When Can You Clear the Intoxicated Cervical Spine?

The answer is: it depends – are we talking about the “real world”, or the world of evidence-based medicine?

This is a qualitative survey and prospective, multi-center observational study of the cervical spine clearance practices following major trauma. Performed at 17 centers, these authors collected data on definitions of evaluability, length of time in cervical-spine immobilization, and the diagnostic characteristics of CT in the context of the intoxicated trauma patient.

These authors analyzed 10,191 patients, approximately 3,000 of whom were intoxicated with alcohol, drugs, or both. The median injury severity score was ~10, with about a quarter of the cohort having “severe injury” or ISS >15. Incidence of any identified cervical spine injury was 7.6%, or overall 1.4% clinically significant CSI. In this intoxicated cohort, the sensitivity and specificity of the CT was 98% and 93%, respectively. A long questionnaire regarding real-world practice is presented, and the responses are very interesting – most surveyed indicated they would not clear the patient until they were clinically sober for a reliable examination, and patients stayed in their cervical collars for up to 8 hours as a result. On the other hand, despite their practice to the contrary, a small majority of respondents indicated they believed it was safe and reasonable to clear the cervical spine following a CT.

The takeaway for us in the Emergency Department, however, is that it is definitely safe to do so. Absent the multi-system trauma and mechanisms involved in this study, our typical otherwise-uninjured intoxicated patient has a vanishingly small chance of significant injury missed on CT. The risks and costs of staying in the collar – including those of follow-up MRI – exceed the potential harms of a missed injury. If these authors, in the Journal of Trauma – despite their spectrum bias – ultimately conclude it is safe to remove the c-collar based on the NPV in their sample, it is even moreso for our less severely-injured general ED population.

“Cervical spine evaluation and clearance in the intoxicated patient: a prospective western trauma association multi-institutional trial and survey”
https://www.ncbi.nlm.nih.gov/pubmed/28723840