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The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

Surgery for chronic subdural hematoma (CSDH) is performed to relieve brain displacement and high intracranial pressure (ICP). However, the intraoperative impression is often that the pressure inside the CSDH is low, despite marked clinical symptoms. We wanted to quantify the CSDH pressure and relate this to radiological and clinical characteristics. This prospective, population-based study of unilateral CSDHs was conducted over a 3-year period. CSDHs that were secondary to other conditions, re-operations, or CSDHs requiring other procedures than burr hole craniostomy under local anesthesia were excluded. Subdural pressure registration was performed via a simple manometric technique, and full compliance with a standardized protocol was mandatory. Sixty patients were included (mean age 76.2 years; for men, 77.4, and for women, 72.9). The mean pressure in the CSDHs was 15.2 cm H(2)O (range, 0-40) with no gender difference. Men had significantly larger volumes (mean 158.1 vs. 103.2 cm(3)) and midline shifts (mean 1.04 vs. 0.68 cm) than did women. Large hematomas with large midline shifts had higher pressures and more often required repeat surgery. With a patient's increasing age, the volumes and midline shifts seemed to become larger, whereas the pressures became lower. We did not find an association between repeat surgery and pressure or age. Our results are generally in line with those of previous studies reporting quantitative pressure registrations. However, there are important disparities regarding methodology, not least when comparing with various subjective scales that are widely used in clinical practice. A mean subdural pressure of 15.2 cm H(2)O is probably within the range of a normal ICP.

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in Western countries. Effective management planning for these patients requires knowledge of TBI epidemiology. The purpose of this study was to describe and analyze the development of TBI mortality in the Nordic countries during the period 1987-2001. Data on TBI deaths were retrieved from the national official statistical agencies according to specified diagnostic codes. We also collected data on the number of operations for acute TBI in the year 2000 from all Nordic hospitals admitting trauma patients. Finland had about twice as high a TBI mortality rate as the other countries. Similarly, the Finnish incidence of acute TBI operations was nearly twice that of the other countries. The median TBI death rate for Finland was 21.2 per 100,000 per year, and for Denmark, Norway, and Sweden 11.5, 10.4, and 9.5, respectively. There were more male than female deaths in all countries. The mortality rate from extracranial injuries was relatively equal between the countries. We observed a sizeable reduction in TBI mortality rates for all countries, except in Finland. Younger age groups had the most pronounced decrease in TBI mortality rates. The oldest age group had the least favorable development of TBI mortality rates, and the mean age of TBI casualties increased substantially during the study period. This study demonstrates considerable differences in and between the Nordic countries regarding TBI mortality. Preventive measures and implementation of regional guidelines are needed to assure a positive development in the future.