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Baylor study doubts neck brace standard

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In some cases, device might hurt accident victims

Applying a brace to the neck of a trauma patient, standard procedure for many decades, can worsen the injury and lead to severe paralysis or death, according to a new study by Houston researchers.

Baylor College of Medicine doctors used cadavers to confirm that so-called cervical collars can be counterproductive, a finding that could upturn the way emergency medical personnel and doctors act to stabilize and protect the upper spine in potentially fatal neck injuries, such as those that commonly occur in bad automobile accidents.

“This study is a proof of concept that in cases of severely unstable neck injuries, cervical collars are not only not helpful, but harmful in many situations,” said Dr. Peleg Ben-Galim, a professor of orthopedic surgery and the study’s lead author. “More research needs to be done, but it might be that we can prevent some of the deaths and quadriplegia that occur in these injuries.”

The study appeared this week in the Journal of Trauma.

Dr. David Persse, medical director of Houston’s Emergency Management Services, called the study “compelling” and “concerning” and said it will come up for discussion at the annual meeting of the nation’s 30 largest EMS departments in Dallas next month. But he also said he doesn’t want to overreact.

“We need to look at this thoughtfully before we change the standard of care,” said Persse. “It concerned a particular kind of injury. It may apply to other injuries as well, but we don’t know that yet.”

But Persse added that he understands the need to act quickly, that “it’s not like a lot of areas where there’s not as serious downside to waiting for the next study.”
Car-crash victims

Ben-Galim said cervical spine injuries are found in the autopsies of up to 94 percent of people who die in car crashes, which claim about 44,000 U.S. lives annually. There are about 11,000 people annually who survive spinal cord injuries.

There is no obvious alternative to cervical collars, though hospitals often place sandbags under the back of the patient’s head and, less commonly, some EMS teams at the scene of the crash wedge the head of the patient between foam bolsters on the backboard.

The injuries in question involve the area where the brain connects to the spinal cord. Doctors treating such injuries work to stabilize the ligaments, muscle and bone to prevent secondary injury and to protect the brain stem and cord.

Baylor researchers undertook the study after a case in which a broken jaw precluded the use of a cervical collar on the survivor of a car wreck brought to Ben Taub. When the doctors started to put a collar on the patient, fluoroscopy showed two of the patient’s vertebrae separate, causing doctors to immediately remove the collar. The treated patient ultimately walked out of the hospital on his own.

Ben-Galim noted that there are other such case histories in medical literature.

To study the phenomenon, Baylor researchers made an incision in cadaver neck ligaments based on patient X-rays, then simulated clinical scenarios by applying cervical collars and putting the bodies in ambulances and driving a distance.

In all of the cadavers, imaging technologies found that the collar increased the rupture.

In effect, the collars pushed the head away from the shoulders, Ben-Galim said.

He said the rupture stretching occurs because of both the application of the collars and their continued use.

One national expert called the study interesting but said he wasn’t sure it would one day change the standard of care.

“There are certain cases, like the ones in this study, that can be dangerous, but they’re rare — most people who suffer high neck injuries die immediately,” said Dr. Tom Scaletta, the past president of the American Academy of Emergency Medicine. “I think the study’s importance will be to raise awareness about the special care that must be taken — preserving patients’ normal head position, making sure they’re not having difficulty breathing.”

Anecdotal cases

Dr. Walter Lowe, director of the Memorial Hermann Sports Medicine Institute and team physician for the Houston Texans football team, said the study wouldn’t change the care of injured football players removed from the field in collars and on stretchers because those injuries tend to involve lower areas of the spine.

Ben-Galim said that since the study was undertaken, Ben Taub doctors have saved patients with severe neck injuries by loosening or removing cervical collars early and rushing them to the operating room, but he acknowledged such cases are anecdotal.

He said the research team looked at 400 articles and found no scientific evidence that cervical collars can stabilize severely unstabilized spine injuries.
Copyright 2010 Houston Chronicle

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