Written by: Jason Chodakowski, MD (NUEM PGY-4) Edited by: Duncan Wilson, MD (NUEM ‘18) Expert commentary by: Matt Levine, MD
Saturday night in the ED. A 28 year old man presents after a low speed motor vehicle accident. Police report that he was seen swerving in the road before rear ending a parked car at approximately 25 mph. He presents to the ED without visible signs of trauma. His trauma exam reveals no cervical spine tenderness, but he is heavily intoxicated with a GCS of 13. Head CT and cervical spine CT are negative and he is currently sleeping in the hallway, periodically waking up to remove his cervical collar. You have very low suspicion that he has a significant cervical spine injury, but you ask yourself, can I clear his cervical spine given his level of intoxication?
Evaluating C-Spine Injuries
The Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Committee recommends the following approach to the care of patients with suspected cervical spine injuries: [1]
In awake, alert patients with trauma without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion of the cervical spine, imaging is not necessary and the cervical collar may be removed.
All other patients in whom cervical spine injury is suspected should have radiographic evaluation, preferably with cervical spine CT imaging.
In patients with negative CT imaging but persistent neck pain, the patient may have a cervical ligamentous injury. Three treatment options exist:
Continue the cervical collar
Cervical collar may be removed after negative MRI
Cervical collar may be removed after negative and adequate flexion/extension plain films.
The Canadian C-Spine and National Emergency X-Radiography Utilization Study (NEXUS) criteria are two widely used, prospectively validated decision rules that can be used by clinicians to clinically rule out clinically significant cervical spine injury, thereby obviating the need for imaging.
Canadian C-Spine criteria [10]: If the patient has all of the below, then radiography is not necessary:
No High Risk Factors: Age >/=65; Dangerous Mechanism, paresthesias in extremities
AND has presence of at least one low risk factor: simple rear-end MVC, sitting position in ED, ambulatory at any time, delayed onset of neck pain, and absence of midline c spine tenderness
AND able to range neck actively (i.e. rotate neck 45 degrees left and right)
National Emergency X-Radiography Utilization Study (NEXUS) criteria [9]: If the patient meets all of the below criteria, no radiology is required.
No posterior midline cervical-spine tenderness
No evidence of intoxication
A normal level of alertness
No focal neurologic deficit
No painful distracting injuries
C-Spine Clearance in Intoxicated Patients
Intoxicated patients are an important population to consider in the setting of suspected cervical spine injury: not only do they make up nearly half of all blunt and penetrating trauma patients [2], but intoxication and reduced level of consciousness disqualify the use of the above decision-rules, thereby necessitating CT imaging. CT is insensitive for ligamentous injuries and current practice dictates that after a negative CT c-spine these patients (and obtunded patients generally) are left in a c-collar until they can be reassessed unaltered or have additional imaging performed, usually MRI.
A wealth of gradually accumulating data challenges the need to keep obtunded patients (and therefore plausibly intoxicated patients) in prolonged immobilization or to obtain MRI after a single negative CT c-spine, notably:
Smith et al [3]: meta-analysis, 16785 obtunded trauma patients
99.9% Sn and 99.9% Sp for CSI; NPV 100%
Panczykowski et al [4]: meta-analysis, 14327 obtunded or intubated patients
99.9% Sn and 99.9% Sp for unstable cervical spine injury
Patel et a [5]: systematic review, 1718 obtunded blunt trauma patients
NPV 100% for unstable CSI, 91% for any stable CSI
Raza et al [6]: meta-analysis, 1850 obtunded blunt trauma patients
93.7% Sn and 99%.7% Sp; NPV 99.7%
Hogan et al [7]: retrospective review, 1400 blunt trauma patients
NPV 98.9% for ligamentous injury; 100% for unstable CSI
EAST Practice Management Guidelines reflect these findings, conditionally recommending c-collar removal after a negative high-quality CT c-spine alone. [5]
Most recently, a prospective observational study of intoxicated patients with blunt trauma was published by Bush et al [8] in JAMA Surgery in 2016. The authors followed 1696 adult blunt trauma patients who underwent 2mm-thickness, three-view CT c-spine, finding that among intoxicated patients (alcohol or other drugs) a single negative CT c-spine alone had a NPV of 99.2% for all cervical spine injuries and 99.8% for unstable cervical spine injuries. Of the 632 intoxicated patients, only 1 had an unstable ligamentous injury that was missed on CT and later identified on MRI. This patient had quadriplegia on initial evaluation. The incidence and types of CSI were similar between intoxicated and sober groups.
Where Do We Go From Here?
Given the high incidence of intoxication in blunt trauma patients who are collared and require c-spine clearance, it is worth considering whether an otherwise neurologically intact intoxicated patient with a negative high-quality CT c-spine requires prolonged immobilization. This is of particular importance in patients that become combative and demand removal of their cervical collar. In such cases, ED physicians may be forced to sedate the patient in order to keep the cervical collar on or obtain an MRI, which may place the patient at risk. While the data is admittedly limited, it does demonstrate that the incidence of clinically significant c-spine injury in the setting of a negative CT scan is very low, with some authors stating it approaches zero. Given this, it may be justifiable to remove an intoxicated patient’s cervical collar in the setting of a reassuring clinical exam and negative CT scan in settings when the risk of keeping the patient in a cervical collar until sober is deemed to outweigh the risks of missed cervical spine injury.
Expert Commentary
Everything we recommend in medicine is a risk-benefit analysis. If there is extremely little to benefit, then do not recommend. If the risk exceeds the benefit, then do not recommend. Keep this in mind when considering various cervical collar scenarios, and the concept of being risk-averse vs being risk-neurotic.
Most of us think we are risk averse, but no one thinks they are risk neurotic. However, many witnessed practices regarding the use of cervical collars are exactly that. For instance, a patient that had an MVC yesterday presents with neck pain after waking up this morning. They have been moving all over, showered, dressed, etc. There is some midline tenderness so now they must lie flat and still and wear a collar. They are not allowed to walk, use the toilet, or move themselves onto a CT table even though they got themselves in and out of the car this morning. This is risk neurosis. This patient has gained nothing from wearing this collar. Furthermore, we have inconvenienced ourselves by having to now logroll this patient for imaging studies, not to mention the bedpan for the negative pregnancy test. Why are we doing this to ourselves and our patients? Risk neurosis.
Do not confuse this with the MVC patient who had immediate neck pain, was removed from the car by EMS and immediately placed in a collar. That patient has not moved around yet and declared themselves low enough risk yet. It is reasonable to handle them with care until the doctor can assess, and possibly image before considering collar removal. Risk averse.
Back to the intoxicated patient demanding collar removal. My risk-benefit calculator which is continuously churning in my head considers the two options:
Sedate and restrain a neurologically intact patient without signs of spine injury, despite not meeting strict clearance criteria due to intoxication. This puts him at risk for violent behavior, over sedation, aspiration, prolonged ED length of stay, etc. Even if the patient is hiding a fracture, is the struggle to restrain him protecting his spine or putting it at risk?
Do not make him wear the collar but make him stay in the ED until he can be clinically reassessed (when sober). Even if he has a c spine fracture, how likely is deterioration during this time?
Which is riskier for the patient’s spine, the restraint to force a collar on or the relatively peaceful collarless period? My risk-benefit calculator tells me the peaceful collarless period is safest.
So remember to ask yourself when faced with a cervical collar scenario what are the risks and benefits of applying this collar? Is there any real benefit? And then ask yourself the truly difficult but introspective question: Am I being risk averse or am I being risk-neurotic?
Matt Levine, MD
Assistant Professor of Emergency Medicine
Northwestern Feinberg School of Medicine
Citations
Como, John J., et al. "Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee." Journal of Trauma and Acute Care Surgery 67.3 (2009): 651-659.
Rivara, Frederick P., et al. "The magnitude of acute and chronic alcohol abuse in trauma patients." Archives of Surgery 128.8 (1993): 907-913.
Smith, Jackie S. "A synthesis of research examining timely removal of cervical collars in the obtunded trauma patient with negative computed tomography: an evidence-based review." Journal of Trauma Nursing 21.2 (2014): 63-67.
Panczykowski, David M., Nestor D. Tomycz, and David O. Okonkwo. "Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma: A review." Journal of neurosurgery 115.3 (2011): 541-549.
Patel, Mayur B., 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." The journal of trauma and acute care surgery 78.2 (2015): 430.
Raza, Mushahid, et al. "Safe cervical spine clearance in adult obtunded blunt trauma patients on the basis of a normal multidetector CT scan—a meta-analysis and cohort study." Injury 44.11 (2013): 1589-1595.
Hogan, Gerard J., et al. "Exclusion of Unstable Cervical Spine Injury in Obtunded Patients with Blunt Trauma: Is MR Imaging Needed when Multi–Detector Row CT Findings Are Normal? 1." Radiology 237.1 (2005): 106-113.
Bush, Lisa, et al. "Evaluation of cervical spine clearance by computed tomographic scan alone in intoxicated patients with blunt trauma." JAMA surgery 151.9 (2016): 807-813.
Hoffman, J.R., et. al. “Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.” NEJM. 2000. 343(2):94-99.
Stiell, IG, et. al. “The Canadian C-Spine rule for Radiography in Alert and Stable Patients.” JAMA. 2001. 286(15):1841-8.
How To Cite This Post
[Peer-Reviewed, Web Publication] Chodakowski J, Wilson D. (2019, Sept 16). Clearing C-Spine in Intoxicated Blunt Trauma Patients. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from http://www.nuemblog.com/blog/cspine-clearance-etoh.
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