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

WTA C-Spine Study Group, Carlos V.R. Brown

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9 Citations (Scopus)

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
StateAccepted/In press - Jul 19 2017

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Spine
Wounds and Injuries
Immobilization
Surveys and Questionnaires
Incidence
Routine Diagnostic Tests
Pharmaceutical Preparations
Multicenter Studies
Urine
Prospective Studies
Serum
Population

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

@article{0551d6006ce143acb06474fc3261cea2,
title = "Cervical spine evaluation and clearance in the intoxicated patient: a prospective western trauma association multi-institutional trial and survey",
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",
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 Brown, {Carlos V.R.} and Brown, {Carlos V.R.} and Ball, {Chad G.} and Cherry-Bukowiec, {Jill R.} and Burlew, {Clay Cothren} and Julie Dunn and Minshall, {Christian T} and Carrick, {Matthew M.} and Berg, {Gina M.} and Demetrios Demetriades and Wolf, {Steven E}",
year = "2017",
month = "7",
day = "19",
doi = "10.1097/TA.0000000000001650",
language = "English (US)",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",

}

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 - Brown, Carlos V.R.

AU - Brown, Carlos V.R.

AU - Ball, Chad G.

AU - Cherry-Bukowiec, Jill R.

AU - Burlew, Clay Cothren

AU - Dunn, Julie

AU - Minshall, Christian T

AU - Carrick, Matthew M.

AU - Berg, Gina M.

AU - Demetriades, Demetrios

AU - Wolf, Steven E

PY - 2017/7/19

Y1 - 2017/7/19

N2 - 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

AB - 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

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DO - 10.1097/TA.0000000000001650

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