Tag Archives: spine


London Trauma Conference 2014 Part 1

I’ve travelled almost the entire length of England to get to the London Trauma Conference this year. What could be more important than attending one of the best conferences of the year? Examining for the DipRTM at the Royal College of Surgeons in Edinburgh

So was it worth the 4am start? Absolutely!

tomMy highlights would be Tom Evens explaining why trauma can be regarded like an elite sport. His background is as a sports coach in addition to his medical accomplishments and walking us through the journey he went through with the athlete he was coaching demonstrates the changes that need to occur when cultivating a performance culture and the results speak for themselves.

I can see similarities in the techniques used by athletes and those we are using in medicine now. Developing a highly performing team isn’t easy as anyone involved in the training of these teams will know.

 

 

jerry3Dr Jerry Nolan answered some questions about cervical spine movement in airway management. The most movement is seen in the upper cervical spine and there is no surprise that there is an increased incidence of cervical spine injury in unconscious patients (10%). The bottom line is that no movement clinicians will make of the cervical spine is greater than that at the time of injury. And whether it be basic airway manoeuvres, laryngoscopy or cricoid pressure the degree of movement is in the same ball park and unlikely to cause further injury. He states that he would use MILS like cricoid pressure and have a low threshold for releasing it if there are difficulties with the intubation. Of course many of us don’t use cricoid pressure in RSI anymore………..

 

After watching Tom and Jerry we heard that ATLS has had its day. Dr Matthew Wiles implores us to reserve ATLS for the inexperienced and move away from this outdated system and move to training in teams using local policies. The Cochrane reviewers found an increase in knowledge but no change in outcomes.

And finally Dr Deasy has convinced me that I will be replaced by a robot roaming around providing remote enhanced care. On the up side I might be the clinician providing that support.

More from me on this fantastic conference soon. In the meantime follow it on Twitter!

telemed

 

Guidelines on prehospital drug-assisted LMA insertion

The UK’s Faculty of Prehospital Care has published a number of consensus guidelines in this month’s EMJ

Dr Minh Le Cong‘s PHARM blog has summaries of three of them:

The final one is the most contentious: Pharmacologically assisted laryngeal mask insertion: a consensus statement(1). Here is the summary:

  1. The PALM technique is an acceptable tool for managing the prehospital airway
  2. The PALM technique is indicated in a rare set of circumstances
  3. The PALM procedure is a rescue technique
  4. The PALM procedure should be checklist driven
  5. At least a second generation SAD should be used
  6. End-tidal CO2 monitoring is mandatory
  7. No preference is expressed for any particular drug
  8. No preference is expressed for any particular dosing regime
  9. Flumazenil is highly unlikely to have a role in managing the PALM patient
  10. The PALM procedure should only be carried out by practitioners of level 7 or above competences
  11. The availability of a trained assistant, familiar with the procedure would be advantageous
  12. The training required to achieve competency in performing the PALM procedure must include in-hospital insertion of SADs, simulation training and training in the transfer of critically ill patients
  13. Data should be collected and collated at a national level for all patients who receive the PALM procedure

They qualify the first point with the statement: The consensus group felt that, in the hands of a specific set of practitioners and in certain circumstances, patients would benefit from the technique. It was recognised that pre-hospital airway management can be very challenging, and deeming the technique unacceptable could deprive patients of a potentially life saving intervention. It was felt that having another tool available to clinicians which could potentially improve patient outcome was important. This was despite the lack of a robust evidence base. It was felt that the technique is indicated in, and should be limited to, a very specific set of circumstances as described below

The publication lists some ‘Organisations represented at the consensus meeting’, which include some commercial training and equipment companies.

It also states that ‘The Royal College of Anaesthetists, although represented at the initial meeting, was unable to support the outcomes agreed by the other represented organisations.

This is a very interesting development. I can see the pros and cons of this. Since practitioners are out there doing PALM anyway, it is in the interests of patients to produce a statement that encourages monitoring, checklists, training, and data collection. To meet all the requirements, one must undergo ‘training in the transfer of critically ill patients’, which would normally necessitate more advanced airway and anaesthesia skills anyway.

A tough one – what would you want if there was no RSI capability but you were hypoxic with trismus and basic airway maneouvres were failing? An all out ban on PALM, or PALM provided by someone trained in surgical airway if it fails (as per the consensus recommendations)?

This and some of the other statements can be downloaded in full at the Faculty of Pre-hospital Care site

1. Pharmacologically assisted laryngeal mask insertion: a consensus statement
Emerg Med J. 2013 Dec;30(12):1073-5

London Calling – part 2

Notes from Days 2 & 3 of the London Trauma Conference

Day 2 of the LTC was really good. There were some cracking speakers who clearly had the ‘gift’ when it comes to entertaining the audience. No death by PowerPoint here (although it seems Keynote is now the presentation software of choice!). The theme of the day was prehospital care and major incidents.

The golden nuggets to take away include: (too many to list all of course)

  • ‘Pull’ is the key to rapid extrication from cars if time critical from the Norweigan perspective. Dr Lars Wik of the Norweigen air ambulance presented their method of rapid extrication. Essentially they drag the car back on the road or away from what ever it has crashed into to control the environment and make space (360 style). They put a paramedic in the car whilst this is happening. They then make a cut in the A post near the roof, secure the rear of the car to a fire truck or fixed object with a chain and put another chain around the lower A post and steering wheel that is then winched tight. This has the effect of ‘reversing’ the crash and a few videos showed really fast access to the patient. The car seems to peel open. As they train specifically for it, there doesn’t seem to be any safety problems so far and its much quicker than their old method. I guess it doesnt matter really how you organise a rapid extrication method as long as it is trained for and everyone is on the same page.
  • Dr Bob Winter presented his thoughts on hangings – to date no survivor of a non-judicial hanging has had a C-spine injury, so why do we collar them? Also there seems no point in cooling them. All imaging and concern for these patients should be based on the significant soft tissue injury that can be caused around the neck.
  • Drownings – if the patient is totally submerged probably reasonable to search for 30mins in water that is >6 degrees or 90mins if <6 degrees. After that it becomes a body recovery (unless there is an air pocket or some exceptional circumstance). Patients that have drowned should have early ventilatory support if they show any signs of resp distress.
  • Drs Julian Thompson and Mark Byers reassured us on a variety of safety issues at major incidents. It seems the risk to rescuers from secondary bombs at scene is low. Very few terrorist attacks world wide, ever, have had secondary devices so rescuers should be reassured (a bit). Greatest risk to the rescuer, like always, are the silly simple things that are a risk every day, like tripping over your own feet! With reference to chemical incidents, simple PPE seems to be sufficient for the vast majority of incidents, even fairly significant chemical ones, all this mucking about in full air tight suits is probably pointless and means patients cant be treated (at all). This led to the debate of how much risk should we, as rescue staff, accept? Clearly there are no absolute answers but minimising all risk to the rescuer is often at conflict with your ability to rescue. Where the balance should lie is a matter for organisations and individuals I guess.
  • Sir Prof Keith Porter also gave us an update on the future of Prehospital emergency medicine as a recognised medical specialty. As those in the know, know, the specialty has been recognised by the GMC and the first draft of trainees are currently in post. More deaneries will be following suit soon to begin training but it is likely to take some time to build up large numbers of trained specialists. Importantly for those of us who already have completed our training there will be an option to sub specialise in PHEM but it will involve undertaking the FIMC exam. Great, more exams – see you there.

 

Day 3 – Major trauma
The focus of day 3 was that of damage control. Damage control surgery and damage control resucitation. We had indepth discussions about how to manage pelvic trauma and some of the finer points of trauma resuscitation.

Specific points raised were:

  • Pelvic binders are great and can replace an ex fix if the abdomen needs opening to fix a spleen for example.
  • You can catheterise patients with pelvic fractures (one gentle try).
  • Most pelvic bleeds are venous which is why surgeons who can pack a pelvis is better than a radiologist who can mainly only treat arterial bleeds.
  • Coagulopathy in trauma is not DIC and is probably caused by peripheral hypoperfusion.
  • All the standard clotting tests that we use (INR etc) are useless and take too long to do. ROTEM or TEG is much better but still not perfect.

Also, as I am sure will please many – pressure isn’t flow so dont use pressors in trauma!

 

 

Chris Hill is an emergency and prehospital care physician based in the United Kingdom

Head injury was not predictive for cervical spine injury

Two papers examining the same massive European trauma dataset identify risk factors for spinal injury. The first examined all spinal injury(1), and the most recent focuses on cervical injury(2). Male gender, decreased GCS, falls > 2m, sports injuries, and road traffic collisions were predictors of any fracture/dislocation or cord injury. Head injury was not an independent risk factor, contrary to much popular teaching. I’ve summarised the two papers’ findings in this table. The odds ratios are reported in the abstracts.

Download Keynote presentation slide (for Mac)

1. Epidemiology and predictors of spinal injury in adult major trauma patients: European cohort study
Eur Spine J. 2011 Dec;20(12):2174-80. Free full text


This is a European cohort study on predictors of spinal injury in adult (≥16 years) major trauma patients, using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Predictors for spinal fractures/dislocations or spinal cord injury were determined using univariate and multivariate logistic regression analysis. 250,584 patients were analysed. 24,000 patients (9.6%) sustained spinal fractures/dislocations alone and 4,489 (1.8%) sustained spinal cord injury with or without fractures/dislocations. Spinal injury patients had a median age of 44.5 years (IQR = 28.8–64.0) and Injury Severity Score of 9 (IQR = 4–17). 64.9% were male. 45% of patients suffered associated injuries to other body regions. Age <45 years (≥45 years OR 0.83–0.94), Glasgow Coma Score (GCS) 3–8 (OR 1.10, 95% CI 1.02–1.19), falls >2 m (OR 4.17, 95% CI 3.98–4.37), sports injuries (OR 2.79, 95% CI 2.41–3.23) and road traffic collisions (RTCs) (OR 1.91, 95% CI 1.83–2.00) were predictors for spinal fractures/dislocations. Age <45 years (≥45 years OR 0.78–0.90), male gender (female OR 0.78, 95% CI 0.72–0.85), GCS <15 (OR 1.36–1.93), associated chest injury (OR 1.10, 95% CI 1.01–1.20), sports injuries (OR 3.98, 95% CI 3.04–5.21), falls >2 m (OR 3.60, 95% CI 3.21–4.04), RTCs (OR 2.20, 95% CI 1.96–2.46) and shooting (OR 1.91, 95% CI 1.21–3.00) were predictors for spinal cord injury. Multilevel injury was found in 10.4% of fractures/dislocations and in 1.3% of cord injury patients. As spinal trauma occurred in >10% of major trauma patients, aggressive evaluation of the spine is warranted, especially, in males, patients <45 years, with a GCS <15, concomitant chest injury and/or dangerous injury mechanisms (falls >2 m, sports injuries, RTCs and shooting). Diagnostic imaging of the whole spine and a diligent search for associated injuries are substantial.

2. Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study
J Trauma Acute Care Surg. 2012 Apr;72(4):975-81


Patients with cervical spine injuries are a high-risk group, with the highest reported early mortality rate in spinal trauma.

METHODS: This cohort study investigated predictors for cervical spine injury in adult (≥ 16 years) major trauma patients using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Univariate and multivariate logistic regression analyses were used to determine predictors for cervical fractures/dislocations or cord injury.

RESULTS: A total of 250,584 patients were analyzed. Median age was 47.2 years (interquartile range, 29.8-66.0) and Injury Severity Score 9 (interquartile range, 4-11); 60.2% were male. Six thousand eight hundred two patients (2.3%) sustained cervical fractures/dislocations alone. Two thousand sixty-nine (0.8%) sustained cervical cord injury with/without fractures/dislocations; 39.9% of fracture/dislocation and 25.8% of cord injury patients suffered injuries to other body regions. Age ≥ 65 years (odds ratio [OR], 1.45-1.92), males (females OR, 0.91; 95% CI, 0.86-0.96), Glasgow Coma Scale (GCS) score <15 (OR, 1.26-1.30), LeFort facial fractures (OR, 1.29; 95% confidence interval [CI], 1.05-1.59), sports injuries (OR, 3.51; 95% CI, 2.87-4.31), road traffic collisions (OR, 3.24; 95% CI, 3.01-3.49), and falls >2 m (OR, 2.74; 95% CI, 2.53-2.97) were predictive for fractures/dislocations. Age <35 years (OR, 1.25-1.72), males (females OR, 0.59; 95% CI, 0.53-0.65), GCS score <15 (OR, 1.35-1.85), systolic blood pressure <110 mm Hg (OR, 1.16; 95% CI, 1.02-1.31), sports injuries (OR, 4.42; 95% CI, 3.28-5.95), road traffic collisions (OR, 2.58; 95% CI, 2.26-2.94), and falls >2 m (OR, 2.24; 95% CI, 1.94-2.58) were predictors for cord injury.

CONCLUSIONS: 3.5% of patients suffered cervical spine injury. Patients with a lowered GCS or systolic blood pressure, severe facial fractures, dangerous injury mechanism, male gender, and/or age ≥ 35 years are at increased risk. Contrary to common belief, head injury was not predictive for cervical spine involvement.

Spinal imaging for the adult obtunded blunt trauma patient

‘You can’t clear the cervical spine until the patient wakes up!’ How often have you heard this said about a patient with severe traumatic brain injury who may not ‘wake up’ for weeks, if at all?

A controversial area, but many institutions now allow collar removal if a neck CT scan is normal. Does this rule out injury with 100% sensitivity? No – but it probably pushes the balance of risk towards removing the collar – an intervention with no evidence for benefit and plenty of reasons why it may be harmful to ventilated ICU patients. For example, clearing the cervical spine based on MDCT was associated with less delirium and less ventilator associated pneumonia, both of which have been associated with increased mortality in critically ill patients (this is referenced in the paper below).

The UK’s Intensive Care Society has had pragmatic guidelines along these lines since 2005, which can be found here. This month’s Intensive Care Medicine publishes an updated literature review providing some further support to this approach.



PURPOSE: Controversy exists over how to ‘clear’ (we mean enable the clinician to safely remove spinal precautions based on imaging and/or clinical examination) the spine of significant unstable injury among clinically unevaluable obtunded blunt trauma patients (OBTPs). This review provides a clinically relevant update of the available evidence since our last review and practice recommendations in 2004.


METHODS: Medline, Embase. Google Scholar, BestBETs, the trip database, BMJ clinical evidence and the Cochrane library were searched. Bibliographies of relevant studies were reviewed.


RESULTS: Plain radiography has low sensitivity for detecting unstable spinal injuries in OBTPs whereas multidetector-row computerised tomography (MDCT) approaches 100%. Magnetic resonance imaging (MRI) is inferior to MDCT for detecting bony injury but superior for detecting soft tissue injury with a sensitivity approaching 100%, although 40% of such injuries may be stable and ‘false positive’. For studies comparing MDCT with MRI for OBTPs; MRI following ‘normal’ CT may detect up to 7.5% missed injuries with an operative fixation in 0.29% and prolonged collar application in 4.3%. Increasing data is available on the complications associated with prolonged spinal immobilisation among a population where a minority have an actual injury.


CONCLUSIONS: Given the variability of screening performance it remains acceptable for clinicians to clear the spine of OBTPs using MDCT alone or MDCT followed by MRI, with implications to either approach. Ongoing research is needed and suggestions are made regarding this. It is essential clinicians and institutions audit their data to determine their likely screening performances in practice.


Clinical review: spinal imaging for the adult obtunded blunt trauma patient: update from 2004
Intensive Care Med. 2012 Mar 10. [Epub ahead of print]

Another reason to be skeptical about collars

More evidence that the obsession with cervical collars is founded on dogma rather than science



Background All trauma patients with a cervical spinal column injury or with a mechanism of injury with the potential to cause cervical spinal injury should be immobilised until a spinal injury is excluded. Immobilisation of the entire patient with a rigid cervical collar, backboard, head blocks with tape or straps is recommended by the Advanced Trauma Life Support guidelines. However there is insufficient evidence to support these guidelines.


Objective To analyse the effects on the range of motion of the addition of a rigid collar to head blocks strapped on a backboard.


Method The active range of motion of the cervical spine was determined by computerised digital dual inclinometry, in 10 healthy volunteers with a rigid collar, head blocks strapped on a padded spine board and a combination of both. Maximal opening of the mouth with all types of immobiliser in place was also measured.


Results The addition of a rigid collar to head blocks strapped on a spine board did not result in extra immobilisation of the cervical spine. Opening of the mouth was significantly reduced in patients with a rigid collar.


Conclusion Based on this proof of principle study and other previous evidence of adverse effects of rigid collars, the addition of a rigid collar to head blocks is considered unnecessary and potentially dangerous. Therefore the use of this combination of cervical spine immobilisers must be reconsidered.


Value of a rigid collar in addition to head blocks: a proof of principle study.
Emerg Med J. 2012 Feb;29(2):104-7

Lateral trauma position

Image from sjtrem.com - click for original

The tradition of transporting trauma patients to hospital in a supine position may not be the safest approach in obtunded patients with unprotected airways. The ‘solution’ of having them on an extrication board (backboard / long spine board) to enable rolling them to one side in the event of vomiting may not be practicable for limited crew numbers.

The Norwegians have been including the option of the lateral trauma position in their pre-hospital trauma life support training for some years now.

A questionnaire study demonstrates that this method has successfully been adopted by Norwegian EMS systems.

The method of application is described as:

  • Check airways (look, listen, feel).
  • Apply chin lift/jaw thrust, suction if needed.
  • Apply stiff neck collar.
  • If the patient is unresponsive, but has spontaneous respiration: Roll patient to lateral/recovery position while maintaining head/neck position.
  • Roll to side that leaves the patient facing outwards in ambulance coupé.
  • Transfer to ambulance stretcher (Scoop-stretcher, log-roll onto stretcher mattress, or use multiple helpers, lifting by patient’s clothing).
  • Support head, secure with three belts (across legs, over hip, over shoulder)
  • Manual support of head, supply oxygen, observation, suction, BVM (big valve mask) ventilation when needed.

Different options for supporting the head in the lateral position, according to questionnaire responders, include:

  • putting padding under the head, such as a pillow or similar item (81%)
  • a combination of padding and putting the head on the lower arm (7%)
  • rest the head on the lower arm alone (10%)
  • rest the head on the ground (<1%)

 



BACKGROUND: Trauma patients are customarily transported in the supine position to protect the spine. The Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) principles clearly give priority to airways. In Norway, the lateral trauma position (LTP) was introduced in 2005. We investigated the implementation and current use of LTP in Norwegian Emergency Medical Services (EMS).


METHODS: All ground and air EMS bases in Norway were included. Interviews were performed with ground and air EMS supervisors. Questionnaires were distributed to ground EMS personnel.


RESULTS: Of 206 ground EMS supervisors, 201 answered; 75% reported that LTP is used. In services using LTP, written protocols were present in 67% and 73% had provided training in LTP use. Questionnaires were distributed to 3,025 ground EMS personnel. We received 1,395 (46%) valid questionnaires. LTP was known to 89% of respondents, but only 59% stated that they use it. Of the respondents using LTP, 77% reported access to written protocols. Flexing of the top knee was reported by 78%, 20% flexed the bottom knee, 81% used under head padding. Of 24 air EMS supervisors, 23 participated. LTP is used by 52% of the services, one of these has a written protocol and three arrange training.


CONCLUSIONS: LTP is implemented and used in the majority of Norwegian EMS, despite little evidence as to its possible benefits and harms. How the patient is positioned in the LTP differs. More research on LTP is needed to confirm that its use is based on evidence that it is safe and effective.


The lateral trauma position: What do we know about it and how do we use it? A cross-sectional survey of all Norwegian emergency medical services
Scand J Trauma Resusc Emerg Med. 2011 Aug 4;19:45
Open Access Full Text

Prehospital Spine Immobilisation for Penetrating Trauma

The Executive Committee of Prehospital Trauma Life Support, comprised of surgeons, emergency physicians, and paramedics, has reviewed the literature and produced the following recommendations on Prehospital Spine Immobilisation for Penetrating Trauma:



PHTLS Recommendations
  • There are no data to support routine spine immobilization in patients with penetrating trauma to the neck or torso.
  • There are no data to support routine spine immobilization in patients with isolated penetrating trauma to the cranium.
  • Spine immobilization should never be done at the expense of accurate physical examination or identification and correction of life-threatening conditions in patients with penetrating trauma.
  • Spinal immobilization may be performed after penetrating injury when a focal neurologic deficit is noted on physical examination although there is little evidence of benefit even in these cases.


Prehospital Spine Immobilization for Penetrating Trauma—Review and Recommendations From the Prehospital Trauma Life Support Executive Committee
Journal of Trauma-Injury Infection & Critical Care September 2011;71(3):763-770

Risk factors for cervical spine injury

Data from the Crash Injury Research Engineering Network (CIREN) database were analysed to identify epidemiologic and biomechanical risk factors for  cervical spinal cord and spinal column injuries. They showed:

  • Older case occupants are at an increased risk of cervical spine injury (CSI)
  • Rollover crashes and severe crashes led to a much higher risk of CSI than other types and severity of MVCs
  • Seat belt use is very effective in preventing CSI
  • Airbag deployment may increase the risk of occupants sustaining a CSI


BACKGROUND: : Motor vehicle collisions (MVCs) are the leading cause of spine and spinal cord injuries in the United States. Traumatic cervical spine injuries (CSIs) result in significant morbidity and mortality. This study was designed to evaluate both the epidemiologic and biomechanical risk factors associated with CSI in MVCs by using a population-based database and to describe occupant and crashes characteristics for a subset of severe crashes in which a CSI was sustained as represented by the Crash Injury Research Engineering Network (CIREN) database.

METHODS: : Prospectively collected CIREN data from the eight centers were used to identify all case occupants between 1996 and November 2009. Case occupants older than 14 years and case vehicles of the four most common vehicle types were included. The National Automotive Sampling System’s Crashworthiness Data System, a probability sample of all police-reported MVCs in the United States, was queried using the same inclusion criteria between 1997 and 2008. Cervical spinal cord and spinal column injuries were identified using Abbreviated Injury Scale (AIS) score codes. Data were abstracted on all case occupants, biomechanical crash characteristics, and injuries sustained. Univariate analysis was performed using a χ analysis. Logistic regression was used to identify significant risk factors in a multivariate analysis to control for confounding associations.

RESULTS: : CSIs were identified in 11.5% of CIREN case occupants. Case occupants aged 65 years or older and those occupants involved in rollover crashes were more likely to sustain a CSI. In univariate analysis of the subset of severe crashes represented by CIREN, the use of airbag and seat belt together (reference) were more protective than seat belt alone (odds ratio [OR] = 1.73, 95% confidence interval [CI] = 1.32-2.27) or the use of neither restraint system (OR = 1.45, 95% CI = 1.02-2.07). The most frequent injury sources in CIREN crashes were roof and its components (24.8%) and noncontact sources (15.5%). In multivariate analysis, age, rollover impact, and airbag-only restraint systems were associated with an increased odds of CSI. Using the population-based National Automotive Sampling System’s Crashworthiness Data System data, 0.35% of occupants sustained a CSI. In univariate analysis, older age was noted to be a significant risk factor for CSI. Airbag-only restraint systems and both rollover and lateral crashes were also identified as risk factors for CSI. In addition, increasing delta v was highly associated with CSIs. In multivariate analysis, similar risk factors were noted. Of all the restraint systems, seat belt use without airbag deployment was found to be the most protective restraint system (OR = 0.29, 95% CI = 0.16-0.50), whereas airbag-only restraint was associated with the highest risk of CSI (OR = 3.54, 95% CI = 2.29-5.46).

CONCLUSIONS: : Despite advances in automotive safety, CSIs sustained in MVC continue to occur too often. Older case occupants are at an increased risk of CSI. Rollover crashes and severe crashes led to a much higher risk of CSI than other types and severity of MVCs. Seat belt use is very effective in preventing CSI, whereas airbag deployment may increase the risk of occupants sustaining a CSI. More protection for older occupants is needed and protection in both rollover and lateral crashes should remain a focus of the automotive industry. The design of airbag restraint systems should be evaluated so that they are not causative of serious injury. In addition, engineers should continue to focus on improving automotive design to minimize the risk of spinal injury to occupants in high severity crashes
Occupant and Crash Characteristics for Case Occupants With Cervical Spine Injuries Sustained in Motor Vehicle Collisions
J Trauma. 2011 Feb;70(2):299-309

Neck movement in spite of collar

A cadaveric study using an artificially created unstable cervical spine injury has shown marked displacement of the vertebrae when cervical collars were applied, and when the bodies were moved in a way that simulated normal transfer and log-rolling. There was no comparison with a no-collar situation, so we can’t say from this that collars are necessarily bad, just that they’re no good in this cadaveric model. I like this statement by the authors:

A variety of collars, backboards, and other equipment and techniques are being used in an attempt to achieve spine stabilization, largely without any validation of efficacy when used in the presence of a severe cervical injury. Randomized, prospective clinical trial designs are challenging in this domain theless, basic cadaver studies can provide valuable insight into potential clinical efficacy.

"Severe unstable injuries were created in seven fresh whole human cadavers"

Even more musical to my ears is the editorial commentary by neurosurgery professor Richard L. Saunders, MD:

…the more compelling question is whether there is a place for collars in emergent protection of the injured cervical spine or are they simply a gimcrack***?
The incidence of second injuries to the spinal cord in the extraction of accident victims under the best of EMT performance is not known and would be difficult to determine. However, in an effort to minimize that incidence, paramedical gospel is the application of a cervical collar, maintaining the neck in in-line and in a neutral position. By definition, this gospel implies the deliberate movement of the neck to apply an orthotic known to be nonprotective. Furthermore, the neutral and in-line admonition implies that the patient’s neck position can be safely adjusted to “look better” without a shred of evidence that this might be a safer strategy than avoiding any unnecessary neck movement whatsoever….
…In a conclusion common to many small study reports, the authors recommend that more work should be done in this area. In my opinion that might be best in refinements of extraction methods with an eye to only that neck movement necessary to resuscitation, collar be damned.

Motion Within the Unstable Cervical Spine During Patient Maneuvering: The Neck Pivot-Shift Phenomenon
J Trauma. 2011 Jan;70(1):247-50

*** I confess never to have encountered this word before. According to the freedictionary.com, a gimcrack is ‘A cheap and showy object of little or no use; a gewgaw‘. Now, WTF is a gewgaw?!?!