Cervical spine evaluation and clearance in the intoxicated patient: a prospective western trauma association multi-institutional trial and survey

WTA C-Spine Study Group

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    Abstract

    INTRODUCTION: Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal 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. EtOH 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: 10,191 patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were male (67%), vehicular trauma or falls (83%), with mean age=48, and mean ISS=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 vs 51, p<0.01) but with similar mean ISS (11) and GCS (13). The TOX+ cohort had a lower incidence of Csp injury vs non-intoxicated (8.4 vs 11.5%, p<0.01). In the TOX+ group, CT had a sens=94%, spec=99.5%, and NPV=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 vs sober patients (mean 8 hrs vs 2 hrs, p<0.01), and prolonged immobilization (>12hrs) 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 this data. CONCLUSIONS: 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: Level II, Diagnostic Tests or Criteria

    Original languageEnglish (US)
    JournalJournal of Trauma and Acute Care Surgery
    DOIs
    Publication statusAccepted/In press - Jul 19 2017

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    ASJC Scopus subject areas

    • Surgery
    • Critical Care and Intensive Care Medicine

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