• 
• 

Three Part Question

[In patients with traumatic brain injury] does [application of a cervical collar] [raise intracranial pressure]?

Clinical Scenario

An otherwise healthy 28-year-old male presents to the emergency department following a motor vehicle collision. The patient, brought in wearing a cervical collar, is obtunded upon arrival and intubated for airway protection. CT imaging shows a multifocal subarachnoid hemorrhage. The patient has signs of increased intracranial pressure (ICP) and despite maximal medical therapy continues to be severely hypertensive and bradycardic. CT of the cervical spine was negative, and you wonder if the patient’s cervical collar is contributing to the elevated intracranial pressure.

Search Strategy

Medline 1966-07/24 using PubMed, Cochrane Library (2024), and Embase
[(Immobilization/adverse effects [MAJR]) AND (intracranial pressure [All Fields]) OR ("Brain Injuries, Traumatic/complications"[MeSH])] Limit to English Language.

[(Intracranial pressure [All Fields] OR brain Injuries, traumatic/complications [MeSH]) AND (cervical collars [All Fields] OR cervical immobilization [All Fields] OR ("spine immobilization"[All Fields])] Limit to English Language.

Search Outcome

29 studies were identified; one systematic review and one clinical trial were identified as both relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Núñez-Patiño RA, et al. April 2020 Argentina, Colombia	Five prospective studies of adult patients (N=86) after traumatic brain injury (TBI).	Systematic review and meta-analysis	Overall increase in intracranial pressure (ICP) after collar application	4.4 mmHg (P<0.01)	Small number of prospective and well designed studies; lack of consistent reporting of baseline characteristics of patients; did not stratify by type of collar.
			Overall decrease in ICP values after collar removal	3.0 mmHg (P=0.65)
Jung E, et al February 2023 Republic of Korea	59,472 adult trauma patients in the Pan-Asian trauma outcome study (PATOS) registry	Prospective multi-center cohort study	Poor functional recovery at hospital discharge	Cervical spine immobilization (CSI) was significantly associated with an increased poor functional outcome (adjusted odd ratio 1.23)	Different types of CSI were applied in each country and region; study did not measure the ICP of the TBI patients; investigators were not blinded to the study hypothesis; study design was not a randomized controlled trial
			Mortality at hospital discharge	CSI was not associated with in-hospital mortality (P=0.88)

Comment(s)

Routine immobilization of the cervical spine has been advocated worldwide for patients with head injury until a cervical spine injury has been excluded. However, several observational studies including case reports, case series and few clinical studies have shown increases in ICP due to cervical collar immobilization [1]. The clinical study by Jung et al. demonstrates that subsequent increases in ICP was associated with an increased poor functional outcomes [2].

Clinical Bottom Line

In adult patients with moderate to severe traumatic brain injury, application of a cervical collar causes a demonstrable increase in intracranial pressure and may result in poor functional neurologic outcomes.

References

1. Núñez-Patiño RA, Rubiano AM, Godoy DA. Impact of Cervical Collars on Intracranial Pressure Values in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prospective Studies. Impact of Cervical Collars on Intracranial Pressure Values in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prospective Studies. Neurocrit Care 2020 Apr;32(2):469-477.
2. Jung E, Ro YS, Ryu HH, Shin SD. Impact of cervical spine immobilization on clinical outcomes in traumatic brain injury patients according to prehospital mean arterial pressure: A multinational and multicenter observational study. Medicine (Baltimore) 2023 Feb 17;102(7):e32849.