Episode 196 - Cervical Spine Immobilization In 2026: Evidence Vs. Dogma

[Music] Hello everybody welcome again to another edition of the MCHD Paramedic Podcast. My name is Dr. Casey Patrick and joining us today is a regular guest assistant medical director Dr. Mike Deepas-Quali and if you have eyes and you're watching us on YouTube maybe we sound a little different we for sure look a little different we've upgraded some of the AV stuff here in the podcast room at MCHD and so if we stumble a little bit on out of sorts we've had the same setup for gosh probably four or five years now so we're really thankful for the support we have around around the agency for this endeavor and so if you're listening out there MCHD board executive staff thank you for your help let's roll into the topic of the day and this springs directly from our second quarter continuing education program and that was a change in our approach to cervical spine immobilization in the field and this is a topic that you can find out there in the foamed world EMS blogs EMS literature not a not a new concept a recent NAMSP or the EMS Physicians Group literature review looked at the existing literature and the evidence around rigid cervical collar placement and trauma patients and we're going to review that and talk a little bit about the approach that we ended up taking here in our service it's not a one size fits all ever in EMS so before we get into the evidence and talk about some of the details let's define what we're concerned about so when we think about putting a collar on a patient what are we trying to fix i think this is no different than if we're going to use an ebb and obstructive lung disease how does that work if we're going to provide defibrillation in vf what's the goal what's the go with rigid collar placement so i think the understood goal is that if you suspect the patient has a cervical spinal injury we put the collar on so that we don't make that cervical spinal injury worse if there's an unstable spinal fracture and there's a risk of spinal cord injury then i think the the teaching and thinking is that the cervical collar will help minimize movement of the spine and prevent any further injury from occurring and that is term delayed spinal cord injury and the idea is you have a c-spon fracture patient moves around and those fracture fragments dig in damaged the spinal cord itself the big nerve and we have paralysis the definition of delayed spinal cord injury is very vague in the literature there's no clear time cutoff these develop sub acutely but we're not you know there's not a lab value or a specific imaging tact that we take with these injuries and honestly a lot of this is anecdote we're going to come back to that several times in our discussion and this goes back to i know you bring this up often but there's the paramedic school case that everyone's presented with a lot of paramedic so i didn't have this one but yeah those nerves will be familiar anyone i'm sure anyone who's gone through EMT or paramedic class knows the story of the someone that got into a car accident and had some neck pain the medics came and they stood the patient up out of the car and the second they stood him up immediately they fell to the ground with a sudden spinal cord injury and they were paralyzed for life and at least i knew i was told that story when i was in EMT school and it scared me at then so we put collars on everyone basically after that but i don't think there's ever been a documented case of that ever happening period so i'm not sure the legitimacy of that story well brings us to the history what's the history of c-spot immobilization with rigid collars in the field and like many things in em s this is a military extension from the 1940s so we're talking world war two pre- Korean war there was a Canadian military physician named Halette who proposed the idea of c-spon fracture so vertibral bony injury plus movement jiggling around leads to spinal cord or nerve injury with paralysis delayed spinal cord injury so that was basically just proposed as a logical thought i mean we split broken arms and broken legs right so why don't we sprint split broken next it's interesting if you dig back into that paper which i always like looking at papers from the forties you find interesting things above spinal cord immobilization in his list of things to do was treat shock which actually in the paper and everything that's there it's the one thing that holds true he also talks about moving the patient with a rug so it was the 1940s a very different time but number two on his list was treat shock which i feel like is actually kind of interesting because that's probably where the delayed spinal cord injury actually comes from sporeal or not some sort of movement of bony fragments into the 50s and 60s there's a couple more descriptions in the literature of this idea of delayed spinal cord injury from fractures being manipulated and moved without immobilization again no control groups nothing prospective no comparators just really anecdote from spinal surgeons then in 1971 the American Academy of Orthopedic Surgeons the Spon Surgeons said hey spinal motion restriction that standard of care they said it and that's what happened and that trickled over to the American College of Surgeons the committee on trauma that was introduced in the HLS in the late 70s and early 80s and if you think about what is really close to spinal cord injury when it comes to diagnostics that's MRI when when it comes to spinal cord injury and want to look at nerve injury the MRIs the diagnostic test of choice this was dogma and accepted as clinical best practice before MRI machines were in widespread use which happened in the late 80s early 1990s so that's an interesting thing to think about as we walk through the idea of this is standard of care this is what we should do all of this was put into place before MRI was available so we're talking about x-rays and flex x-films and maybe rudimentary you know CT scanners no MRI machine so that's the history of where this came from anecdote in the 40s to 50s military basis spawn surgeons in the 70s the trauma surgeons in the 80s then we had MRI come along and we've had some studies since then that have looked not at the positive effects of rigid cervical collar placement but more at the negative effects are these clinically impactful let's talk through some of these and you know it's interesting to think about well there's no evidence to support their use well there is definitely some evidence for harm increased ICP you've got a patient that has a cervical spine injury they're going to have intercranial injury as well so you know you can take your stab at this one multiple papers from the 90s looking at patients in the ICU with interpantricular or interparenquinal pressure monitors in place put a collar on and what happens that ICP goes up now just five millimeters of mercury increased in ICP does that matter clinically? it's your might I think might is safe we know that ICP directly correlates with CPP a negative fashion so increasing ICP decreases your cerebral fusing pressure it's not a great thing we know they're uncomfortable I mean that's probably the least clinically impactful but probably the most patient oriented piece of this and there are some interesting pieces to the uncomfortability and that is when you put the collars on healthy volunteers what they found was they can have neck pain up to 24 hours later these are healthy folks it just had a collar placed so when we think about our cervical spine decision rules which one do you use in your practice? the Canadian C-spin rule so Canadian C-spin or Nexus or even a combination of those when we're in the emergency department deciding who we're going to image if you have midline tenderness most recommendations today or those patients get imaged if you put cervical collars on healthy patients and you palpate their neck the next day significant percentage of those somewhere greater than 10 percent will have pain the next day so is that impacting our imaging use could that be potentially leading to over imaging? I'll take the answer from the first question it might it might right? I mean I think it definitely does I mean if you've ever put one of these on you know right away how uncomfortable they are there's no doubt that I think people get it over image with this because of the pain that they're having from it so what about a hard collar in general what kind of collars will we talking about? that's another facet to this as I was reading through it that I thought was worth speaking about for at least a couple seconds and when we talk to our neuro surgeon colleagues and you've worked in the neuro ICU I've worked in the neuro ICU if you ask a neurosurgeon do we need a cervical collar in this patient? what collars to neurosurgeons place? those has been really nice soft ones and if you've never placed an aspen collar they're fitted they have like an inflation port where you can inflate and make everything snug not too tight not too loose it adjusts they're also very expensive which reflects the comfort What do we use? We use the stiff necks and those are exactly as they sound they are not comfortable They're not adjustable. They're poorly fitting. Somewhere in between are Philadelphia collars Which I've never used in any of my EDS, but they're drastically different from stiff neck EMS collars. They're drastically different from Aspons there's the Miami J which is also nice and fits well and so sometimes I believe we Equate all of those together when we're talking especially with our consultants and our colleagues like hey We don't think these rigid collars fit well and we don't think that they're comfortable for our patients We were talking about this before we came on we know the 78 year old that comes in to the ER and I let you Describe them to us because you hit it pretty much nail on the head. Everyone has seen the Mima who's eating her cervical collar upon arrival to the emergency department or the top part of the collar is rubbing against the nose Just poorly sized you know at the opening you said you were talking about one size fits all I thought that was appropriate because I feel like cervical collar application winds up being a one size fits all everyone gets the no neck We put it on and we move on but really how many of these are actually even being applied the way that they're supposed to be Let alone do they even work and so going back to the literature piece not to Stay in that world too long, but when we talk about cervical collars causing harm some of these studies are with Philly collars an aspen collars and Miami J collars and We know that the ones they're on the truck here at mchd and for all the EMS listeners out there are much much less comfortable and form fitting and You know just overall patient compatible than the more expensive and the more Adjustable Miami J's and aspen's that the neurosurgeons are talking about so I do believe if you're gonna go out and advocate for change That's an important piece to delineate because not every collar is created the same We know that when you put these things on healthy patients the respiratory function declines somewhere you know in the neighborhood of You know 10 to 15% when you're talking about pulmonary function tests force photocopacities flow volume loops things that we remember from back in med school and residency and Shockingly, who does that affect the most? Patients at the extremes of age so you've got an 80 year old that rose their car and they have right two through 10 rib fracture and maybe developing some contusions Is a device that decreases their pulmonary function 10 to 15% is that is that a Patient impactful number. I would say again it might it surely could so You know we know that those studies exist and the wild thing about looking back at this literature is this is not from 2025 This is not from March of 2026 These are in big-name journals injury trauma and acute care surgery pre-hospital emergency care Analysts of emergency medicine Journal of emergency medicine Neurospein journals from the 1990s in the early 2000s. So this has been out there and around and we've known that these negative Factors exist for a couple decades so It's not something that that is should be a shock to anyone What about evidence for improved outcomes does that exist? No, so there's no data There's anecdote again from the 50s and 60s and I don't think anyone approached this. Let me be really clear. I don't think this was Came from a negative place or some sort of You know, nobody was trying to Harm patients to your point we spent arms we spent legs we should split the neck is a logical spot to land and if you Move bony fragments you can damage the soft tissue of the spinal cord is the logic and logically it makes sense But the problem is that that progressed to dogma Without any real supporting literature and now it's the standard of care in the United States system from a trauma and neurosurgical perspective Oftentimes when we discuss this in the MS world and even bringing in some of the emergency department You know the neurosurgeons they they're very protective over spinal injuries and why is that who do they see? Well, they get to see the worst of the worst they see the people who have paralysis and neurologic deficits They don't see the 90% of people who come in with a c-collar and either clear clinically by us or have negative imaging and go home Yeah, and I would say that's probably closer to 99% right? They see but they see the folks that are paralyzed so they have that perspective The paper that I found in this entire process if you want to take a look and that that really solidified hate maybe we are on the right track here because sometimes I worry a little bit about hey We're on the ambulance or we're in the emergency department and we're saying these collars They're they're net negative. They don't help we need to pull these off we need to pull these back and I'll worry a little bit about the fact that the neurosurgeons are the one that see these patients and are we getting too far ahead of ourselves and Have we involved expert opinion and expert experience? But there is one paper and I'll read the title We take a look if you like we'll link it in the show notes pre-hospital use of cervical collars in trauma patients a critical review This was in the Journal of Neurotrauma in 2014 and it was written by some Norwegian neurosurgeons and I would explain to you what the paper said but it Lined out all of those net negatives that we just talked about and came to the same conclusion that we did and that is maybe cervical spine Mobilization dogma is harming patients and not helping them and we should reconsider it and this came from neurosurgeons about a decade ago and so There is precedent out there for even the folks who see the worst of the worst to say hold on a second Where do this dogma come from why are we doing it and you know how are we gonna? You know ever move away from that because it is the standard of care the trauma surgeons are also very protective and why because they're in the same boat They see the worst of the worst but even the American College of Surgeons Committee on trauma in 2026 so this was just this year Emergency physicians across America at some point or another have to take Advanced trauma-loss support the atls class and it's really the where all of the trauma dogma lives I'll quote from a recent review of 2026 atls routine spinal mobile restriction motion restriction It's not recommended because spinal injuries are rare rigid improperly applied callers can increase intercranial pressure and or make intubation more difficult Increasing risk of mortality So even the trauma surgeons and the trauma recommendations are starting to recognize some of these negatives so That leads us to what we decided here at MCHD We can move more into opinion because other systems out there have done this differently There are a lot of systems who still put cervical callers on everyone who are involved in trauma There are systems who have moved entirely away from cervical callers So what do we decide we removed all the callers, right? You just heard about the literature took them all off the truck and we're all better off We thought about it. We thought about it We took a good look at this literature and said boy, why don't we just get rid of these callers? And then we realized we we don't live in a bubble and we work in a healthcare system and a system of care We have partners and we have FRO partners and hospital partners and several other stakeholders involved and so we Had discussions with them and got them involved and sought their opinion and presented this data and There was a would you say varying level of engagement and and ingredients and discord regarding this topic and ultimately we settled out with kind of a two-tier high-risk low-risk criteria for patients and instead of no-collar We've moved to the soft collar and what kind of soft collar did we move to? Well, just just a standard Velcro soft collar and it's important to remember that absence of evidence is not Evidence of absence. In other words, there is no evidence to say that cervical callers rigid callers help patients, but that doesn't mean they don't and so we don't want to take Too big of a step forward Colors may help. I think it's very very doubtful. How would you arrange that prospective study? How is that going to happen? It probably never will so we have to make a decision in the real world like you said We don't know what patient they might help in we don't know what type and the potential harm signal just to hit it one more time it's real and We talked to our trauma surgery neurosurgery partners here in the county and I will say the one thing that was unanimous was there was Zero support for a no-collar approach You've got to do something I will put it lightly and there are other EMS folks and EMS leaders out there you guys can listen to other podcasts look at other YouTube videos that are out there with With folks that we know and respect in the EMS world who have moved to a no-collar approach and we are by no means saying that they are wrong or Casting shade on anyone who has not done it exactly this way I believe this is a reflection of the fact that we work in A system of care with other trauma surgeons other neurosurgeons other emergency physicians And I'm not even saying that they're necessarily wrong We just have to play not us in the sandbox and so going back to how we ended up and this is for the MCHD listeners out there. We did come to a two-tier approach and decided to really move towards more of the model that ambulance Victoria and Australia has used with soft cervical collars to try to increase comfort, decrease that poor fitting nature of the stiff net collars, and really save rigid collars for the highest risk patients. And yes, I hear you if you're going to be really logical and say what the highest risk patients are, the ones that the rigid collars probably harm the most. We don't disagree with you. We also don't want to put our medics in the crossfire when they deliver patients to our subspecialist. And again, we want to play nice and take reasonable steps to try to move the science and the patient care forward. So our low-risk patients are who in the MCHD protocol, we're talking specific MCHD protocol now. So you're not MCHD listeners. Take this with a grain of salt, but those that are low-risk that have mid-long tenderness only and/or are elderly as their only risk factor, they receive a soft collar, all other folks that are high-risk, altered neurologic deficits, angulated femur fracture, slash distraction injuries, language barriers, those patients are still going to receive a hard collar. And so yes, for the folks out there that are banging the pots and pans and the drums saying you didn't do enough, no, I would say that if you ask each of us individually in the privacy of this podcast recording, we would agree with you, but we don't operate in a vacuum. We work in a system of healthcare and we made our collaborative efforts and this was where we felt like we could best meet in the middle. How do you feel about that? Yeah, I agree completely. I will say having put one of those soft collars on, that it's much easier to place and it's much more comfortable to wear than the hard rigid collar, while also reminding me to keep my head still, so for whatever that's worth, if that does anything for the patient, they will still have that reminder to keep their head facing forward and not turn their head 90 degrees to look at your respond to questions because they have the collar on. And this has some precedent in the world of EMS, again in Australia, looking at some of the movement in Great Britain and their pre-hospital world to allow patients to self-extricate. There's some movement in this space to continue trying to find a happy medium between dogma and evidence and patient comfort and ultimately decreasing bad patient outcomes in the end is the goal. So partnerships are crucial. We believe that's the case here in the county for those other medical directors out there who would say, you know, in other medics and other services that you didn't go far enough, we agree with you. We're not done moving this protocol forward. We believe that a couple years of good solid work with the protocol as is will allow us to continue to move forward and potentially move away from rigid collars altogether. That's my goal. I think we can do it. I mean, we forever backboards were the standard and we moved away from that to the point where we don't do it anymore. So I think we're headed the same direction. It's just going to take time. There was not a switch that was flipped there. That took a decade or so. Standard care also must be considered. I really don't want to get too far off the road into medical legal concerns. I believe we take care of patients the best that we can and the medical legal side will sort itself out. But there is a medical legal component in the United States with standard of care as consideration. And I believe if you talk to most neurosurgeons and spine surgeons out there, they would agree that standard of care is rigid cervical collar placement and trauma patients with midline tenderness and all the other high risk factors that we talked about. In the end, we're trying to minimize use of rigid collars and we took a step forward. And so hopefully we can use this protocol as a stepping stone to continue to reduce their use while continuing collaborative discussions and not putting what we really wanted to avoid here was putting our medics in the crosshairs and most importantly putting the patient in the crosshairs for disagreement between EMS and hospital level care, whether that's trauma surgeons, ER dogs or the neurosurgeons and any combination of those. So that gets us through most of the media discussion today. Anything you'd like to add before we wrap it up? You know, I'm really, I have to say, proud of the work that we've been doing here with this. And I think that for the vast majority, when it comes to the low risk patients, ground level falls and elderly patients or people with low risk mechanism with neck pain, that's midline and otherwise nothing else. That's high risk. This is going to let us put a soft collar on them instead of that rigid, uncomfortable, questionably useful collar that we've been putting on them for eternity. So I think this is a really excellent step in the right direction. We'd like any of our protocols as always reach out. We're happy to share. We'll link the major studies that we referenced here in the show notes. If you'd like any of those, you have any questions ideas for future podcasts. Please email us podcast at mchd-x.org. Like, review, subscribe, all of those things you're supposed to do wherever you listen to podcasts. Hopefully the audio sounds a little better maybe. The setup is definitely nice. Huge thanks to Jay Roberts, Chief Nick Tobin, Andy Adams, all the folks behind the scenes that have helped revamp this room. Mr. Willingham, thank you all. This is a super nice and I feel like I've got some room here. It's really, really wonderful. So we appreciate it if you're watching on YouTube. Thank you for watching. As always, we back with another episode soon. Thanks for listening. Thanks for watching. Have a great day. Visit copyright. You have a McLeod in Competect.com. License is in a creative confidence by Andre Nation 3.0.