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A Real Pain in the Neck – C-Collar Adherence in Children After PED Discharge

July 26, 2022

Written by Rebecca White

Spoon Feed
Many children discharged from the emergency department with minor traumatic cervical spine injury do not adhere to recommendations for cervical immobilization or outpatient follow-up, with no significant clinical consequences observed.

Why does this matter?
After sustaining a minor traumatic cervical spine injury (CSI), children are often discharged home in a rigid cervical orthosis (RCO) if cervical spine clearance is not possible, with instructions for outpatient follow-up. But do they adhere to treatment recommendations?

Not worth getting hot under the collar…
This prospective observational study included 98 children with mild CSI evaluated at a level 1 pediatric trauma center. Patients had normal neurologic exams and cervical spine x-rays, with persistent posterior neck pain for which they were discharged from the emergency department in a RCO. Prior to discharge, families received instruction on using the RCO and scheduling follow-up.

Overall, collars were discontinued by patients or families without follow-up in 47% of cases, while half sought follow-up care. Average time to follow-up was 11.3 ± 4.9 days, and average collar compliance lasted 9.8 ± 5.7 days. On final follow-up of 51 patients (52% response rate), 32 children had no pain after collar removal, 14 had mild pain but no extended collar use (1 kept in RCO for additional 2 weeks but eventually cleared), 3 had some pain and limitations (no injury found, collar removed), and 2 had more significant continued pain (1 child kept in RCO for additional week before clearance, and 1 child required C1–2 fusion for odontoid fracture). There were no complications from collar use, and no patients had unrecognized injury after final follow-up.

Editor’s note: If you have a negative c-spine CT and normal neuro exam, one could argue that – even with persistent midline tenderness, a RCO at discharge is unnecessary (also see WEST adult c-spine algorithm). This study used plain x-ray. That’s fine, but if a child has persistent symptoms, I would consider a CT rather than sending them home in a RCO. Regarding symptoms, children with a broken neck who are alert (GCS 14-15) will hold their head oddly and won’t want to move their neck. ~Clay Smith

The Fate of the Cervical Collar: An Observational Pilot Study Investigating Follow-up Care After Emergency Department Discharge in Children With Mild Traumatic Neck Injuries. Pediatr Emerg Care. 2022 May 25. doi: 10.1097/PEC.0000000000002755. Online ahead of print.