Cervical collars: probably useless; definitely cause harm!

Achieving Value in Spine Surgery: 10 Major Cost Contributors

STUDY DESIGN

Narrative Review.

OBJECTIVES

The increasing cost of healthcare overall and for spine surgery, coupled with the growing burden of spine-related disease and rising demand have necessitated a shift in practice standards with a new emphasis on value-based care. Despite multiple attempts to reconcile the discrepancy between national recommendations for appropriate use and the patterns of use employed in clinical practice, resources continue to be overused-often in the absence of any demonstrable clinical benefit. The following discussion illustrates 10 areas for further research and quality improvement.

METHODS

We present a narrative review of the literature regarding 10 features in spine surgery which are characterized by substantial disproportionate costs and minimal-if any-clear benefit. Discussion items were generated from a service-wide poll; topics mentioned with great frequency or emphasis were considered. Items are not listed in hierarchical order, nor is the list comprehensive.

RESULTS

We describe the cost and clinical data for the following 10 items: Over-referral, Over-imaging & Overdiagnosis; Advanced Imaging for Low Back Pain; Advanced imaging for C-Spine Clearance; Advanced Imaging for Other Spinal Trauma; Neuromonitoring for Cervical Spine; Neuromonitoring for Lumbar Spine/Single-Level Surgery; Bracing & Spinal Orthotics; Biologics; Robotic Assistance; Unnecessary perioperative testing.

CONCLUSIONS

In the pursuit of value in spine surgery we must define what quality is, and what costs we are willing to pay for each theoretical unit of quality. We illustrate 10 areas for future research and quality improvement initiatives, which are at present overpriced and underbeneficial.

A prospective evaluation of cervical spine immobilisation in low-risk trauma patients at a tertiary Emergency Department

BACKGROUND

In the Emergency Department cervical spine immobilisation precautions are frequently used. There is controversy in regard to the balance of risks and benefits of routine immobilisation in conscious patients.

METHODS

A prospective multi-methods evaluation in a tertiary trauma referral centre. The objectives were to investigate current practices and rate of concordance with established international guidelines. A provider survey focused on current knowledge, skills and attitudes and was disseminated to nurses, doctors and paramedics treating trauma patients. Additionally, clinical data were collected on a cohort of immobilised trauma patients. Demographic data were analysed using SPSS and content analysis was completed by manifest coding.

RESULTS

The response rate to the survey was 85.2%. Interdisciplinary providers included nurses (n=46), doctors (n=68) and paramedics (n=41). Content analysis revealed a range of themes for improving care. Themes identified included improved application of guidelines, tailored use of equipment in low-risk patients, improved access to radiology results, and staff education. The series of five case vignettes provided to participants revealed a high level of variance in intended approaches to immobilisation. In the cohort of trauma patients (n=54), the median age was 54 years and the most common mechanism of injury was falls (40.7%). Median time spent with immobilisation was 325min. Adherence to a recognised decision tool was 35/54 (64.8%). Precautions were initiated by paramedics in 42/54 (77.8%).

CONCLUSIONS

Despite widespread dissemination of guidelines, observed approaches to patient immobilisation appear to be highly variable in this trauma centre. Reducing variation for low-risk patients is likely to improve the patient journey and minimise the risk of prolonged immobilisation. Further assessment of the causes of variation could define goals for targeted translational change.

Prehospital use of cervical collars in trauma patients: a critical review

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.