Cervical Spine Clearance Guideline for Severe Head Injury Patients and Cervical Collar Related Complications

Likana  Pattanapongsa; Narain Chotirosniramit; Kaweesak Chittawatanarat

Authors

Likana Pattanapongsa Department of Surgery, Faculty of Medicine, Chiang Mai University, thailand https://orcid.org/0000-0002-5977-003X
Narain Chotirosniramit Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand https://orcid.org/0000-0002-5569-2230
Kaweesak Chittawatanarat Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand https://orcid.org/0000-0002-0285-6596

Keywords:

cervical spine clearance, decubital ulcer, guideline implementation, severe head injury

Abstract

Objective Severe head injury patients commonly experience several negative effects from wearing a cervical collar for an extended period of time. This study was conducted to evaluate the results after cervical spine clearance guideline implementation. at a tertiary level-I University-hospital-based trauma center in the Northern region of Thailand.

Methods This is retrospective pre- and post-guideline implementa-tion observational study included severe head injury patients who were admitted between January 2008 and December 2013. The pre- implementation phase (Pre) was January 2008 through October 2010 (34 months) and the post-implementation period (Post) was between November 2010 and December 2013 (38 months). The primary outcome was the incidence of cervical collar-associated decubital ulcer. P values less than 0.05 were considered statistical significance.

Results A total of 899 patients with severe head injury were observed over 72 months (437 in Pre and 461 in Post). There were no significant differences in patient baseline characteristics with the exception of median age. The incidence of collar-related complications significantly decreased following introduction of the cervical spine clearance guideline [Pre 26 (5.95%) vs. Post, 8 (1.74%); p = 0.001] , the incidence of other decubital ulcers [90 (20.59%) vs. 64 (13.88%), p = 0.008], median cervical collar time in hour (interquartile range, IQR) [8 (22%) vs. 2 (13%), p < 0.001], and median time to diagnosis in hours [8 (23) vs. 1 (6), p < 0.001]. However, there were no differences in the implementation phases of intubation time or length of hospital and ICU stay.

Conclusions Implementation of a cervical spine clearance guideline could decrease the incidence of collar-related decubital ulcer and shorten the cervical collar time as well as diagnostic time.

References

Banit DM, Grau G, Fisher JR. Evaluation of the acute cervical spine: a management algorithm. J Trauma. 2000;49:450-6.

American College of Surgeons. Advanced Trauma Life Support® Student Course Manual. In: Banit DM, editor. 9th ed. Chicago, IL: The United States of America; 2012. p. 6.

Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma. 2009;67:651-9.

Ackland HM, Cooper DJ, Malham GM, Kossmann T. Factors predicting cervical collar-related decubitus ulceration in major trauma patients. Spine. 2007;32:423-8.

Chendrasekhar A, Moorman DW, Timberlake GA. An evaluation of the effects of semirigid cervical collars in patients with severe closed head injury. Am Surg. 1998;64:604-6.

Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia. 2001;56:511-3.

Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical hard collar on intracranial pressure after head injury. ANZ J Surg. 2002;72:389-91.

Webber-Jones JE, Thomas CA, Bordeaux RE, Jr. The management and prevention of rigid cervical collar complications. Orthop Nurs. 2002;21:19-25; quiz -7.

Moeri M, Rothenfluh DA, Laux CJ, Dominguez DE. Cervical spine clearance after blunt trauma: current state of the art. EFORT Open Rev. 2020;5:253-9.

Patel MB, Humble SS, Cullinane DC, Day MA, Jawa RS, Devin CJ, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;78:430-41.

Inaba K, Byerly S, Bush LD, Martin MJ, Martin DT, Peck KA, et al. Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial. J Trauma Acute Care Surg. 2016; 81:1122-30.

Halpern CH, Milby AH, Guo W, Schuster JM, Gracias VH, Stein SC. Clearance of the cervical spine in clinically unevaluable trauma patients. Spine. 2010;35:1721-8.

Malhotra A, Wu X, Kalra VB, Nardini HK, Liu R, Abbed KM, et al. Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis. Eur Radiol. 2017;27:1148-60.

Murphy KM, Musiak H. Patient with occipital pressure ulcer requiring continued cervical collar use. J Wound Ostomy Continence Nurs. 1997;24:58-60.

Powers J, Daniels D, McGuire C, Hilbish C. The incidence of skin breakdown associated with use of cervical collars. J Trauma Nurs. 2006;13:198-200.

Tafti AA, Sajadi S, Rafiei H. Pressure ulcer stage IV caused by cervical collar in patients with multiple trauma in intensive care unit. Int Wound J. 2015; 12:606-7.

Auiwattanakul S, Ungpinitpong W, Yutthakasemsunt S, Buranapin S, Chittawatanarat K. Prevalence of pressure ulcer and nutritional factors affecting wound closure success in Thailand. Mater Sociomed. 2017;29:196-200.