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Three Part Question

In [alert, adult blunt trauma patients with suspected cervical spine injury] are [blocks alone just as efficacious as a combination of a cervical collar and blocks] at [providing sufficient immobilisation of the cervical spine]?

Clinical Scenario

A 32 year old gentleman is brought to the Emergency Department via an ambulance. On arrival he is immobilised with a long board, cervical collar and blocks.
The paramedics tell you that he has been involved in an RTC. He was the driver of a car and was wearing a seatbelt. He was driving between 30-35 miles/hour, when a car pulled out of a junction suddenly. Although the patient braked he collided with the car as it pulled out.
On paramedic assessment he had mid-line c-spine tenderness so the patient was immobilised at the scene. The patient is finding the collar too tight. You wonder if a collar is essential and whether adequate c-spine immobilisation could be achieved with the blocks alone.

Search Strategy

A search for relevant papers was carried out in Medline and the Cochrane library. The reference list of relevant papers were also examined to identify any other papers that may be relevant to the 3 part question.

The following search strategy was employed:

Medline 1974-2020: (Adults.mp) AND (Trauma.mp) AND (cervical spine injury.mp OR exp.c-spine injury) AND (cervical spine immobilisation.mp) AND (Blocks.mp OR collar and blocks.mp) LIMIT to humans.
Cochrane database of systematic reviews: 1/1/2000-1/1/2020 (Cervical Spine.mp) AND (immobilisation.mp) AND (trauma.mp).

Search Outcome

8 possible relevant paper identified. On review only 2 papers were included, one of which was identified from a reference on a less relevant paper.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Holla, M 2012 Netherlands	10 healthy volunteers	Proof of principle	Range of neck motion (flexion, extension, rotation and lateral) wearing either collar alone, blocks alone or combination of the two. Degree of mouth opening with collar alone, blocks alone and combination of the two.	Range of neck movement significantly reduced (p<0.005) in blocks alone vs collar alone (12% to 34%). No significant reduction in the combination of blocks and collar. Mean mouth opening was significantly reduced (p<0.01) from 47mm without a collar to 34mm with a collar.	Very very small sample size Observer/research bias Findings may not be applicable to a trauma patient as used healthy volunteers. All volunteers below the age of 45, so not representative of the general population and may not be applicable to the elderly Did not do a simulation of the extrication and transport of a trauma victim, which again makes the findings unreliable Unable to draw any meaningful conclusions.
Sundstrom et al	Trauma patients	Critical review	Pros and cons of collar use	Collars should not be applied and that blocks blocks alone will provide adequate immobilisation.	No clear outcome measures. No detailed information of method of analysis or comment on level of evidence. No PRISMA diagram. No mention of who assessed each of the studies and criteria for inclusion.

Comment(s)

Unfortunately, I was unable to find any high quality evidence and only one study which directly compared the 2 different methods. There are many limitations of this small study so no strong conclusions can be made. My reading and appraising the limited amount of evidence has highlighted the fact that no RCT exists comparing blocks alone versus a combination of collar and blocks and their effectiveness at immobilising the cervical spine. Due to ethical and medico-legal issues an RCT may be difficult to perform in the pre-hospital setting.

Clinical Bottom Line

There is no published evidence favouring one method over another and so I am unable to answer the 3 part question: local/national guidelines should be followed.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Holla M Value of a rigid collar in addition to head blocks: a proof of principle study. EMJ 2012; 29: 104-107.
2. Sundstrom et al Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review. J Neurotrauma 2014 Mar 15;31(6):531-40