Written by Rebecca White
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.