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

Martin, Matthew J. MD; Bush, Lisa D. PA-C; Inaba, Kenji MD; Byerly, Saskya MD; Schreiber, Martin MD; Peck, Kimberly A. MD; Barmparas, Galinos MD; Menaker, Jay MD; Hazelton, Joshua P. DO; Coimbra, Raul MD, PhD; Zielinski, Martin D. MD; Brown, Carlos V.R. MD; Ball, Chad G. MD; Cherry-Bukowiec, Jill R. MD; Burlew, Clay Cothren MD; Dunn, Julie MD; Minshall, C. Todd MD; Carrick, Matthew M. MD; Berg, Gina M. PhD; Demetriades, Demetrios MD, PhD; Long, William MDthe WTA C-Spine Study Group

Journal of Trauma and Acute Care Surgery: December 2017 - Volume 83 - Issue 6 - p 1032–1040
doi: 10.1097/TA.0000000000001650
WTA 2017 Plenary Papers
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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.

Supplemental digital content is available in the text.

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.

Submitted: February 16, 2017, Revised: June 17, 2017, Accepted: June 28, 2017, Published online: July 19,2017.

This paper was presented at the 2017 Western Trauma Association Annual Meeting, March 5–10, Snowbird, Utah.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

Address for reprints: Matthew J. Martin, MD, Trauma and Emergency Surgery Service, Legacy Emanuel Medical Center, 2801N., Gantenbein Ave, Portland, OR 97227; email: traumadoc22@gmail.com.

© 2017 Lippincott Williams & Wilkins, Inc.