Benefit and Harm in the Early Management of Suspected Cervical Spine Injury: A Narrative Review

Suspected cervical spine injury is managed with a bundle applied largely by reflex: a rigid collar, sequential imaging, and, in some settings, corticosteroids, alongside interventions whose benefit depends on speed.This review sets the strength of evidence behind each component against the readiness with which it is applied.Sources were identified by targeted searching of PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE) and by reference tracking; the review is not systematic.The interventions applied most reflexively are the least supported.Prehospital immobilisation has never been shown to reduce neurological deterioration, spinal cord injury, or mortality, and the only study to compare an immobilising with a non-immobilising system found less neurological disability in the patients who were not immobilised.Pooled data across 25 studies give a pressure ulcer prevalence of 7% with prolonged collar use, and collar application raises intracranial pressure by 4.43 mmHg.MRI after a normal CT finds abnormalities in 17% of patients and changes management in 4%, with heterogeneity above 90%, and a practice management guideline has already concluded that the collar may be removed in obtunded patients after a negative highquality CT alone.Methylprednisolone produces no long-term motor recovery and increases gastrointestinal bleeding.The interventions that do alter outcome are those most easily lost to delay: decompression within 24 hours yields 4.0 additional motor points, and 2.57-fold odds of two-grade improvement in impairment grade; hypotension carries a 2.71-fold risk of adverse functional outcome, and specialist referral reduces pulmonary embolism from 5.4% to 0.7%.Three national and consensus bodies have already moved away from routine rigid immobilisation.Initial management would be improved less by adding investigation than by withdrawing interventions of unproven benefit and protecting those that are time-dependent.