Adverse Events Relating to Prolonged Hard Collar Immobilisation: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To evaluate systematically the complications of prolonged cervical immobilisation in a hard collar.

METHODS

Following registration with PROSPERO, a systematic search of electronic databases (MEDLINE, EMBASE) was conducted. Two reviewers independently screened the search results according to pre-determined search criteria. Data was extracted and tabulated. Joanna Briggs Institute checklists were used for assessing the quality of included studies.

RESULTS

The search identified 773 articles. A total of 25 studies were selected for final inclusion. The results largely comprised a mixture of case reports/series, cohort studies and reviews. The most commonly reported complications were pressure ulcers, dysphagia and increased intracranial pressure. A pressure ulcer pooled prevalence of 7% was calculated. There was insufficient data for quantitative analysis of any other complication.

CONCLUSIONS

There is significant morbidity from prolonged hard collar immobilisation, even amongst younger patients. Whilst based upon limited and low-quality evidence, these findings, combined with the low-quality evidence for the efficacy of hard collars, highlights a knowledge gap for future research.

Comparison of Hard and Soft Cervical Collars for the Management of Odontoid Peg Fractures in the Elderly

Introduction

Odontoid peg fractures (OF) are the most common cervical spine fracture in the elderly. This retrospective analysis aimed to compare the outcomes of older patients with OF who had been managed non-operatively with either a hard or soft cervical collar.

Materials and Methods

We analysed the retrospective data of the clinical and radiographic records of patients 60 years or older who presented over a 10-year period with OF and were treated non-operatively with a cervical collar. Mortality was the primary outcome measure with mechanism of injury, complications, and fracture healing secondary measures.

Results

45 patients (hard collar n = 22; soft collar n = 23) were included with comparable demographics for frailty and co-morbidities in each group; age was significantly higher in the soft collar group (80.6 vs 86.4 years; P = .0065). Associated injuries and complications were not significantly different overall, or when Type II fractures were separately analysed (P = .435 associated injuries, P = .121 complications). All-cause mortality was greater in the soft collar group (30-day mortality hard: 0%, soft: 9%; 1-year mortality hard: 18%, soft: 48% P = .035). However, once corrected for age, this proved not to reach significance (P = .333) in any fracture type. Non-union was common (77%) but was not significantly different (hard = 70%; soft = 87%; P = .419).

Discussion

Consistent with other reports, non-union rates remained substantial regardless of which collar was used. After controlling for age, there was no difference in all-cause mortality between elderly patients treated with a hard or soft cervical collar for odontoid peg fractures.

Conclusions

Soft collars appear suitable for the treatment of odontoid peg fractures in the elderly without compromising outcome. Larger cohort analyses will help confirm this finding.

Clinical Outcomes of Cervical Facet Fractures Treated Nonoperatively With Hard Collar or Halo Immobilization

STUDY DESIGN

Retrospective review.

OBJECTIVES

To evaluate the rate of nonoperative treatment failure for cervical facet fractures while secondarily validating computed tomography-based criteria proposed by Spector et al for identifying risk of failure of nonoperative management.

METHODS

Single-level or multilevel unilateral cervical facet fractures from 2007 to 2014 were included. Exclusion criteria included spondylolisthesis, dislocated or perched facets, bilateral facet fractures at the same level, floating lateral mass, thoracic or lumbar spine injuries, or spinal cord injury. Patients were placed into 3 groups for evaluation: immediate operative management, successful nonoperative management, and failed nonoperative treatment requiring surgical intervention.

RESULTS

Eighty-eight patients (106 facets) were included. Twenty-one patients underwent operative treatment with anterior cervical discectomy and fusion or posterior spinal instrumentation and fusion without any failures. Sixty-seven of these patients were treated nonoperatively with either a hard collar (n = 62) or halo vest (n = 5). Eleven patients failed nonoperative treatment (16.4%), all with an absolute fracture height of at least 1 cm and 40% involvement of the absolute height of the lateral mass. Of the 56 patients successfully treated through nonoperative measures, 8 (14.3%) had fracture measurements exceeding both operative parameters.

CONCLUSION

We conclude that it is safe and appropriate for patients with unilateral cervical facet fractures to receive a trial period of nonoperative management. However, patients who weigh over 100 kg, have comminuted fractures, or have radiographic measurements outside of the proposed computed tomography criteria for nonoperative treatment should be educated on the risks of treatment failure.

Cervical spine immobilisation in the elderly: a literature review

Developed populations are ageing rapidly and by 2040, approximately 1 in 4 adults will be over 65 years of age. This is resulting in higher incidence of traumatic injury in older patients. Cognitive and physical comorbidities in this group can pose significant challenges. Due to mechanisms of injury and pre-existing degenerative spinal disease, cervical spine fractures are particularly prevalent in elderly patients. These are associated with significant morbidity and mortality. In this literature review we examine current evidence surrounding the use of cervical spine immobilisation in elderly patients in the pre-hospital and emergency department setting and also as a treatment option for cervical spine fractures. We explore evidence surrounding the complications that can arise from cervical spine immobilisation, including the development of pressure sores, raised intracranial pressure, dysphagia, breathing difficulties, delirium, compliance issues, mobility and functional outcome.