Cervical spine evaluation and clearance in the intoxicated patient

A prospective Western Trauma Association Multi-Institutional Trial and Survey

WTA C-Spine Study Group

Research output: Contribution to journalArticle

8 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)1032-1040
Number of pages9
JournalJournal of Trauma and Acute Care Surgery
Volume83
Issue number6
DOIs
StatePublished - Dec 1 2017
Externally publishedYes

Fingerprint

Spine
Wounds and Injuries
Tomography
Immobilization
Surveys and Questionnaires
Injury Severity Score
Incidence
Routine Diagnostic Tests
Pharmaceutical Preparations
Multicenter Studies
Alcohols
Urine
Prospective Studies
Serum
Population

Keywords

  • alcohol
  • cervical collar
  • Cervical spine
  • drugs
  • intoxication

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Cervical spine evaluation and clearance in the intoxicated patient : A prospective Western Trauma Association Multi-Institutional Trial and Survey. / WTA C-Spine Study Group.

In: Journal of Trauma and Acute Care Surgery, Vol. 83, No. 6, 01.12.2017, p. 1032-1040.

Research output: Contribution to journalArticle

@article{c071ed821f3847268dc1945bbd5b2e5e,
title = "Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey",
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.",
keywords = "alcohol, cervical collar, Cervical spine, drugs, intoxication",
author = "{WTA C-Spine Study Group} and Martin, {Matthew J.} and Bush, {Lisa D.} and Kenji Inaba and Saskya Byerly and Martin Schreiber and Peck, {Kimberly A.} and Galinos Barmparas and Jay Menaker and Hazelton, {Joshua P.} and Raul Coimbra and Zielinski, {Martin D.} and Brown, {Carlos V.R.} and Ball, {Chad G.} and Cherry-Bukowiec, {Jill R.} and Burlew, {Clay Cothren} and Julie Dunn and Minshall, {C. Todd} and Carrick, {Matthew M.} and Berg, {Gina M.} and Demetrios Demetriades and William Long and Robert Brookshire and Breanna Roche and Amelia Johnson and Frederick Cole and Riyad Karmy-Jones and Megan Linnebur and Ranan Mendelsberg and Moazzam Khan and Yvonne Hojberg and Wong, {Monica D.} and Jayun Cho and Tom Maxim and Elizabeth Benjamin and Martin, {David T.} and Dunne, {Casey E.} and Ley, {Eric J.} and Srour, {Marrisa K.} and Bradley, {Matthew J.} and Scalea, {Thomas M.} and Capano-Wehrle, {Lisa M.} and {De Angelis}, {Ryan D.} and Pariaszevski, {Aneta S.} and Berndtson, {Allison E.} and Choudhry, {Asad J.} and Klein, {Amanda L.} and Almadani, {Ammar A.} and Alexandra Sheth and Kathryn Beauchamp and Steven Wolf",
year = "2017",
month = "12",
day = "1",
doi = "10.1097/TA.0000000000001650",
language = "English (US)",
volume = "83",
pages = "1032--1040",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",
number = "6",

}

TY - JOUR

T1 - Cervical spine evaluation and clearance in the intoxicated patient

T2 - A prospective Western Trauma Association Multi-Institutional Trial and Survey

AU - WTA C-Spine Study Group

AU - Martin, Matthew J.

AU - Bush, Lisa D.

AU - Inaba, Kenji

AU - Byerly, Saskya

AU - Schreiber, Martin

AU - Peck, Kimberly A.

AU - Barmparas, Galinos

AU - Menaker, Jay

AU - Hazelton, Joshua P.

AU - Coimbra, Raul

AU - Zielinski, Martin D.

AU - Brown, Carlos V.R.

AU - Ball, Chad G.

AU - Cherry-Bukowiec, Jill R.

AU - Burlew, Clay Cothren

AU - Dunn, Julie

AU - Minshall, C. Todd

AU - Carrick, Matthew M.

AU - Berg, Gina M.

AU - Demetriades, Demetrios

AU - Long, William

AU - Brookshire, Robert

AU - Roche, Breanna

AU - Johnson, Amelia

AU - Cole, Frederick

AU - Karmy-Jones, Riyad

AU - Linnebur, Megan

AU - Mendelsberg, Ranan

AU - Khan, Moazzam

AU - Hojberg, Yvonne

AU - Wong, Monica D.

AU - Cho, Jayun

AU - Maxim, Tom

AU - Benjamin, Elizabeth

AU - Martin, David T.

AU - Dunne, Casey E.

AU - Ley, Eric J.

AU - Srour, Marrisa K.

AU - Bradley, Matthew J.

AU - Scalea, Thomas M.

AU - Capano-Wehrle, Lisa M.

AU - De Angelis, Ryan D.

AU - Pariaszevski, Aneta S.

AU - Berndtson, Allison E.

AU - Choudhry, Asad J.

AU - Klein, Amanda L.

AU - Almadani, Ammar A.

AU - Sheth, Alexandra

AU - Beauchamp, Kathryn

AU - Wolf, Steven

PY - 2017/12/1

Y1 - 2017/12/1

N2 - 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.

AB - 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.

KW - alcohol

KW - cervical collar

KW - Cervical spine

KW - drugs

KW - intoxication

UR - http://www.scopus.com/inward/record.url?scp=85025140098&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85025140098&partnerID=8YFLogxK

U2 - 10.1097/TA.0000000000001650

DO - 10.1097/TA.0000000000001650

M3 - Article

VL - 83

SP - 1032

EP - 1040

JO - Journal of Trauma and Acute Care Surgery

JF - Journal of Trauma and Acute Care Surgery

SN - 2163-0755

IS - 6

ER -