication System. The incidence of injury detection was recorded, and detection of otherwise-missed cervical spinal injuries using FECTR and CT scanning were also recorded. This technique was also applied, without causing any new neurological complications, for comatose patients if the original CT showed no suspicion of unstable injury. The study end point was determination of the presence of cervical spinal column injury that would pose a threat of instability or injury to the patient.

RESULTS

Seventy-seven consecutive patients who underwent FECTR were identified. Far superior visualization of the cervicothoracic junction was achieved compared with flexion-extension cervical spine radiographs. In this case series, the sensitivity and specificity, respectively, of both FECTR and CT were 80% and 98.6% for all radiographic abnormalities. More importantly, for clinically unstable injuries, FECTR had a sensitivity of 100%. The use of FECTR added approximately 10-12 minutes to the time required for CT scanning.

CONCLUSIONS

The authors' initial findings show FECTR to be a safe, effective, and efficient method of posttraumatic cervical spine clearance. In unconscious or obtunded patients, FECTR facilitates cervical spine clearance with a high degree of accuracy. A larger prospective study is needed to confirm these findings.

Assessing range of motion to evaluate the adverse effects of ill-fitting cervical orthoses

BACKGROUND CONTEXT

Although previous studies have primarily focused on testing the effectiveness of cervical orthoses under properly fit conditions, this study focuses on analyzing the effects of an ill-fitted cervical orthosis (Miami J). This may have significance to health-care providers in understanding the effects of an improperly fitted neck brace.

PURPOSE

The aims of this study were threefold: first, to apply virtual reality (VR) feedback control to repeatedly measure orthoses effectiveness in the primary motions; second, to use this control methodology to test the orthoses ability to restrict flexion/extension (FE) as a function of axial rotation (AR); third, to test the effects of an ill-fitting Miami J on cervical motion.

STUDY DESIGN/SETTING

This study combines six degrees of freedom electromagnetic trackers and VR feedback to analyze the effectiveness of common cervical orthoses under less than optimal conditions.

PATIENT SAMPLE

Twelve healthy male subjects aged 21 to 35 (mean 29.44 years, SD 6.598) years with no previous spinal cord injuries or current neck pain participated in the study.

OUTCOME MEASURES

Cervical range of motion (CRoM) measurements were used to determine the amount of motion restriction for each of the fitted (too small, correct size, and too big) Miami J orthoses.

METHODS

One Nest of Birds (NOB) electromagnetic sensor (Ascension Technology) was placed on the head and another on the upper back to measure motion of the head relative to the torso. The VR goggles (i-O Display Systems) were worn so that real-time feedback was available to the subject for motion control. The subject executed the primary motions of FE, AR, and lateral bending (LB) in separate sets of five trials each. Next, in combined motion, the subject axially rotated to a set point and then FE to his maximums. This entire set of motions was repeated for each (soft collar, Miami J, Miami J with chest extension, Sternal Occipital Mandibular Immobilizer (AliMed, Inc.), (SOMI and Halo) as well as the Miami J (one size too small and one size too big); the fitting of each brace was done by a board certified orthotist. A repeated measures analysis of variance was used to determine differences between the tested states (*p=.05).

RESULTS

For the validation test, the primary motions recorded for subjects wearing each cervical brace, which demonstrated that the various orthoses all restricted CRoM. The soft collar restricted less motion than the other devices, whereas the Halo restricted the most motion throughout. For the ill-fitting cervical collar comparison, motion in the correct size collar was normalized to 1.0, and the correct size allowed less motion than either the too big or too small braces. In FE, the too big brace tended to allow more motion than the too small, but only the too big brace in extension was significantly different from the correct size. In AR, the too small brace seemed to allow more motion than the too big. Both the too big and too small braces were significantly different than the correct size in both left and right AR. In LB, the too big brace and too small brace were very similar in the amount of motion they were able to restrict. Both braces were significantly different than the correct size in right LB, whereas only the too small brace was significantly different from the correct size in left LB. In the combined motion data, both the too big and too small braces allowed more motion than the correct size. The too small brace seemed to allow more FE at all degrees of AR except for extreme right AR.

CONCLUSIONS

To our knowledge, the effects of improperly fitted cervical orthoses on CRoM are still unknown. Using the NOB electromagnetic tracking system combined with VR feedback, we were able to consider the motion restriction of ill-fitting Miami J orthoses for both primary and combined motions. For both motion types, increased motion was possible when the subject was improperly fitted with the Miami J. If not considered, these excessive motions could potentially have detrimental effects on patient satisfaction, clinical outcomes, or even lead to increased secondary injury.

Risks associated with magnetic resonance imaging and cervical collar in comatose, blunt trauma patients with negative comprehensive cervical spine computed tomography and no apparent spinal deficit

INTRODUCTION

In blunt trauma, comatose patients (Glasgow Coma Scale score 3 to 8) with a negative comprehensive cervical spine (CS) computed tomography assessment and no apparent spinal deficit, CS clearance strategies (magnetic resonance imaging [MRI] and prolonged cervical collar use) are controversial.

METHODS

We conducted a literature review to delineate risks for coma, CS instability, prolonged cervical collar use, and CS MRI.

RESULTS

Based on our search of the literature, the numbers of functional survivor patients among those who had sustained blunt trauma were as follows: 350 per 1,000 comatose unstable patients (increased intracranial pressure [ICP], hypotension, hypoxia, or early ventilator-associated pneumonia); 150 per 1,000 comatose high-risk patients (age > 45 years or Glasgow Coma Scale score 3 to 5); and 600 per 1,000 comatose stable patients (not unstable or high risk). Risk probabilities for adverse events among unstable, high-risk, and stable patients were as follows: 2.5% for CS instability; 26.2% for increased intensive care unit complications with prolonged cervical collar use; 9.3% to 14.6% for secondary brain injury with MRI transportation; and 20.6% for aspiration during MRI scanning (supine position). Additional risk probabilities for adverse events among unstable patients were as follows: 35.8% for increased ICP with cervical collar; and 72.1% for increased ICP during MRI scan (supine position).

CONCLUSION

Blunt trauma coma functional survivor (independent living) rates are alarming. When a comprehensive CS computed tomography evaluation is negative and there is no apparent spinal deficit, CS instability is unlikely (2.5%). Secondary brain injury from the cervical collar or MRI is more probable than CS instability and jeopardizes cerebral recovery. Brain injury severity, probability of CS instability, cervical collar risk, and MRI risk assessments are essential when deciding whether CS MRI is appropriate and for determining the timing of cervical collar removal.

Use of a noninvasive halo in children

STUDY DESIGN

Retrospective review of clinical experience in children using a new noninvasive halo.

OBJECTIVE

To report on the efficacy, complications and indications for use of a noninvasive halo in the pediatric population.

SUMMARY OF BACKGROUND DATA

A halo vest with pins in the skull is the gold standard for providing maximum immobilization and control of the cervical spine. Inherent complications include scarring, infection, cerebral spinal fluid leakage, loosening of pins, and penetration of the cranial vault. Less invasive orthoses historically provide significantly less immobilization and control of the cervical spine. A Minerva cast has problems with patient tolerance and skin care.

METHODS

The noninvasive halo was used on 30 children (ages 6 months to 16 years) for the following indications: muscular torticollis release, 18 children; cervical fusion immobilization 7 children; closed reduction of C1-C2 rotatory subluxation, 5 children.

RESULTS

The noninvasive halo was successful with no complications in 29 of 30 patients. One complication consisted of dislodgment of a C2-C4 anterior strut graft, though fusion ensued without further surgery and the clinical result was successful. Longstanding C1-C2 rotatory subluxations were safely reduced in 5 children with the noninvasive halo. In 18 children following sternocleidomastoid release, the cervical spine was successfully immobilized in an overcorrected position after surgery.

CONCLUSION

A noninvasive halo was used successfully for postoperative immobilization of children with stable cervical spines. This device was particularly useful for the gentle and safe reduction of C1-C2 subluxations, and for postoperative immobilization in an overcorrected position following stenocleidomastoid release for congenital muscular torticollis.

Reduction in head and intervertebral motion provided by 7 contemporary cervical orthoses in 45 individuals

STUDY DESIGN

Biomechanical evaluation of cervical orthoses.

OBJECTIVE

To provide data to help clinicians select an orthosis for immobilization of the adult cervical spine.

SUMMARY OF BACKGROUND DATA

There are limited data on the effectiveness of cervical orthoses at restricting intervertebral motion, and many of the commonly used, contemporary braces have not been evaluated. Additionally, no data exist comparing the effectiveness of braces in the supine versus the upright position. New technology is available to measure intervertebral motion with greater accuracy.

METHODS

Overall range of motion of the head in 3 planes as well as intervertebral motion in the sagittal plane were measured in 45 healthy adult volunteers while wearing 7 cervical orthoses. Subject-reported comfort of each brace was also recorded.

RESULTS

All braces significantly reduced intervertebral motion. Effectiveness and comfort varied between braces. In general, orthoses could be grouped as cervical braces or cervicothoracic braces. The latter was consistently better at limiting motion, with some differences within these groups as well.

CONCLUSION

These data will help to guide the clinician in selecting the appropriate cervical orthosis for their adult patient based on comfort, morphologic considerations, and degree of immobilization required.

[Pressure sores secondary to immobilization with cervical collar: a complication of acute cervical injury]

Cervical collars are essential in the treatment of patients with suspicion or verification of acute cervical spine injury (ACSI). One of the complications of these devices is the development of pressure scores (PS). This study aims to determine its incidence in our unit, the characteristics of patients with ACSI who suffer PS due to the collar and to describe aspects related with these injuries. We include 92 patients with ACSI hospitalized more than 24 hours from January 2002 to December 2003. We analyze demographic variables, incidence, risk factors and characteristics of the PS that develop. The incidence of these lesions was 23.9%. Patients with PS presented: a higher injury severity score (ISS) (37.5 9.8 vs. 31.3 14.9), a greater percentage of catheter carriers of intracraneal pressure (ICP) (55.6% vs. 16.2%), longer time of mechanical ventilation (15.4 8.2 vs. 6.1 9) and longer stays (24.6 10.9 vs. 10 10.3), all statistically significant (p< 0.05). A total of 38 PS were detected, 7 (RI 5-13.8) being the median of the detection day. The chin, occipital and suprascapular zone were the most frequent locations. A total of 42.1% were grade II and 39.5% grade III. The occipital injuries were the most serious and those detected the latest. We conclude that a high index of suspicion of PS due to collar in patients with ACSI, elevated ISS, monitoring of ICP, mechanical ventilation and prolonged stays is required. The occipital zone requires special attention due to the seriousness of the injuries recorded. We suggest a specific multidisciplinary protocol for this problem.

The effectiveness of extrication collars tested during the execution of spine-board transfer techniques

BACKGROUND CONTEXT

In the prehospital stages of emergency care, cervical collars are (supposedly) used to aid rescuers in maintaining in-line stabilization of the spinal column as patients with potential or actual injuries are shifted onto a spine board to achieve full spinal immobilization. Unfortunately, not a single study has examined the effectiveness of cervical collars to control motion during the execution of spine-board transfer techniques.

PURPOSE

To evaluate the controlling effect of three cervical collars during the execution of spine-board transfer techniques.

STUDY DESIGN

This was a repeated measures investigation in which a cadaveric model was used to test the effectiveness of the Ambu (Ambu, Inc., Linthicum, MD), Aspen (Aspen Medical Products, Inc., Long Beach, CA) and Miami J (Jerome Medical, Moorestown, NJ) collars during the execution of the log-roll (LR) maneuver and the lift-and-slide (LS) technique.

METHODS

Six medical professionals executed the LR and the LS on five cadavers. An electromagnetic tracking device was used to capture angular movements generated at the C5-C6 vertebral segment during the execution of both transfer techniques. The types of motion that were analyzed in this study were flexion-extension, lateral flexion and axial rotation motion. To test the three cervical collars, an experimental lesion (ie, a complete segmental instability) was created at the aforementioned spinal level of the cadavers and sensors from the electromagnetic tracking device were affixed to the specified vertebrae to record the motion generated at the site of the lesion.

RESULTS

Statistical tests did not reveal a significant interaction between the independent variables of this study (ie, transfer technique and collar type), lending no support to the notion that there may be a combination of collar and transfer technique that could theoretically offer added protection to the patient. Although there was a decrease in the amount of motion generated in every one of the planes of motion as a result of wearing each of the three collars, none of the changes that emerged proved to be significantly different. A significant difference was noted between the LR and LS techniques when the amount of lateral flexion and axial rotation motion generated with each of the procedures were compared. In both cases, execution of the LR maneuver resulted in significantly more motion.

CONCLUSIONS

The data presented here suggest that the collars tested in this study are functionally similar. It is recommended that this study be repeated with a larger sample size.

Motion Generated in the Unstable Spine during Hospital Bed Transfers

BACKGROUND

The purpose of this study was to compare the motion generated when executing the bed transfer procedure in cadavers with unstable lower cervical spines.

METHODS

Five cadavers received a global instability at the C5-6 level. Each cadaver was moved with and without a rigid cervical collar. The amount of translation resulting from the bed transfer was measured.

RESULTS

Statistical analysis revealed no difference in spinal movement between treatments (with or without a collar). Anterior/posterior (AP) and medial/lateral motions were similar in magnitude and much higher than longitudinal motion.

CONCLUSIONS

There was very little resistance to motion in the AP and lateral directions. Thus, it may not be surprising that no difference in the amount of motion was noted between transfers conducted by skilled hands with or without a collar. Current hospital transfer techniques have the potential to inflict an unacceptably large displacement on an unstable spine.

Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening

Cervical spine injury occurs in 5-10% of cases of blunt polytrauma. A missed or delayed diagnosis of cervical spine injury may be associated with permanent neurological sequelae. However, there is no consensus about the ideal evaluation and management of the potentially injured cervical spine and, despite the publication of numerous clinical guidelines, this issue remains controversial. In addition, many studies are limited in their application to the obtunded or unconscious trauma victim. This review will provide the clinician managing unconscious trauma victims with an assessment of the actual performance of clinical examination and imaging modalities in detecting cervical spine and isolated ligamentous injury, a review of existing guidelines in light of the available evidence, relative risk estimates and a proposed management scheme.

The management and prevention of rigid cervical collar complications

The rigid cervical collar has been a great addition to the successful management of cervical spine injuries. But the collar has been known to offer a false sense of security in terms of totally preventing additional and further spinal cord compromise and damage. Also, with increased length of collar wear, there is development of skin pressure points and ulcer formation, possible delay in weaning from a ventilator, potential for exposure to transmission of blood-borne diseases. Photographs are used to demonstrate examples of related skin breakdown, show proper collar fit, present the result of ineffective cervical immobilization, and show how to stabilize the head and neck during a collar change. These problem areas are addressed with the dos and don'ts for nursing management.