Cervical spine evaluation and clearance in the intoxicated patient

Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal CT scan. The authors evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice. 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. 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.
The study concludes that 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.