Journal article
Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey
The journal of trauma and acute care surgery, Vol.83(6), pp.1032-1040
01 Dec 2017
PMID: 28723840
Featured in Collection : UN Sustainable Development Goals @ Drexel
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.
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Details
- Title
- Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey
- Creators
- Matthew J. Martin - Legacy Emanuel Medical CenterLisa D. Bush - University of Colorado DenverKenji Inaba - University of Colorado DenverSaskya Byerly - University of Colorado DenverMartin Schreiber - University of Colorado DenverKimberly A. Peck - University of Colorado DenverGalinos Barmparas - University of Colorado DenverJay Menaker - University of Colorado DenverJoshua P. Hazelton - University of Colorado DenverRaul Coimbra - University of Colorado DenverMartin D. Zielinski - University of Colorado DenverCarlos V. R. Brown - University of Colorado DenverChad G. Ball - University of Colorado DenverJill R. Cherry-Bukowiec - University of Colorado DenverClay Cothren Burlew - University of Colorado DenverJulie Dunn - University of Colorado DenverC. Todd Minshall - University of Colorado DenverMatthew M. Carrick - University of Colorado DenverGina M. Berg - University of Colorado DenverDemetrios Demetriades - LACWilliam Long - University of Colorado DenverWTA C-Spine Study Grp
- Publication Details
- The journal of trauma and acute care surgery, Vol.83(6), pp.1032-1040
- Publisher
- Lippincott Williams & Wilkins
- Number of pages
- 9
- Resource Type
- Journal article
- Language
- English
- Academic Unit
- Surgery
- Web of Science ID
- WOS:000416832700005
- Scopus ID
- 2-s2.0-85025140098
- Other Identifier
- 991022056904004721
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- Collaboration types
- Domestic collaboration
- International collaboration
- Web of Science research areas
- Critical Care Medicine
- Surgery