A 27-year old female presented with persistent central intrascapular pain after a high-speed skiing injury in Japan. Imaging revealed fractures at C7, T1 spinous processes, and T7 vertebral body. She was initially managed conservatively with a cervical collar and neuro checks. However, evidence shows cervical collars may do more harm than good and their use is based more on tradition than clinical evidence. Proper history and exam, along with imaging as indicated, are more important for assessing spinal injury and instability than routine hard collar use.

1. Spinal Trauma:
The Legend of the C-Spine Collar
Trauma Grand Rounds 14/04/15
Dr Emma McVeigh
Emergency Medicine Registrar

2. Case Report
 27 year old female presents 18/7 post high
speed ski injury in Japan
 c/o persistent central intrascapular pain
worse on lifting
 Denies any focal or peripheral neurology
 Systemically well

3. Mechanism/ Hx of Injury
 Injury at approximately 60kph
 Hyperflexion injury with axial loading
 c/o “excruciating 10/10 pain” at time of injury over cervical and thoracic
spine
 No paraesthesiae/ No weakness
 Patient mobilised 10min post-injury and continued to ski down slope
 C/o severe intermittent pain localised Cervico-Thoracic junction over
next 1/52
 Some relief from simple analgesia
 Continued to ski again 2/7 post injury
 Went surfing twice
 Returned to work for 2/52 in a physical occupation

4. HxPc
 Urged to present to ED on the advice of friends due
to persistent pain
 Maximal pain over T1 post lifting/mobilising lasting
for several hours
 Intermittent Naproxen 1000mg SR provided relief
 No paraesthesia
 No weakness
 No incontinence

5. O/E:
 Vitals: Stable
 GCS: 15
 Mobilising
 No focal neurology
 No peripheral neurology
 Tender to palpation over cervico-thoracic
junction to mid-thoracic spine
 All other examination grossly normal

8. Epidemiology
 US 10,000 Spinal fractures/ year
 Peak incidence 15-35yo, 61%Male
 Associated w/ RTAs and Sports injuries
 USA nationwide study 8634 spinal fractures 2000-2008
 Alpine tertiary centre 728 fractures 2000-2006
– Subluxation/dislocation 73 patients
 Skiers = C-spine Vs Snowboarders= Lumbar
– Cervical 19.6%
– Thoracic10.9%
– Lumbar 6%

9. Anatomy of the Spine

10. Anatomy

11. Anatomy

12. Classification
 Flexion injury
 Flexion – Rotation injury
 Extension injury
 Vertical (Axial) Compression Injury
 Multiple or complex injuries

13. Stable Vs Unstable
 Most important concept is that of “stability”White et Al.
 Definition of Instability:
“The loss of ability of the cervical spine under
physiological loads to maintain relationships between
the vertebrae in such a way, that spinal cord or nerve
roots are not damaged or irritated and deformity or
pain does not occur”Leemans and Calder 2012

14. White and Panjabi Scale

16. An Approach to the Spinal Patient
1) Full spinal immobilization care until cleared
2) Detailed Hx and Exam
 Mechanism of injury
 Speed
 Other injuries
1) CT C-Spine (High Resolution)
2) Formal Radiologist/Orthopaedic/Neurosurgical opinion
3) Any doubt
 High risk injury / Neuro deficit  MRI
 CT Abnormal  MRI
 Normal  Clear C-Spine

17. American Spinal Association
Impairment Scale (ASIA)

18. Assessment of Potential C-spine Injury
 Canadian c-spine rules
 Nexus c-spine rules

21. C-Spine X-rays
 A standard series of X-rays of the cervical spine consists of three views:
– AP
– Lateral
– AP odontoid peg
 Lateral view must show the top of the T1 vertebral body
 Odontoid peg view should show the lateral masses of the atlanto-axial articulation
 In children aged <10, use a AP and lateral radiographs,
 No peg view
 CT imaging to clarify abnormalities or uncertainties
 Indications:
– Patients with neck pain or midline tenderness if aged ≥65 years
– Any age if there was a dangerous mechanism of injury
– Definitive diagnosis of cervical spine injury is needed urgently (eg, before surgery)
– Any patients where it is considered unsafe to assess movement.

22. C-spine CT Scanning
 CT scan is indicated immediately if:
– GCS <13
– Intubated
– Multi-region trauma
 CT is also indicated:
– If plain films are inadequate/suspicious/definitely abnormal
– High clinical suspicion
 CT is superior to plain radiography
– Sensitivity: 100%
– Specificity: 99%.

23. C-spine MRI Scanning
 Soft tissue structures
 Intervertebral disc injury
– Sensitivity: 93%
 Posterior longitudinal injury
– Sensitivity: 93%
 Interspinous Ligament injury
– Sensitivity: 100%
 MRI is indicated for patients with neurological signs, even if plain films
are negative
 MRI can distinguish haematoma from oedema

24. Complications
 Paralysis
 Neurogenic Shock
 Respiratory Failure
 Thrombosis
 Haemorrhage
 Infection
 Autonomic Hyper-reflexia

25. Case Report
 Diagnosis of:
– C7 Fracture
– T1 Spinous Process Fractures
– T7 Vertebral Body Compression Fracture

26. Initial Management
 Full C-spine Precaution
 Neurology Examination: Normal
 4-hourly Neuro Observation
 Further imaging including CT
Cervical/Thoracic Spine and MRI Spine

30. Definitive Management
 Transfer to RPH Spinal Unit in full spinal
precautions awaiting Spinal Review
 Initial decision for C7/T1 Fusion
 Remained in full spinal precaution 4.5/7
 S/B Spinal Consultant 5/7 post diagnosis
 Decision for conservative mx in Thoracic
Aspen collar

32. Discussion: When can we clear the c-
spine?
 Controversial issue
 C-spine clearance can be clinical +/- Radiological
 Treatments are vastly different
– Stability
 Until patients are cleared they must be immobilized
in a hard-collar, in line stabilisation and log rolled

33. Hard collars
 Use of hard-collars is standard of care
– Fear of not using the collar in undx SCIs or
worse….being judged by colleagues

34. Evidence?

35. Why do we use the collar?
 American Association of neurological
surgeons
– Guidelines mandate use of hard collar
– 1970s full Neurological Lesions 55%
– In 1980s Partial lesion 61%.......at same time as
hard collars introduced
 Correlation vs Causality

36. But it’s a harmless intervention…
 Ulcers
 Raised ICP – ‘Brain tourniquet’
 Actually could make fractures worse
 Intoxicated patient
 Airway management
 Painful
 Increased cost and time
– 4hr rule…

37. Is it harmful?
 Myths of the cervical collar…
1. Injured patients may have an unstable injury of the
cervical spine
2. Further movement of the c-spine could cause addition
damage to the spinal cord over and above that already
caused by the initial trauma
3. The application of a semi-rigid collar prevents potentially
harmful movements of the c-spine
4. Immobilisation of the c-spine is a relatively harmless
measure and can therefore be applied to a large number
of patients with a relatively low risk of injury “as a
precaution”.

38. Take Home Message…….
 Mechanism of injury should arouse suspicion
– i.e. falling while skiing at 60kph Vs tripping over
your shoelaces
 Knowledge of anatomy and the concept of
stability
 Ax rules are useful but not very specific, a
senior clinician’s gestalt is all important
 The hard collar is not the be all and end all

39. THM cont…
 Don’t transfer a trauma patient to RPH the
same week as FSH changeover….
 Don’t go skiing with two other emergency
registrars…

43. THANKS!!!

44. References
[1] Sanders KM1, Seeman E, Ugoni AM, Pasco JA, Martin TJ, Skoric B, Nicholson GC, Kotowicz MA.
Age- and gender-specific rate of fractures in Australia: a population-based study. Osteoporosis
International. 1999; 10 (3) 240-7
[2] Hubbard M.E., Jewell R.P., Dumont T.M., Rughani A.R. (2011). Spinal injury patterns among skiers and
snowboarders. Neurosurgical FOCUS. Nov 2011; 31: 5
[3] White AA 3rd, Johnson RM, Panjabi MM. Biomechanical analysis of clinical stability in the cervical
spine. Clin Orthop. 1975;(109):85-96. [Medline].
[4] Leemans and Calder. The Unstable Cervical Spine. In: (eds) Johnston I, Harrop-Griffiths W. and Gemmell
L. AAGBI Topics in Anaesthesia 2012. Chichester, UK: Wiley-Blackhall 2012 p88-104
[5] Sundstrøm T, et al. Prehospital use of cervical collars in trauma patients: a critical review.Review
article J Neurotrauma. 2014
[6] Wee B, Reynolds JH, Bleetman A; Imaging after trauma to the neck. BMJ. 2008 Jan 19;336(7636):154-7.
Triage - assessment - investigation and early management of head injury in infants, children and
adults; NICE Clinical Guideline (September 2007)

45. Questions