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J Trauma Acute Care Surg. 2017 Dec;83(6):1032-1040. doi: 10.1097/TA.0000000000001650.

Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey.

Author information

1
From the Legacy Emanuel Medical Center (M.J.M., L.D.B., W.L.), Portland, Oregon; LAC+USC Medical Center (K.I., S.B. D.D.), Los Angeles, California; Oregon Health and Science University (M.S.), Portland, Oregon; Scripps Mercy Hospital (K.A.P.), San Diego; Cedars-Sinai Medical Center (G.B.), Los Angeles, California; R Adams Cowley Shock Trauma Center (J.M.), Baltimore, Maryland; Cooper University Hospital (J.H.), Camden, New Jersey; University of California-San Diego (R.C.), La Jolla, California; Mayo Clinic (M.D.Z.), Rochester, Minnesota; University Medical Center at Brackenridge (C.V.R.B.), Austin, Texas; University of Calgary-Foothills Medical Center (C.G.B.), Calgary, Alberta, Canada; University of Michigan (J.R.C-B.), Ann Arbor, Michigan; Denver Health Medical Center (C.C.B.), Denver, Colorado; University of Colorado Health-Medical Center of the Rockies (J.D.), Loveland, Colorado; University of Texas Southwestern Medical Center Parkland Memorial Hospital (C.T.M.), Dallas; Medical Center of Plano (M.M.C.), Plano, Texas; and Wesley Medical Center (G.M.B.), Wichita, Kansas.

Abstract

BACKGROUND:

Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice.

METHODS:

A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered.

RESULTS:

Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p < 0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p < 0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p < 0.01), and prolonged immobilization (>12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data.

CONCLUSION:

For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers.

LEVEL OF EVIDENCE:

Diagnostic tests or criteria, level II.

PMID:
28723840
DOI:
10.1097/TA.0000000000001650
[Indexed for MEDLINE]

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