Several concepts should be kept in mind concerning cervical immobilization in children It has been estimated that 3% to 25% of spinal cord injuries occur during transit or early in the course of management, although a 2001 Cochrane report noted that there are no randomized controlled studies on the effect of immobilization on mortality, neurologic injury, spinal stability, and other adverse effects It is also important to realize that as many as 20% of spinal injuries involve noncontiguous vertebral elements, so entire spinal column immobilization and evaluation are imperative Currently, the Congress of Neurological Surgeons recommends a cervical collar and backboard immobilization in the setting of nonnegligible risk of injury after trauma Soft cervical collars offer no protection to an unstable spine, and hard collars alone may allow a fair amount of flexion, extension, and lateral movement of the cervical spine Ideal immobilization involves a hard cervical collar in conjunction with a full spine board, soft spacing devices, and securing straps ( Fig 112.10 ) Hard collars, including the C-Breeze and XTW (DeRoyal Industries, Inc Powell, TN), Miami J (Jerome Medical, Moorestown, NJ), Philadelphia (Philadelphia Collar Company, Thorofare, NJ), Stifneck (Laerdal, Stavanger, Norway), and Aspen (Medical Products, Long Beach, CA), are effective in restricting most of the range of motion in the cervical spine Miami J collars have been associated with lower levels of mandibular and ocular pressures, reducing the risk of occipital pressure ulcers while maintaining appropriate immobilization