Case Based for August

Cervical Spine Clearance in the Intoxicated Trauma Patient

 

This case involves a 51-year-old woman who presented to the Emergency Department via EMS after a motor vehicle accident.

This was a single-vehicle MVA, and she was the only occupant of a midsize pickup truck. EMS reported that the patient had self-extricated prior to their arrival. They suspected that she may have been unrestrained based on spider webbing noted on the windshield. EMS estimated that the vehicle was traveling approximately 50 mph.

EMS was unable to place the patient in a cervical collar prior to arrival, and no other interventions were performed en route. She met criteria for a trauma activation.

Upon arrival in the Emergency Department, the patient was quite agitated and unable to provide additional details about the accident. She was also unable to provide a meaningful medical history, apparently due to a combination of intoxication and confusion.

The patient smelled of alcohol and was exhibiting behaviors consistent with intoxication. However, given the mechanism of injury, a complete trauma evaluation was indicated.

Initial vital signs: BP 103/76 mmHg | HR 85 bpm | Temp 36.2°C (97.2°F) | RR 19/min | SpO₂ 96%

We attempted to place a cervical collar upon arrival, but the patient was not cooperative with care and repeatedly stated that she did not understand why she was in the Emergency Department.

To facilitate the examination and necessary imaging, she was treated with low-dose midazolam and haloperidol. This had a good effect and allowed the required examinations to be completed without excessive respiratory depression. She was monitored with continuous end-tidal CO₂.

Primary and secondary surveys were performed, along with an E-FAST examination.

Her examination was limited by her participation, but she had scattered abrasions without lacerations or gross deformities. She was moving all four extremities spontaneously and had no apparent facial asymmetry or focal neurologic deficit.

After medication, she was able to tolerate the cervical collar.

Trauma imaging was obtained, including CT of the head, cervical spine, chest, abdomen, and pelvis.

Laboratory results were notable for a serum alcohol level of 323 mg/dL.

CT imaging demonstrated no major traumatic injuries. At our facility, the cervical spine report typically reads:

1. No CT evidence of an acute intracranial abnormality.
2. No acute fracture or subluxation of the cervical spine.

Can We Clear the C-Spine?

This raised an important question: Could the cervical collar be safely removed despite the patient’s ongoing intoxication?

Historically, the teaching has been that an intoxicated or otherwise unreliable patient could not have the cervical spine clinically cleared, even after a negative CT scan. However, with modern multidetector helical CT, is continued immobilization still necessary?

To answer this question, I turned to the literature.

Clinical clearance using the NEXUS or Canadian C-Spine Rule was not appropriate in this patient. NEXUS requires the absence of intoxication, and her mechanism and inability to participate reliably in the examination also prevented clinical clearance using the Canadian C-Spine Rule.

The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) 2022 Best Practices Guidelines: Spine Injury specifically state that a negative helical cervical CT scan is sufficient to remove a cervical collar in an adult blunt-trauma patient who is obtunded or otherwise unevaluable. The Eastern Association for the Surgery of Trauma (EAST) similarly conditionally recommends cervical collar removal after a negative high-quality cervical CT alone in obtunded adult blunt-trauma patients.¹˒²

Importantly, these recommendations do not mean that every patient with a negative CT can automatically have their collar removed. The CT examination must be of adequate quality, and patients with focal neurologic deficits or other clinical findings concerning for spinal cord or ligamentous injury may require additional evaluation with MRI and/or spine consultation.

What Does the Evidence Show?

The evidence supporting CT-based clearance is reassuring. A large prospective Western Trauma Association multicenter study enrolled more than 10,000 blunt-trauma patients. For clinically significant cervical spine injury, CT had a sensitivity of 98.5% and a negative predictive value of 99.97%. Only three clinically significant injuries were missed by CT, and all three patients had focal neurologic abnormalities on their initial examination consistent with central cord syndrome.³

There is also evidence specifically addressing intoxicated patients.

A prospective Western Trauma Association multicenter study evaluated more than 10,000 blunt-trauma patients, including a large subgroup of intoxicated patients. Among intoxicated patients, CT had a negative predictive value of 99.9% for clinically significant cervical spine injuries and 100% for unstable cervical spine injuries. The authors concluded that CT-based clearance in intoxicated patients appears safe and may avoid unnecessary prolonged immobilization.⁴

A separate prospective study published in JAMA Surgery evaluated 1,668 blunt-trauma patients, including 632 intoxicated patients. Among intoxicated patients, CT had a negative predictive value of 99.8% for injuries requiring immobilization or stabilization. In the subgroup of intoxicated patients with no gross motor deficits and a normal CT, the negative predictive value was 100%.⁵

These studies are particularly relevant to this case because the patient, despite being intoxicated and unable to provide a reliable history or participate fully in the examination, was moving all four extremities spontaneously without an apparent focal neurologic deficit.

What Did We Do?

In this case, I elected to remove the cervical collar after reviewing the negative, high-quality CT scan and confirming that there was no apparent focal neurologic deficit.

This greatly improved the patient’s comfort and minimized the need for additional medication to manage agitation and discomfort. The patient eventually became clinically sober and had no complications or other significant issues.

Important Caveats

There are several important caveats to CT-based cervical spine clearance in the intoxicated or otherwise unevaluable patient.

First, this approach depends on a high-quality CT examination. If the study is technically inadequate or significantly degraded by motion or other artifact, additional evaluation may be necessary.

Second, a negative CT should not override concerning clinical findings. Patients with a focal neurologic deficit, suspected spinal cord injury, or other clinical findings that are not adequately explained by the CT should remain immobilized while additional evaluation, including MRI and/or spine consultation, is considered.

Third, these recommendations apply to adult blunt-trauma patients and should not automatically be extrapolated to pediatric trauma patients.

Finally, it is worth recognizing that these recommendations may not yet be familiar to every clinician or institution. I recently reviewed a case in which a receiving hospital expressed concern that one of our physicians had removed the cervical collar from an obtunded patient after a negative CT scan. I directed them to the current ACS guidelines supporting this practice.

Take-Home Point

For the adult blunt-trauma patient who is intoxicated, obtunded, or otherwise unable to participate in a reliable cervical spine examination, a negative, high-quality CT of the cervical spine can be sufficient for cervical collar removal, provided there is no focal neurologic deficit or other clinical concern for occult spinal cord or unstable ligamentous injury.

The traditional practice of leaving an intoxicated patient immobilized until they become clinically sober is not necessarily required when a high-quality CT is negative and there are no concerning neurologic findings.

I encourage everyone to review the full ACS TQIP guidelines. The relevant discussion regarding cervical collar clearance is on page 10.  The link is in the first reference below.

References

1. American College of Surgeons Trauma Quality Improvement Program. Best Practices Guidelines: Spine Injury. American College of Surgeons; 2022:10. ACS TQIP Spine Injury Guidelines
2. Patel MB, Humble SS, Cullinane DC, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;78(2):430-441. doi:10.1097/TA.0000000000000503.
3. Inaba K, Byerly S, Bush LD, et al. Cervical spinal clearance: a prospective Western Trauma Association multi-institutional trial. J Trauma Acute Care Surg. 2016;81(6):1122-1130. doi:10.1097/TA.0000000000000978.
4. Martin MJ, Bush LD, Inaba K, et al. Cervical spine clearance in intoxicated patients: a prospective Western Trauma Association multi-institutional trial and survey. J Trauma Acute Care Surg. 2017;83(6):1032-1040. doi:10.1097/TA.0000000000001650.
5. Bush L, Brookshire R, Roche B, et al. Evaluation of cervical spine clearance by computed tomographic scan alone in intoxicated patients with blunt trauma. JAMA Surg. 2016;151(9):807-813. doi:10.1001/jamasurg.2016.1248.

Written by Brad Roth, MD

ERx Clinical Partners Medical Director

This is for informational purposes only. For medical advice or diagnosis, consult a physician