Cervical collars – why do they help some people and not others?

Ross Hauser, MD

Many patients we see have a long history of neck pain treatment. One of the treatments or therapies that they have been prescribed is the use of a cervical collar or cervical traction in an attempt to alleviate the patient’s symptoms by stretching the spinal vertebrae to relieve pressure and pain on the nerves that transverse the cervical vertebrae. For many patients, this will provide relief of symptoms. For some patients, the cervical collar may cause more problems than it was designed to help.  The automatic prescription of a cervical collar in instances of neck pain should not be automatic, but, carefully considered in each patient’s situation to maximize benefit and minimalize complication.

When should a cervical collar be used to treat neck pain?

The above question was asked by a team lead by Harvard Medical School researchers in a 2008 paper appearing in the journal Current Reviews in Musculoskeletal Medicine.(1)

Let’s look at what this paper says:

“Although cervical collars are a seemingly benign intervention, they can have adverse effects, especially when used for longer periods of time. It is feared that a long period of immobilization, can result in atrophy-related secondary damage. Many physicians cite anecdotal evidence of their clinical utility and soft cervical collars are often prescribed by convention for patients complaining of neck pain. The use of cervical collars to treat neck pain is an area of controversy.

Comment: Below we discuss the challenges and problems a patient may face in prolonged cervical spine immobilization.

Back to this study, the researchers looked at whiplash patients, traumatic injury patients, and patients with cervical radiculopathy.

“In whiplash patients, most studies suggest that early mobilization and activity is superior to immobilization and soft cervical collar use. However, more recent studies have not found any long-term benefits of early aggressive treatment as compared to immobilization. Therefore, no definite conclusion can be drawn about the efficacy of cervical collars in this population. Our conclusions are that cervical collars should not be universally recommended to all whiplash patients. However, for patients who find it useful for symptom relief, a soft cervical collar for 10 days or less has not been shown to have any adverse impact.

Rigid cervical collars have a well-established role in the acute management of trauma patients to prevent instability of the cervical spine. They also may play a role in the conservative treatment of certain types of cervical fractures such as nondisplaced axis fractures and C2 body fractures. However, since most of the studies done in patients with fractures, were case series and lacked an adequate control group, no specific recommendations can be made in this population.

Several studies suggest that hard cervical collars may play a role in the conservative management of cervical radiculopathy. However, sufficient evidence is lacking to advocate its routine usage. Further studies are needed for patients with non-traumatic axial neck pain, and radicular pain with or without trauma to understand the role that cervical collars may play in their management.”

That of course was a 2008 study. Have recommendations changed in the 15 years since?

Here are the observations of an April 2020 study published in the Yeungnam University Journal of Medicine.(2)

• Citing the 2008 Harvard research, these researchers noted no reported side effects (e.g., muscle weakness) associated with the use of soft cervical collars for fewer than 10 days.
• Further research was cited to suggest that in patients with acute cervical whiplash injuries who used a soft cervical collar for 2 weeks reported a higher reduction in both the intensity of pain and range of motion of the cervical spine than similar patients who did not use a soft collar. Yet another study did not offer similar findings and found little added benefit to soft collar use.

In examining the Philadelphia collar, a more rigid plastic molded collar, the researchers noted that the “Philadelphia collar slightly reduces the load on the spine by promoting the correct posture at the cervical spine and plays a role in limiting the cervical flexion/extension, lateral flexions and rotation. Nonetheless, some pressure may be applied on the clavicle by the Philadelphia collar. Considering that excessive pressure can cause discomfort or pressure sores, special attention is required for users with sensitive skin. The Philadelphia collar can be used to treat injuries of the bones and ligaments in the mid-cervical spine region and for postsurgical stabilization. In addition, it can be used instead of the halo orthosis to stabilize upper cervical fractures (Jefferson and hangman’s fractures) and fractures of the odontoid process.”

So the conclusion we arrive at again is: For some patients, a soft or rigid collar can be helpful when used appropriately. But it should not be used always.

Is my cervical collar helpful following Cervical fusion?

We see many patients following a cervical fusion with varying issues following the surgery. This section is added here to demonstrate that cervical collars do not always help a patient for many years collars following surgery were almost always prescribed. In recent years the prescribing of a cervical collar following cervical fusion has been questioned.

A December 2018 report in the journal World neurosurgery (5)  examined the use of  postoperative cervical collars following cervical fusions. The reason to use cervical collars following fusion is its supposed means to improve fusion rates and outcomes. However the researcher write, there is a lack of evidence as to whether this is true of not. In reviewing previously reported studies, the researchers “found no strong evidence to support the use of cervical collars after 1- and 2-level anterior cervical discectomy and fusion procedures, and no studies comparing collar use and no collar use after posterior cervical fusions. Given the cost and likely impact of collar use on driving and the return to work, our study shows that currently there is no proven benefit to routine use of postoperative cervical collar in patients undergoing 1- and 2-level anterior cervical discectomy and fusion for degenerative cervical pathologies.”

An August 2020 (6) study using this research reported that in their study 20% of surgeons recommend a cervical collar after a single-level ACDF, while 70% do so after a multilevel ACDF, for an average of 9.1 weeks.

In October 2021 physical therapists from University College of Northern Denmark and the University of Queensland in Australia compared physical therapy (active rehabilitation) to passive treatments such as soft-collars for whiplash injury victims. What the research questioned was the effectiveness of soft-collar use in these patients. The research was published in Musculoskeletal science & practice.(7)

• In this study, four previously published studies were included with three using a soft collar in addition to other conservative treatment while one study compared soft-collar use to act-as-usual. (Act as usual is as it sounds, few or no restrictions on regular activities). All studies found that an active or act-as-usual approach was more effective in reducing pain intensity compared to soft-collar use. However, the evidence was not as strong as researchers would like.

A March 2023 systematic review in the Global spine journal (x) “found that external bracing, though widely used following cervical spine surgery, may not offer any advantages in patient-reported outcomes, as compared to not bracing. In regard to the effect of bracing on fusion rates, no strong consensus can be made as the methods of fusion assessment in the included studies were heterogenous and suboptimal.”

Is my collar too tight? Is it making my symptoms worse?

As discussed in many research papers some cervical collars have been shown to increase intracranial pressure. The mechanism is felt to be due to compression of both the internal and external jugular veins.

An April 2020 randomized controlled trial study published in the journal Medicine (3) measured the effect of different cervical collars on optic nerve sheath diameter. Optic nerve sheath diameter was used as a compression measurement to see if the collars caused detrimental effects of venous compression which would develop into intracranial pressure.

Learning points of this research were:

• There is considerable evidence that prolonged use of cervical collars could potentially cause detrimental effects including increase in optic nerve sheath diameter among healthy volunteers.
• Different types of cervical collars immobilize cervical spine differently and may cause different effects of venous compression and intracranial pressure.
• Results in sixty healthy volunteers showed there was significant increase of optic nerve sheath diameter from the start of wearing a poorly fitting or not appropriate collar for that patient. Measurements taken at 5 and 20 minutes revealed the compression. The researchers noted: “Clinicians should take proactive steps to assess the actual need of cervical collar case by case basis.”

When you wear a hard collar too long

A March 2022 paper in the Global spine journal (4) evaluated the complications of prolonged cervical immobilization in a hard collar. The researchers examined 25 previously published research studies and found that the most commonly reported complications were pressure ulcers, dysphagia (Swallowing difficulties) and increased intracranial pressure. Conclusions: There is significant problems from prolonged hard collar immobilization, even amongst younger patients. Whilst based upon limited and low-quality evidence, these findings, combined with the low-quality evidence for the efficacy of hard collars, highlights a knowledge gap for future research.

Cervical collars – why they help some people and not others?

Over the years we have kept track and studied why some of our patients did not respond well to treatment. In over 30 years of helping patients, we have continuously used these observations to change, develop, and advance our treatment protocols to adjust for our findings and to maximize treatment benefits.

This helps us understand why two patients with similar DMX findings (digital motion x-ray) and symptoms take different healing paths where one patient will show excellent results after 3 – 4 visits, and another patient will be on their sixth visit and be struggling.

A case history: Young female patient with cervical spine instability and a collar comparison

We took a young female patient who had cervical spine instability, very loose neck ligaments. We did DMX imaging (displayed and explained in the image below). 

• The patient has significant left side C1-C2 instability. When wearing one type of collar, the instability was not helped.
  • Then we put her in a normal (over the counter type) cervical collar, something you would get at the CVS or the Walgreens or online. Sometimes, in some patients, this type of collar is enough to limit motion and provide patient benefit. HOWEVER, when we repeated the DMX Imaging, with the patient wearing the collar, you could see that she still had C1 C2 instability, it wasn’t stabilizing her.
  • We then put her in a Hauser-Hatto collar which we offer to some patients to provide added support to the collar immobilization. This was the right collar for this patient because as she tried to bend or flex her neck, the collar held her in proper alignment. This helps us demonstrate that while we treat the cervical ligaments to strengthen them and bring stability into the cervical spine, we need good, temporary immobilization to allow our treatments to achieve maximum benefit.

In this image we have a patient who had DMX imaging done: 1) Without a collar 2) With a standard over the counter type collar 3) With a Hauser Hatto collar or a collar that had more stability to it. (Similar collars can be recommended by your doctors or researched online.) This collar is not necessary in all patients.

In this image we have a patient who had DMX imaging done: 1) Without a collar 2) With a standard over the counter type collar 3) With a Hauser Hatto collar or a collar that had more stability to it. (Similar collars can be recommended by your doctors or researched online.) This collar is not necessary in all patients.

We are not proponents of telling somebody that we want you to be immobilized for long periods of time. However when you have a lot of instability sometimes you need periods of immobilization to allow treatments to have their best chance of success in strengthening and regenerating the soft tissue of the ligaments and supportive connective tissue in the neck.

• We want to make sure that while the patient is wearing their collar which could be depending on your individual case could be for as short as a week and could be for a couple of months, but, while the patient is wearing the collar we want to make sure that the neck has stability and integrity and to allow our treatments to have maximum effect.

Static and Dynamic imaging and checking the collar

We do static and dynamic (motion) imaging to test and check the collar in some patients and depending on their case.

• Sometimes the collar can give you too much motion which can inhibit the healing by not allowing the ligaments time to repair. Sometimes the collar can compress the internal jugular vein. The collar is too tight. In one patient, we saw compression of the jugular vein that was causing pressure on their optic nerve. We had to get them into a collar that not only supported their chin but did not compress the jugular vein which can increase intracranial pressure which we were seeing in this patient by optic nerve sheath diameter swelling.

Caring Medical Florida and the Hauser Neck Center

References

1 Muzin S, Isaac Z, Walker J, El Abd O, Baima J. When should a cervical collar be used to treat neck pain?. Current Reviews in Musculoskeletal Medicine. 2008 Jun;1(2):114. [Google Scholar]
2 Choo YJ, Chang MC. Effectiveness of orthoses for treatment in patients with spinal pain. Yeungnam University Journal of Medicine. 2020 Apr;37(2):84. [Google Scholar]
3 Ladny M, Smereka J, Ahuja S, Szarpak L, Ruetzler K, Ladny JR. Effect of 5 different cervical collars on optic nerve sheath diameter: A randomized crossover trial. Medicine. 2020 Apr 1;99(16):e19740. [Google Scholar]
4 Brannigan JF, Dohle E, Critchley GR, Trivedi R, Laing RJ, Davies BM. Adverse Events Relating to Prolonged Hard Collar Immobilisation: A Systematic Review and Meta-Analysis. Global Spine Journal. 2022 Mar 25:21925682221087194. [Google Scholar]
5 Karikari I, Ghogawala Z, Ropper AE, Yavin D, Gabr M, Goodwin CR, Abd-El-Barr M, Veeravagu A, Wang MC. Utility of cervical collars following cervical fusion surgery. Does it improve fusion rates or outcomes? A systematic review. World neurosurgery. 2019 Apr 1;124:423-9. [Google Scholar]
6 De Biase G, Chen S, Bydon M, Elder BD, McClendon J, Deen HG, Nottmeier E, Abode-Iyamah K. Postoperative restrictions after anterior cervical discectomy and fusion. Cureus. 2020 Aug 3;12(8). [Google Scholar]
7 Christensen SW, Rasmussen MB, Jespersen CL, Sterling M, Skou ST. Soft-collar use in rehabilitation of whiplash-associated disorders-A systematic review and meta-analysis. Musculoskeletal Science and Practice. 2021 Oct 1;55:102426. [Google Scholar]

This page was updated March 31, 2022

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