Current Trends in the Use of Cervical Collar Immobilization After Cervical Spine Surgery
June 11, 2025
Survey
S:NA-MD.10
Study Design & Objective
Study Design: We surveyed spine surgeons regarding their postoperative usage of cervical collars.
Objective: This study aimed to survey an extensive population of attending physicians and trainees to explore the current trends in the use of cervical collar immobilization after cervical spine surgery.
Summary of Background Data: Practice patterns for using cervical collars vary widely following cervical spine surgery.
Key Findings
Survey Response
- • 340 participants from 39 US states and 41 countries
- • 85% attending physicians, 5% fellows, 10% residents
- • 55% neurosurgeons, 45% orthopedic surgeons
- • 71% from academic hospitals
Practice Patterns
- • 53% believe there’s benefit to routine collar use
- • 81% use collars for trauma cases
- • 74% use collars after multilevel corpectomy
- • 88% have observed collar-related complications
Cervical Collar Immobilization
Methods
Survey Procedures
The University of Pittsburgh Institutional Research Board (IRB) approved the study protocol. All methods were performed per relevant guidelines and regulations. We recruited participants through e-mail and by posting the survey on different social media platforms.
The survey was opened on May 24, 2023, and data was collected through February 29, 2024. Participants were limited to one response.
Survey Development and Content
A 19-question online survey was formed after extensive discussion between attending surgeons and trainees. The survey was completed anonymously on Google Forms and took approximately 10 minutes to complete.
The survey assessed several factors including:
- Demographic characteristics of respondents
- General attitudes towards collars and indications for use
- Type of collar utilized and duration of immobilization
- Differences in use by surgical approach and procedure
- Complications observed after prescribing postoperative cervical collars
Statistical Analysis
Statistical analysis was performed with Stata 12.0, and figures were generated with Prism. Gwet first-order agreement coefficient (AC1) was used to calculate inter-rater reliability among survey participants. Binomial probability P-values and confidence intervals were calculated and compared with the 50% agreement expected by chance alone.
Results
Geographic Distribution
Three hundred forty incomplete and complete responses were received for analysis. Participants represented 41 countries and 39 American states. The geographic distribution was skewed in favor of North America (67%), Asia (14%), and Europe (12%), with fewer responses from South America (4%), Oceania (3%), and Africa (1%).
Respondent Characteristics
| Characteristic | Count (%) |
|---|---|
| Physician Title | |
| Attending physician | 286 (85%) |
| Surgical fellow | 16 (5%) |
| Resident physician | 34 (10%) |
| Surgical Training | |
| Neurological surgery | 187 (55%) |
| Orthopedic surgery | 153 (45%) |
| Practice Setting (Attending) | |
| Academic setting | 202 (71%) |
| Private practice | 84 (29%) |
Indications by Pathology
Most Common Indications
- • Trauma: 81%
- • Cervical deformity: 60%
- • Neoplasm: 49%
- • Degenerative: 44%
Least Common Indications
- • Thoracolumbar deformity: 18%
- • Infection: 41%
Rationale for Cervical Collar Use
Surgeons have differing rationales for prescribing cervical collars. The most common reasons include:
- • Limit patient activity: 56%
- • Support bone healing: 47%
- • Manage postoperative pain: 41%
- • Prevent screw or plate loosening: 39%
- • Prevent focal kyphosis: 29%
- • Prevent graft extrusion: 23%
- • Prevent graft subsidence: 22%
Duration of Collar Use
Soft Collar Duration
- • 1 week: 6%
- • 2-4 weeks: 12%
- • 4-6 weeks: 5%
- • 6 weeks: 5%
- • >6 weeks: 2%
- • Patient-specific: 17%
Hard Collar Duration
- • 1 week: 1%
- • 2-4 weeks: 6%
- • 4-6 weeks: 10%
- • 6 weeks: 17%
- • >6 weeks: 6%
- • Patient-specific: 35%
Collar Use by Surgical Procedure
Collar Utilization by Procedure Type
High Utilization Procedures
- • Multilevel corpectomy (2+ levels): 74%
- • ACDF (3+ levels): 64%
- • PCF (3+ levels): 63%
- • Occipitocervical fusion: 58%
- • Cervical corpectomy (1 level): 58%
Low Utilization Procedures
- • Cervical arthroplasty: 13%
- • Cervical laminectomy (1-2 levels): 22%
- • Cervical laminectomy (3+ levels): 34%
- • ACDF (1-2 levels): 39%
- • PCF (1-2 levels): 44%
Complications with Postoperative Cervical Collars
88% of providers have observed complications related to cervical collars in their practice.
Most Common Complications
- • Discomfort: 71%
- • Pressure ulcers: 45%
- • Impaired sleep: 43%
- • Disruption of daily activities: 43%
- • Pain: 29%
Other Complications
- • Muscular atrophy: 23%
- • Surgical wound breakdown: 21%
- • Dysphagia: 20%
- • Respiratory obstruction: 5%
- • Venous obstruction: 2%
Discussion
Current Evidence and Practice Variation
The effectiveness of cervical spine collars in preventing postoperative complications after cervical spine surgery has been a subject of debate. Some studies have shown that using cervical spine collars reduces the risk of postoperative complications such as hematoma formation, hardware complications, pseudoarthrosis, and spinal cord injury.
However, other studies have shown that using cervical spine collars does not prevent postoperative complications and may even increase the risk of complications. Our team surveyed an extensive sample of spine surgeons, finding trauma (81%) as the most common pathology for cervical collar utilization, with multilevel corpectomy (74%) being the most common procedure after which surgeons would recommend collar usage.
Clinical Considerations
Opinions regarding the utilization of cervical collars can be evaluated based on the pathology of the patient the surgeon is treating. For instance, randomized controlled trials have suggested collar fixation may not be mandatory after certain procedures like cervical laminoplasty, as findings did not demonstrate significant differences in clinical outcomes with or without collar use.
Miller et al found that both soft and rigid collars similarly restricted cervical range of motion during activities of daily living, implying that the choice between collar types may be less critical than previously assumed, provided that some form of immobilization is used.
Benefits vs. Complications
The participants reported that 41% utilized collars as a tool for improving postoperative pain, whereas 29% reported noticing “pain” as a complication of utilizing collars. Some studies suggest that rigid cervical collars after certain procedures can lead to reduced axial neck pain in the early postoperative period.
However, there is growing evidence that hard collars may cause neck and back pain, dysphagia, delirium, increased intracranial pressure, and pressure injury. Our study found that 88% of surgeons reported encountering complications related to cervical collars, with discomfort (71%) and pressure ulcers (45%) being most common.
Study Limitations
- • Sample bias: Survey results may not represent the entire population of neurosurgeons or orthopedic spine surgeons
- • Response bias: Participants may have distinctive characteristics compared to non-respondents
- • Academic bias: 71% of responses came from academic hospitals, limiting generalizability to private practice settings
- • Lack of causal inference: Study did not determine underlying reasons for participants’ responses
- • Response rate: Could not be accurately determined due to distribution through multiple channels
Conclusion
The results of this global survey highlight substantial heterogeneity in the use of postoperative cervical collars among spine surgeons. While roughly half of the respondents believe in the benefits of routine collar use, significant variability exists regarding indications, duration, and type of collar prescribed.
Trauma was the most common indication for cervical collar use, whereas corrective surgery for thoracolumbar deformity had the highest agreement for nonuse. Surgeons cited various rationales for prescribing collars, including limiting patient activity, supporting bone healing, and preventing hardware complications, yet no single factor achieved strong consensus.
Despite widespread use, nearly 90% of surgeons reported encountering complications related to cervical collars, the most frequent being discomfort, pressure ulcers, and impaired sleep.
These findings underscore the lack of standardized guidelines for postoperative cervical collar use and highlight the need for further clinical studies and prospective trials to establish evidence-based recommendations for optimal postoperative management.
Key Takeaways
Practice Variation
Significant variability exists in collar use patterns across different pathologies, procedures, and geographic regions, indicating lack of consensus.
Evidence Gap
Current practice patterns are not uniformly supported by high-quality evidence, highlighting the need for more rigorous research.
Complication Awareness
High rates of collar-related complications reported by surgeons emphasize the importance of weighing benefits versus risks.