A prospective multicenter study of cervical spine injury in children

The Dangers of Spear Tackling: A Case Report of a NEXUS-negative High School Football Player

BACKGROUND

Although "spear tackling" is known to be a risk factor for cervical spine injury due to axial loading of the neck, and although this technique was officially banned from American football in 1976, football-associated cervical spine injuries continue to be reported. This case highlights the importance of recognizing high-risk mechanisms for cervical spine injury, and specifically the danger of spear tackling among football players at all levels.

CASE REPORT

A 16-year-old male high school football player presented to the pediatric emergency department for a neck injury sustained after spear tackling during a football game. He had no neurologic symptoms and met the NEXUS criteria for omitting x-ray evaluation. However, the description of spear tackling as the mechanism of injury led to the ordering of cervical radiographs, which revealed a C5 fracture. The patient was ultimately taken to the operating room for internal fixation, with a final surgical diagnosis of a C5 teardrop fracture. On outpatient follow-up at 1 year, the patient has had no neurologic sequelae. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case serves as a reminder that all evaluations of trauma patients should begin with an attempt to determine, as precisely as possible, the mechanism that was in play at the time of injury. The reassurance provided by a normal physical examination may be misleading. Spear tackling is not an uncommonly encountered cause of injury in American football, despite the practice being prohibited since a rule change in 1976. Continued education and increased awareness of the association of axial load injury with spear tackling may make it possible to avoid missing a potentially devastating cervical spine injury.

Pediatric Spine Emergencies

Acute onset of neurological signs and symptoms referable to the spine including difficulty walking, bowel and bladder dysfunction, and paresthesias in the extremities may be manifestations of pediatric spine emergency. Trauma is the most common etiology for a pediatric spinal emergency. Because a history of trauma is often available, the role of imaging involves detection of spinal injuries. Other pathologies such as infection, inflammation, vascular, and neoplasms may lead to pediatric spinal emergencies that also require imaging for assistance in determining the etiology and appropriate management.

Examination of Pediatric Radiation Dose Delivered After Cervical Spine Trauma

OBJECTIVES

Pediatric cervical spine injuries (CSIs) are rare but potentially fatal injuries. Plain radiographs (x-rays) and computed tomography (CT) are used to diagnose CSIs. Given concerns related to radiation exposure, the utility of x-rays in diagnosing CSIs compared with other forms of imaging must be examined.

METHODS

Patients younger than 19 years presenting with possible CSI to an urban tertiary care hospital who received imaging for possible CSI between January 1, 2011, and December 31, 2013, were included. The dose-length product was abstracted from the PACS system. Test performance for x-ray, CT, and MRI were calculated and effective radiation dose by age group was analyzed using the Kruskal-Wallis Test.

RESULTS

A total of 671 patient charts were reviewed, 574 children were included in the study cohort. Median age of enrolled children was 9.70 (interquartile range, 4.78-13.83) years; 42.5% were female. Test performance of x-ray, CT, and MRI to detect CSI were calculated. Cervical x-rays performed only slightly inferior to CT. Sensitivity was 83% (95% confidence interval [CI], 36-99%), and specificity was 97% (95% CI, 96%-99%) versus 100% (95% CI, 96%-100%) for CT. Median effective dose of radiation for cervical CTs was 4.51 mSv (interquartile range, 3.84-5.59 mSv). Median dose significantly increased with age (2.94-5.10 mSv, P < 0.001).

CONCLUSIONS

Plain radiographs were largely sufficient to screen for CSIs, indicating their utility as a screening tool for CSIs. The incidence of CSIs in our sample was similar to prior reports. The effective radiation dose delivered during pediatric head and cervical CTs were lower than previously published estimates.

Cervical Spine Injuries in Children Associated With Sports and Recreational Activities

OBJECTIVE

The aim of this study was to ascertain potential factors associated with cervical spine injuries in children injured during sports and recreational activities.

METHODS

This is a secondary analysis of a multicenter retrospective case-control study involving children younger than 16 years who presented to emergency departments after blunt trauma and underwent cervical spine radiography. Cases had cervical spine injury from sports or recreational activities (n = 179). Comparison groups sustained (1) cervical spine injury from other mechanisms (n = 361) or (2) other injuries from sports and recreational activities but were free of cervical spine injury (n = 180).

RESULTS

For children with sport and recreational activity-related cervical spine injuries, common injury patterns were subaxial (49%) and fractures (56%). These children were at increased odds of spinal cord injury without radiographic abnormalities compared with children with cervical spine injuries from other mechanisms (25% vs 6%). Children with sport and recreational activity-related trauma had increased odds of cervical spine injury if they had focal neurologic findings (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.5-9.4), had complaints of neck pain (OR, 3.1; 95% CI, 1.9-5.0), were injured diving (OR, 43.5; 95% CI, 5.9-321.3), or sustained axial loading impacts (OR, 2.2; 95% CI, 1.3-3.5). Football (22%), diving (20%), and bicycle crashes (11%) were the leading activities associated with cervical spine injury.

CONCLUSIONS

In children injured during sports and recreational activities, focal neurologic findings, neck pain, axial loading impacts, and the possibility of spinal cord injury without radiographic abnormality should guide the diagnostic evaluation for potential cervical spine injuries. Certain activities have a considerable frequency of cervical spine injury, which may benefit from activity-specific preventive measures.

Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts

The clinical presentation and diagnostic workup in pediatric cervical spine injuries (CSI) are different from adults owing to the unique anatomy and relative immaturity. The current article reviews the existing literature regarding the uniqueness of these injuries and discusses the current guidelines of radiological evaluation. A PubMed search was conducted using keywords "paediatric cervical spine injuries" or "paediatric cervical spine trauma." Six hundred and ninety two articles were available in total. Three hundred and forty three articles were considered for the review after eliminating unrelated and duplicate articles. Further screening was performed and 67 articles (original articles and review articles only) related to pediatric CSI were finally included. All articles were reviewed for details regarding epidemiology, injury patterns, anatomic considerations, clinical, and radiological evaluation protocols. CSIs are the most common level (60%-80%) for pediatric Spinal Injuries (SI). Children suffer from atlantoaxial injuries 2.5 times more often than adults. Children's unique anatomical features (large head size and highly flexible spine) predispose them to such a peculiar presentation. The role of National Emergency X-Ray Utilization Study, United State (NEXUS) and Canadian Cervical Spine Rule criteria in excluding pediatric cervical injury is questionable but cannot be ruled out completely. The minimum radiological examination includes 2- or 3-view cervical X-rays (anteroposterior, lateral ± open-mouth odontoid views). Additional radiological evaluations, including computerized tomography (CT) and magnetic resonance imaging (MRI) are obtained in situations of abnormal physical examination, abnormal X-rays, inability to obtain adequate X-rays, or to assess cord/soft-tissue status. The clinical criteria for cervical spine injury clearance can generally be applied to children older than 2 years of age. Nevertheless, adequate caution should be exercised before applying these rules in younger children. Initial radiographic investigation should be always adequate plain radiographs of cervical spine. CT and MRI scans should only be performed in an appropriate group of pediatric patients.

Radiographic morphology of normal ring apophyses in the immature cervical spine

BACKGROUND

The ring apophyses of the cervical spine have a variable appearance that changes with age. The times at which they appear and fuse at each level are not fixed. In this study, we aim to detail normal ranges of appearance of these ossification centers for each age group.

MATERIALS AND METHODS

One hundred and eighty patients under the age of 21 attending the Royal Stoke University Hospital for cervical spine radiographs were retrospectively identified. The presence or absence of ring apophyses at each cervical level and whether these had undergone fusion was reported, as were the thickness, length, and craniocaudal and anteroposterior distance of the apophysis from the vertebral body. The angulation of the apophysis relative to the endplate was also noted.

RESULTS

The youngest patient in which apophyses were seen was aged 3, but apophyses were otherwise rarely seen before the age of 6. All apophyses were present from age 14, and the superior apophyses fused by the age of 18, although unfused inferior apophyses were still seen in the 20-year age group. It was observed that apophyses were rarely separated from the vertebral body by greater than 1 mm in craniocaudal distance (1%) or 2.5 mm in anteroposterior distance (2.6%) and the anterior apophysis was angulated towards the endplate in only 1% of cases.

CONCLUSIONS

We have detailed the range of normal appearances of the ring apophyses of the developing cervical spine. Cervical spine apophyseal injury is thought to be rare, but knowledge of normative morphological features should help in this diagnosis.

Neurophysiological monitoring of displaced odontoid fracture reduction in a 3-year-old male

Introduction

Odontoid fractures in young children are rare. Most authors advocate for closed reduction and external stabilization as first line treatment. Unlike adults, young children are much less amenable to an awake reduction for real-time assessment of neurological function. We used spinal cord monitoring, as used in spine surgery, to assess the function of the spinal cord during the closed reduction in our 31-month-old patient.

Case presentation

A 31-month-old male presented with a displaced odontoid fracture and ASIA C spinal cord injury. Given his age, closed reduction and halo application were completed under general anesthesia guided by neuromonitoring. A less-than-ideal reduction initially was accepted due to a decline in motor-evoked potentials. Subsequently, there was no change in neurological status. The reduction was repeated under anesthesia, with monitoring, a number of times until good correction was achieved. Ultimately, a surgical fusion was required due to ligamentous instability. The child achieved a very good neurological outcome and a stable spine.

Discussion

Neuromonitoring is an important adjunct to closed reductions when complete and reliable neurological assessment is not possible.

Surgical treatment for old subaxial cervical dislocation with bilateral locked facets in a 3-year-old girl: A case report

RATIONALE

This study aimed to describe the case of a 3-year-old girl with old bilateral facet dislocation on cervical vertebrae 6 and 7, who had spinal cord transection, received surgical treatment, and achieved a relative satisfactory therapeutic effect.

PATIENT CONCERNS

A 3-year-old girl was urgently transferred to the hospital after a car accident. DIAGNOSES:: she was diagnosed with splenic rupture, intracranial hemorrhage, cervical dislocation, spinal transection, and Monteggia fracture of the left upper limb.

INTERVENTIONS

The girl underwent emergency splenectomy and was transferred to the intensive care unit of the hospital 15 days later. One-stage anterior-posterior approach surgery (anterior discectomy, posterior laminectomy, and pedicle screw fixation) was performed when the patient stabilized after 45-day symptomatic treatment. The operation was uneventful.

OUTCOMES

The reduction of lower cervical dislocation was satisfactory, with sufficient spinal cord decompression. The internal fixation position was good, and the spinal sequence was well restored. The girl was discharged 2 weeks later after the operation and followed up for 2 years. The major nerve function of both upper limbs was recovered, with no obvious retardation of the growth of immature spine.

LESSONS

A satisfactory therapeutic effect was achieved for a pediatric old subaxial cervical dislocation with bilateral locked facets using anterior discectomy, posterior laminectomy, and pedicle screw fixation. The posterior pedicle screw fixation provided a good three-dimensional stability of the spine, with reduced risk and complications caused by anterior internal fixation. The growth of immature spine was not obviously affected during the 2-year follow-up.

Errors in cervical spine immobilization during pediatric trauma evaluation

BACKGROUND

The purpose of this study was to identify factors during trauma evaluation that increase the likelihood of errors in cervical spine immobilization ('lapses').

MATERIALS AND METHODS

Multivariate analysis was used to identify the associations between patient characteristics, event features, and tasks performed in proximity to the head and neck and the occurrence and duration of a lapse in maintaining cervical spine immobilization during 56 pediatric trauma evaluations.

RESULTS

Lapses in cervical spine immobilization occurred in 71.4% of patients (n = 40), with an average of 1.2 ± 1.3 lapses per patient. Head and neck tasks classified as oxygen manipulation occurred an average of 12.2 ± 9.7 times per patient, whereas those related to neck examination and cervical collar manipulation occurred an average of 2.7 ± 1.7 and 2.1 ± 1.2 times per patient, respectively. More oxygen-related tasks were performed among patients who had than those who did not have a lapse (27.3 ± 16.5 versus 11.5 ± 8.0 tasks, P = 0.001). Patients who had cervical collar placement or manipulation had a two-fold higher risk of a lapse than those who did not have these tasks performed (OR 1.92, 95% CI 0.56, 3.28, P = 0.006). More lapses occurred during evaluations on the weekend (P = 0.01), when more tasks related to supplemental oxygen manipulation were performed (P = 0.02) and when more tasks associated with cervical collar management were performed (P < 0.001).

CONCLUSIONS

Errors in cervical spine immobilization were frequently observed during the initial evaluation of injured children. Strategies to reduce these errors should target approaches to head and neck management during the primary and secondary phases of trauma evaluation.

Imaging Gently

Advances in medical imaging are invaluable in the care of pediatric patients in the emergent setting. The diagnostic accuracy offered by studies using ionizing radiation, such as plain radiography, computed tomography, and fluoroscopy, are not without inherent risks. This article reviews the evidence supporting the risk of ionizing radiation from medical imaging as well as discusses clinical scenarios in which clinicians play an important role in supporting the judicious use of imaging studies.

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

General and central nervous system anatomy and physiology in children is different to that of adults and this is relevant to traumatic brain injury (TBI) and spinal cord injury. The controversies and uncertainties in adult neurotrauma are magnified by these differences, the lack of normative data for children, the scarcity of pediatric studies, and inappropriate generalization from adult studies. Cerebral metabolism develops rapidly in the early years, driven by cortical development, synaptogenesis, and rapid myelination, followed by equally dramatic changes in baseline and stimulated cerebral blood flow. Therefore, adult values for cerebral hemodynamics do not apply to children, and children cannot be easily approached as a homogenous group, especially given the marked changes between birth and age 8. Their cranial and spinal anatomy undergoes many changes, from the presence and disappearance of the fontanels, the presence and closure of cranial sutures, the thickness and pliability of the cranium, anatomy of the vertebra, and the maturity of the cervical ligaments and muscles. Moreover, their systemic anatomy changes over time. The head is relatively large in young children, the airway is easily compromised, the chest is poorly protected, the abdominal organs are large. Physiology changes—blood volume is small by comparison, hypothermia develops easily, intracranial pressure (ICP) is lower, and blood pressure normograms are considerably different at different ages, with potentially important implications for cerebral perfusion pressure (CPP) thresholds. Mechanisms and pathologies also differ—diffuse injuries are common in accidental injury, and growing fractures, non-accidental injury and spinal cord injury without radiographic abnormality are unique to the pediatric population. Despite these clear differences and the vulnerability of children, the amount of pediatric-specific data in TBI is surprisingly weak. There are no robust guidelines for even basics aspects of care in children, such as ICP and CPP management. This is particularly alarming given that TBI is a leading cause of death in children. To address this, there is an urgent need for pediatric-specific clinical research. If this goal is to be achieved, any clinician or researcher interested in pediatric neurotrauma must be familiar with its unique pathophysiological characteristics.

Triage tools for detecting cervical spine injury in pediatric trauma patients

BACKGROUND

Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population.

OBJECTIVES

To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma.

SEARCH METHODS

We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility.

SELECTION CRITERIA

We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy.

MAIN RESULTS

Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity.

AUTHORS' CONCLUSIONS

There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.

Interobserver Agreement in Pediatric Cervical Spine Injury Assessment Between Prehospital and Emergency Department Providers

BACKGROUND

Investigators have derived cervical spine injury (CSI) decision support tools from physician observations. There is a need to demonstrate that prehospital emergency medical services (EMS) providers can use these tools to appropriately determine the need for spinal motion restrictions and make field disposition decisions.

OBJECTIVES

The objective was to determine the interobserver agreement between EMS and emergency department (ED) providers for CSI risk assessment variables and overall gestalt for CSI in children after blunt trauma.

METHODS

This was a planned, substudy of a four-site, prospective cohort of children < 18 years transported by EMS to pediatric EDs for evaluation of CSI after blunt trauma. Inclusion criteria were trauma team activation and/or EMS-initiated spinal motion restriction. Exclusion criteria were penetrating trauma, transfer to another facility for definitive care, state custody, or substantial language barrier. For each eligible child, the transporting EMS provider and treating ED provider independently recorded their clinical assessment for CSI. This included mechanism of injury and patient history and physical examination findings. We assessed each paired variable for interobserver agreement between EMS and ED provider using kappa (κ) analysis. We considered variables with κ lower confidence interval values ≥0.4 to have moderate or better agreement.

RESULTS

We obtained 1,372 paired observations for 29 variables. After finding prevalence and observer bias were adjusted for, all variables achieved moderate to better agreement including eight variables previously shown to be independently associated with CSI in children: diving mechanism, high-risk motor vehicle collision, altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, and predisposing medical condition. EMS and ED providers, however, showed less than moderate agreement for their overall gestalt for CSI in children. Of note, both EMS and ED providers did not assess for neck pain, inability to move the neck, and/or cervical spine tenderness in more than 10% of study patients.

CONCLUSIONS

Emergency medical services and ED providers achieved at least moderate agreement in the assessment of CSI risk factors in children after blunt trauma. However, EMS and ED providers did not achieve moderate agreement on gestalt for CSI and some risk factors went unassessed by providers. These findings support the development of a pediatric CSI risk assessment tool for EMS and ED providers to reduce interventions for those children at very low risk for CSIs while still identifying all children with injury.

X-ray vs. CT in identifying significant C-spine injuries in the pediatric population

PURPOSE

Evaluation of cervical spine injury (CSI) in children requires rapid, yet accurate assessment of damage. Given concerns of radiation exposure, expert consensus advises that computed tomography (CT) should be used sparingly. However, CT can provide superior image resolution and detection of pathology. Herein, we evaluate if X-ray offers equal diagnostic accuracy compared to CT imaging in identifying CSI in children.

METHODS

We conducted a retrospective study between October 2000 and March 2012 of pediatric patients evaluated for cervical spine injury at a level 1 trauma center. All patients included in this study were imaged with cervical spine X-rays and CT at the time of injury. Demographic information, mechanism of injury, significant versus non-significant injury (as defined by the NEXUS criteria), radiographic findings, level of the injury, presence of spinal cord injury, treatment, clinical outcome, and length of follow-up were collected. Chi-squared (χ ²) and Fisher's exact tests were used as appropriate and means and standard deviations were reported.

RESULTS

We identified 1296 patients who were screened for CSI. Of those, 164 patients were diagnosed with spinal cord/column injuries (CSI). Eighty-nine patients were excluded for only having a CT or X-ray imaging without the other modality. Thus, a total of 75 patients with CSI were included in the final cohort. Using the NEXUS definitions, 78% of patients had clinically significant injuries while 22% had non-significant injuries. There were no injuries detected on X-ray that were not also detected on CT. For all injuries, X-ray sensitivity was 50.7%. X-rays were more sensitive to significant injuries (62.3%) compared in non-significant injuries, which were missed on all X-rays (0%). Therefore, X-rays did not identify 24 significant cervical spine injuries (32%) as defined by NEXUS.

CONCLUSIONS

CT is superior to X-rays in detecting both clinically significant and insignificant cervical spine injuries. These results were not dependent on patient age or location of the injury. We recommend CT imaging in the evaluation of suspected cervical spine injuries in children.

LEVEL OF EVIDENCE

III.

Imaging in paediatric spinal injury

Background

Paediatric spinal injury is rare and exhibits many unique features. Attending clinicians and radiologists often lack knowledge, expertise and experience in dealing with a potential injury to the paediatric spine. Within the paediatric age range itself there are different age-dependent mechanisms that can injure the paediatric spine. Moreover, the anatomical features and degree of osseous maturity of the developing paediatric spine determine the biomechanical characteristics which promote unique patterns of spinal injury in each paediatric age group.

Methods

An expert illustrated narrative review of the literature.

Results

Multiple factors make the imaging interpretation of the injured paediatric spine challenging. Each imaging modality has strengths and weaknesses in depicting spinal anatomy which vary with the type of spinal injury and age of the paediatric patient.

Conclusions

Attending doctors need to be familiar with the imaging appearances of the normal paediatric spine, its normal variants as well as the imaging features characteristics of paediatric spinal injury seen on radiographs, computed tomography and magnetic resonance imaging.

Performance improvement and patient safety program-guided quality improvement initiatives can significantly reduce computed tomography imaging in pediatric trauma patients

BACKGROUND

Morbidity and mortality of cervical spine (C-spine) injury in pediatric trauma patients are high, necessitating quick and accurate diagnosis. Best practices emphasize minimizing radiation exposure through decreased reliance on computed tomography (CT), instead using clinical assessment, physical examination, and alternate imaging techniques. We implemented an institutional performance improvement and patient safety (PIPS) program initiative for C-spine clearance in 2010 because of high rates of CT scans among pediatric trauma patients.

METHODS

A retrospective review of pediatric trauma patients, aged 0 years to 14 years, in the pre- and post-PIPS implementation periods was conducted. Rates of C-spine CT, overall CT, other imaging modalities, radiation exposure, patient characteristics, and injury severity were compared, and compliance with PIPS protocol was reviewed.

RESULTS

Patient characteristics and injury severity were similar before and after PIPS implementation. C-spine CT rates decreased significantly between groups (30% vs. 13%, p < 0.001), whereas C-spine plain x-ray rates increased significantly (7% vs. 25%, p < 0.001). There was no difference in C-spine magnetic resonance imaging between groups (12% vs. 10%, p = 0.11). In 2007, 71% of patients received a CT scan for any reason. However, the overall CT rate decreased significantly between groups (60% vs. 45%, p < 0.001). There was an estimated 22% decrease in lifetime attributable risk (LAR) for any cancer due to ionizing imaging exposure in males and 38% decrease in females between the pre- and post-PIPS groups. There was a 54% decrease in LAR for thyroid cancer in males and females between groups; 2014 compliance with the protocol was excellent (82-90% per quarter).

CONCLUSIONS

Performance improvement and patient safety program-generated protocol can significantly decrease ionizing radiation exposure. We demonstrate that a simple protocol focused on C-spine imaging has high compliance, decreased C-spine CT scans, and decreased LAR for thyroid cancer. A secondary benefit is a reduction in total CT imaging, with an associated decrease in LAR for all cancers.

LEVEL OF EVIDENCE

Therapeutic study, level IV; diagnostic study, level III.

Cervical Spine Clearance in Pediatric Trauma Centers: The Need for Standardization and an Evidence-based Protocol

BACKGROUND

Cervical spine clearance in the pediatric trauma patient represents a particularly challenging task. Unfortunately, standardized clearance protocols for pediatric cervical clearance are poorly reported in the literature and imaging recommendations demonstrate considerable variability. With the use of a web-based survey, this study aims to define the methods utilized by pediatric trauma centers throughout North America. Specific attention was given to the identification of personnel responsible for cervical spine care, diagnostic imaging modalities used, and the presence or absence of a written pediatric cervical spine clearance protocol.

METHODS

A 10-question electronic survey was given to members of the newly formed Pediatric Cervical Spine Study Group, all of whom are active POSNA members. The survey was submitted via the online service SurveyMonkey (https://www.surveymonkey.com/r/7NVVQZR). The survey assessed the respondent's institution demographics, such as trauma level and services primarily responsible for consultation and operative management of cervical spine injuries. In addition, respondents were asked to identify the protocols and primary imaging modality used for cervical spine clearance. Finally, respondents were asked if their institution had a documented cervical spine clearance protocol.

RESULTS

Of the 25 separate institutions evaluated, 21 were designated as level 1 trauma centers. Considerable variation was reported with regards to the primary service responsible for cervical spine clearance. General Surgery/Trauma (44%) is most commonly the primary service, followed by a rotating schedule (33%), Neurosugery (11%), and Orthopaedic Surgery (8%). Spine consults tend to be seen most commonly by a rotating schedule of Orthopaedic Surgery and Neurosurgery. The majority of responding institutions utilize computed tomographic imaging (46%) as the primary imaging modality, whereas 42% of hospitals used x-ray primarily. The remaining institutions reported using a combination of x-ray and computed tomographic imaging. Only 46% of institutions utilize a written, standardized pediatric cervical spine clearance protocol.

CONCLUSIONS

This study demonstrates a striking variability in the use of personnel, imaging modalities and, most importantly, standardized protocol in the evaluation of the pediatric trauma patient with a potential cervical spine injury. Cervical spine clearance protocols have been shown to decrease the incidence of missed injuries, minimize excessive radiation exposure, decrease the time to collar removal, and lower overall associated costs. It is our opinion that development of a task force or multicenter research protocol that incorporates existing evidence-based literature is the next best step in improving the care of children with cervical spine injuries.

LEVEL OF EVIDENCE

Level 4-economic and decision analyses.

Craniovertebral junction injuries in children. A Review

The craniovertebral junction (CVJ) is the most complex and dynamic region of the cervical spine. The wide range of movements possible at this region makes it vulnerable to injury and instability. The special anatomical features make children more prone to injuries of CVJ than adults where lower cervical spine is involved more frequently. The classical clinical manifestation in CVJ injury patients are pyramidal signs including weakness and spasticity, stigmata of CVJ anomalies (short neck, low hair line, facial or hand asymmetry, high arched palate, ), torticolis and neck movement restriction. The history of transient loss of consciousness or sudden neurological deterioration following minor trauma may be elicited. Most authors advocate conservative management (in form of immobilization) of CVJ injuries in children as is true in adults. Halo vest provides superior immobilization in upper cervical and CVJ injuries and can be used in a child as young as 1 year of age with minimal difficulty. Early surgical intervention, i.e. within 2 weeks of injury include is indicated in injuries that cannot be reduced and stabilized by external means, partial spinal cord injury with progressive neurological deficit and in children with extradural hematoma.

Methods for Collecting Paired Observations From Emergency Medical Services and Emergency Department Providers for Pediatric Cervical Spine Injury Risk Factors

OBJECTIVES

Cervical spine injuries (CSIs) after blunt trauma in children are rare, but cause substantial morbidity and mortality. Emergency medical services (EMS) and emergency department (ED) providers routinely use spinal precautions and cervical spine imaging, respectively, during the management of children experiencing blunt trauma. These practices lack evidence, and there is concern that they may be harmful. A pediatric CSI risk assessment tool is needed to inform EMS and ED provider decision making. Creating this tool requires prospective data collection from EMS and ED providers at the time of patient evaluation. The purpose of this article is to describe the methods used to prospectively capture paired EMS and ED provider observations of children cared for after blunt trauma. Given the rarity of prospective observational research with EMS, the novel use of Research Electronic Data Capture (REDCap) in this study, and the potential to inform future studies, we are publishing our methodology in advance of outcome data related to the risk assessment tool.

METHODS

The study was conducted at four tertiary children's hospitals as a prerequisite for a planned larger study to derive a CSI risk assessment tool. We created a web-based, branch-logic questionnaire using the REDCap data collection system. The survey was administered via tablet computer to ED providers evaluating children with blunt trauma and, if applicable, to EMS providers who provided patient care at the scene. We collected information regarding factors determined a priori to be plausibly associated with CSI in children. Eligible children presenting to the ED after blunt trauma with at least one of the following one of the following were included: prehospital EMS spinal precautions, ED trauma team evaluation, or cervical spine imaging in the ED. Exclusions included penetrating trauma, language barrier, or state's custody. Enrollment occurred when research coordinators (RCs) were available, generally 12-16 hours/day. RCs approached EMS providers prior to departing the ED and ED providers after they completed their patient assessments. An ED provider survey was required for enrollment. Enrolled children were followed for 28 days to determine the presence of CSI (primary outcome) by subsequent imaging or by patient/family telephone follow-up for those without imaging.

RESULTS

Over 18 months, we prospectively enrolled 4,144 of 5,764 (71.9%) eligible children, including 74 of 110 (67.3%) children diagnosed with CSI. Enrollment during RC hours was 85.9%. Fifty-three enrolled children were withdrawn from the study. Of those in the final study cohort, 36.5% arrived by EMS scene response in spinal precautions. The remaining 63.5% arrived by EMS scene response without spinal precautions or by private vehicle or interfacility transfer. EMS scene response providers completed surveys for 60.2% of enrolled children arriving in spinal precautions. RCs missed the EMS providers for 37.1% of children; however, EMS declined participation for only 2.6%.

CONCLUSIONS

Our method of data collection demonstrates the ability to prospectively capture paired observations from EMS and ED personnel for children undergoing evaluation after blunt trauma. While this methodology will be used to implement and evaluate a CSI tool in future studies, it may also be adapted to studies requiring prospective data collection from EMS and ED personnel.

Atlantoaxial Rotatory Subluxation in Children

OBJECTIVES

Pediatric cervical injuries are uncommon. This study was to describe injury circumstances, clinical findings, and management among children diagnosed with atlantoaxial rotatory subluxation (AARS) to aid in its recognition and management.

METHODS

Subanalysis of a large case-control study from January 2000 to December 2004 in 17 hospitals in the Pediatric Emergency Care Applied Research Network was performed. Cases were children younger than 16 years with AARS after blunt trauma (n = 55); controls were (a) children with other cervical spine injuries (other CSI, n = 485) and (b) those with normal imaging of the cervical spine (non-CSI, n = 1060).

RESULTS

Children with AARS were younger (mean [SD] age, 7.7 [3.8] vs 10.7 [4.6]; Wilcoxon P < 0.01). Falls accounted for 36% of injuries; there were no diving mechanisms (vs other CSI, falls 19%, Fisher exact P < 0.01, and diving 7%, P = 0.04). Children with AARS sought medical care more than 24 hours after the injury event (21% vs 1% for non-CSI controls, P < 0.01). Clinical findings associated with AARS included neck pain (67%) and torticollis (57%) versus other CSI, pain (47%) and torticollis (5%, P < 0.01) for each, and versus non-CSI controls, pain (33%) and torticollis (6%, P < 0.01) for each. Management of AARS included no intervention (n = 6, 11%), soft or rigid collar only (n = 24, 44%), traction (n = 14, 25%), halo (n = 9, 16%), internal fixation (n = 2, 4%), and varied across institutions (P = 0.02).

CONCLUSIONS

Children with AARS often have a delayed presentation with neck pain and torticollis; falls are a common injury mechanism. Treatment varied across institutions. Further work is needed to identify optimal management.

Number of positive radiographic findings in pediatric trauma patients

PURPOSE

Conventional radiography is frequently performed in pediatric patients in whom fractures and dislocations are suspected. However, until now, the rate of positive findings of the most commonly performed radiographic examinations in pediatric patients is unknown. The aim of this study was to evaluate the number of positive findings in the 20 most frequently requested standard radiographic examinations in pediatric patients in a level 1 trauma center systematically.

METHODS

A transversal cohort study was conducted at a level 1 trauma center in Germany (2008-2014). In a statistical pre hoc analysis, a sample size of 200 images of each standard radiograph was determined. The picture archiving and communication system (PACS) was searched for radiographic examinations in patients under 18 years.

RESULTS

The following fracture rates for the investigated 20 most common examinations were found: 70.5% clavicle, 54.5% forearm, 53% wrist, 41.5% elbow, 30.5% lower leg, 20% hand, 18.5% finger, 12.5% toe, 12% forefoot, 11.5% ankle, 9% shoulder, 6.5% patella, 5.5% foot, 4% knee, 2% conventional rib series, 1.5% lumbar spine, 1% Towne view, 0.5% skull, 0% cervical spine, and 0% odontoid. Differences in the mean age of analyzed pediatric trauma patients in correlation to different standard radiographs were found.

CONCLUSIONS

In our study, a relevant amount of different standard radiographs revealed a low fracture rate. Therefore, indications for X-ray should be checked properly and alternative procedures should be discussed with the patient and the parents. Clinical decision rules should be developed and pathways have to be implemented to minimize radiation exposure, waiting time, and costs.

Imaging investigations in Spine Trauma: The value of commonly used imaging modalities and emerging imaging modalities

Traumatic spine injuries can be devastating for patients affected and for health care professionals if preventable neurological deterioration occurs. This review discusses the imaging options for the diagnosis of spinal trauma. It lays out when imaging is appropriate and when it is not. It discusses strength and weakness of available imaging modalities. Advanced techniques for spinal injury imaging will be explored. The review concludes with a review of imaging protocols adjusted to clinical circumstances.

The sensitivity and negative predictive value of a pediatric cervical spine clearance algorithm that minimizes computerized tomography

BACKGROUND

It is crucial to identify cervical spine injuries while minimizing ionizing radiation. This study analyzes the sensitivity and negative predictive value of a pediatric cervical spine clearance algorithm.

METHODS

We performed a retrospective review of all children <21years old who were admitted following blunt trauma and underwent cervical spine clearance utilizing our institution's cervical spine clearance algorithm over a 10-year period. Age, gender, International Classification of Diseases 9th Edition diagnosis codes, presence or absence of cervical collar on arrival, Injury Severity Score, and type of cervical spine imaging obtained were extracted from the trauma registry and electronic medical record. Descriptive statistics were used and the sensitivity and negative predictive value of the algorithm were calculated.

RESULTS

Approximately 125,000 children were evaluated in the Emergency Department and 11,331 were admitted. Of the admitted children, 1023 patients arrived in a cervical collar without advanced cervical spine imaging and were evaluated using the cervical spine clearance algorithm. Algorithm sensitivity was 94.4% and the negative predictive value was 99.9%. There was one missed injury, a spinous process tip fracture in a teenager maintained in a collar.

CONCLUSIONS

Our algorithm was associated with a low missed injury rate and low CT utilization rate, even in children <3years old.

LEVEL OF EVIDENCE

IV.

Traumatic central cord syndrome after blunt cervical trauma: a pediatric case report

INTRODUCTION

Traumatic central cord syndrome (CCS) is the most frequently encountered incomplete spinal cord injury (SCI). The patient presents weakness, which is usually greater in the upper extremities than in the lower extremities, secondary to damage to the cervical spinal cord and anatomic distribution of the corticospinal tracts. CCS is seen commonly after a hyperextension mechanism in older patients with spondylotic changes. There are few literature reports regarding CCS in pediatric patients. We present an unusual case of traumatic CCS in a pediatric patient.

CASE PRESENTATION

A 15-year-old male patient, victim of bullying at school, received cervical blunt trauma with a plastic tube.  Within 3 h, the patient developed generalized weakness, which was greater in the upper extremities than in the lower extremities. Upon evaluation, the patient was found with marked upper extremity weakness compared to the lower extremities, with a Manual Muscle Test difference of 11 points. Imaging studies showed contusive changes in the C4-C7 central spinal cord. After rehabilitation therapies the patient gained 23 points in MMT at the day of discharge.

DISCUSSION

Different etiologies of CCS have previously been described in pediatric patients. However, this is the first case that describes a bullying event with cervical blunt trauma and subsequent CCS. In this case, history and physical examination, along with imaging studies, helped in the diagnosis, but it is important to be aware of the possibility of SCI without radiographic abnormalities, as it is common in the pediatric population. CCS occurs rarely in pediatric patients without underlying pathology. Physicians must be aware of the symptoms and clinical presentation in order to provide treatment and start early rehabilitation program.

Fractures of the axis: a review of pediatric, adult, and geriatric injuries

Fractures of the second cervical vertebra (C2, axis) are common in adult spine surgery. Those fractures occurring in younger adult patients are often associated with high-energy mechanism trauma, resulting in a "Hangman's Fracture." Management of these fractures is often successful with nonoperative means, though surgery may be needed in those fractures with greater displacement and injury to the C2-C3 disc. Older patients are more likely to sustain fractures of the odontoid process. The evidence supporting surgical management of these fractures is evolving, as there may be a mortality benefit to surgery. Regardless of treatment, longer-term mortality rates are high in this patient population, which should be discussed with the patient and family at the time of injury. Pediatric patients may suffer fractures of the axis, though differentiation of normal and pathologic findings is necessary and more difficult with the skeletally immature spine.

Prediction of blunt traumatic injuries and hospital admission based on history and physical exam

BACKGROUND

We evaluated the ability of experienced trauma surgeons to accurately predict specific blunt injuries, as well as patient disposition from the emergency department (ED), based only on the initial clinical evaluation and prior to any imaging studies. It would be hypothesized that experienced trauma surgeons' initial clinical evaluation is accurate for excluding life-threatening blunt injuries and for appropriate admission triage decisions.

METHODS

Using only their history and physical exam, and prior to any imaging studies, three (3) experienced trauma surgeons, with a combined Level 1 trauma experience of over 50 years, predicted injuries in patients with an initial GCS (Glasgow Coma Score) of 14-15. Additionally, ED disposition (ICU, floor, discharge to home) was also predicted. These predictions were compared to actual patient dispositions and to blunt injuries documented at discharge.

RESULTS

A total of 101 patients with 92 blunt injuries were studied. 43/92 (46.7 %) injuries would have been missed by only performing an initial history and physical exam ("Missed injury"). A change in treatment, though often minor, was required in 19/43 (44.2 %) of the missed injuries. Only 1/43 (2.3 %) of these "missed injuries" (blunt aortic injury) required surgery. Sensitivity, specificity, and accuracy for injury prediction were 53.2, 95.9, and 92.3 % respectively. Positive and negative predictive values were 53.8 and 95.8 % respectively. Prediction of disposition from the ED was 77.8 % accurate. In 7/34 (20.6 %) patients, missed injuries led to changes in disposition. "Undertriage" occurred in 9/99 (9.1 %) patients (Predicted for floor but admitted to ICU). Additionally, 8/84 (9.5 %) patients predicted for floor admission were sent home from the ED; and 5/13 (38.5 %) patients predicted for ICU admission were actually sent to the floor after complete evaluations, giving an "overtriage" rate of 13/99 (13.1 %) patients.

CONCLUSIONS

In a neurologically-intact group of trauma patients, experienced trauma surgeons would have missed 46.7 % of the actual injuries, based only on their history and physical exam. Once accurate diagnoses of injuries were completed, usually with the help of CT scans, admission dispositions changed in 20.6 % of patients. Treatment changes occurred in 44.2 % of the missed injuries, though usually minimal. Broad elimination of early imaging studies in alert, blunt trauma patients cannot be advocated.

Heterogeneity in cervical spine assessment in paediatric trauma: A survey of physicians' knowledge and application at a paediatric major trauma centre

OBJECTIVE

Evidence-based decision-making tools are widely used to guide cervical spine assessment in adult trauma patients. Similar tools validated for use in injured children are lacking. A paediatric-specific approach is appropriate given important differences in cervical spine anatomy, mechanism of spinal injury and concerns over ionising radiation in children. The present study aims to survey physicians' knowledge and application of cervical spine assessment in injured children.

METHODS

A cross-sectional survey of physicians actively engaged in trauma care within a paediatric trauma centre was undertaken. Participation was voluntary and responses de-idenitified. The survey comprised 20 questions regarding initial assessment, imaging, immobilisation and perioperative management. Physicians' responses were compared with available current evidence.

RESULTS

Sixty-seven physicians (28% registrars, 17% fellows and 55.2% consultants) participated. Physicians rated altered mental state, intoxication and distracting injury as the most important contraindications to cervical spine clearance in children. Fifty-four per cent considered adequate plain imaging to be 3-view cervical spine radiographs (anterior-posterior, lateral and odontoid), whereas 30% considered CT the most sensitive modality for detecting unstable cervical spine injuries. Physicians' responses reflected marked heterogeneity regarding semi-rigid cervical collars and what constitutes cervical spine 'clearance'. Greater consensus existed for perioperative precautions in this setting.

CONCLUSIONS

Physicians actively engaged in paediatric trauma care demonstrate marked heterogeneity in their knowledge and application of cervical spine assessment. This is compounded by a lack of paediatric-specific evidence and definitions, involvement of multiple specialties and staff turnover within busy departments. A validated decision-making tool for cervical spine assessment will represent an important advance in paediatric trauma.

Radiological assessment of paediatric cervical spine injury in blunt trauma: the potential impact of new NICE guidelines on the use of CT

AIM

To determine the potential effect of changes to the National Institute for Health and Care Excellence (NICE) guidelines to the use of computed tomography (CT) in the assessment of suspected paediatric cervical spine (c-spine) injury.

MATERIAL AND METHODS

A 5 year retrospective study was conducted of c-spine imaging in paediatric (<10 years) patients presenting following blunt trauma at a Level 1 trauma centre in London. All patients under the age of 10 years who underwent any imaging of the c-spine following blunt trauma were included. Clinical data relating to the presenting signs and symptoms were obtained from the retrospective review of electronic records and paper notes. This was then applied to the previous NICE guideline (CG56) and to the new NICE guideline (CG176). Patients with incomplete data were excluded.

RESULTS

Two hundred and seventy-eight patients <10 years underwent imaging of the c-spine following blunt trauma. Two hundred and seventy (97.12%) examinations had complete data and were included in further analysis. One hundred and forty-nine (55.19%) met the criteria for a CT of the c-spine under NICE CG56, whereas 252 (93.33%) met the updated NICE CG176 criteria for c-spine CT. Five (1.85%) patients had a c-spine injury and met the criteria under both CG56 and CG176 NICE guidelines.

CONCLUSION

Recent changes to NICE Head Injury Guidelines relating to radiological assessment of paediatric c-spine following blunt trauma are likely to result in an increased usage of CT as the initial radiological investigation over plain radiographs, without an apparent increase in specificity in the present series.

Do not waste your time: straight to magnetic resonance imaging for pediatric burners and stingers

BACKGROUND

Permanent neurologic injury in pediatric patients with burner and stinger syndrome (BSS) is unlikely. This study aims to assess the feasibility of clinical observation without extensive radiologic workup in this selective population.

METHODS

A retrospective study was conducted of patients aged younger than 18 years evaluated at a level I trauma center from 2012 to 2014. Patients were grouped according to positive deficit (PD) or negative deficit (ND) upon physical examination. Demographics, clinical findings, and outcomes were analyzed.

RESULTS

Thirty patients (ND, n = 14; PD, n = 16) were evaluated for BSS, most often as a result of injurious football tackle. Age and length of stay were similar between groups. Injury Severity Score was lower in the ND group than the PD group (1.6 ± 1.2 vs 3.8 ± 3.1, respectively; P< .05). Cervical computed tomography was performed on 11 patients (78.6%) in the ND group and 15 patients (93.8%) in the PD group at considerable added cost, with only 1 positive result in the ND group and none in the PD group. Magnetic resonance imaging (MRI) revealed 2 positive findings in each group, and no surgical interventions were indicated. Ten ND (71.4%) and 12 PD (75%) patients reported complete resolution of symptoms at discharge (P> .05).

CONCLUSIONS

Children presenting with BSS experience temporary symptoms that resolve without surgical intervention. Magnetic resonance imaging identified more injuries than computed tomographic imaging; therefore, we suggest that management for BSS should include observation, serial neurologic examinations, and MRI evaluation as appropriate.

Pediatric Cervical Spine Injuries: A Rare But Challenging Entity

BACKGROUND

Injuries to the cervical spine in pediatric patients are uncommon. A missed injury can have devastating consequences in this age group. Because of the lack of routine in diagnosis and management of pediatric cervical spine injuries (PCSI), each of these cases represents a logistic and personal challenge.

METHODS

By means of clinical cases, we demonstrate key points in diagnostics and treatment of pediatric spine injuries. We highlight typical pediatric injury patterns and more adult-like injuries.

RESULTS

The most common cause of injury is blunt trauma. There is an age-related pattern of injuries in pediatric patients. Children under the age of 8 frequently sustain ligamentous injuries in the upper cervical spine. After the age of 8, the biomechanics of the cervical spine are similar to adults, and therefore, bony injuries of the subaxial cervical spine are most likely to occur. Clinical presentation of PCSI is heterogeneous. Younger children can neither interpret nor communicate neurological abnormalities, which make timely and accurate diagnosis difficult. Plain radiographs are often misinterpreted. We find different types of injuries at different locations, because of different biomechanical properties of the immature spine. We outline that initial management is crucial for long-term outcome.

CONCLUSIONS

Knowledge of biomechanical properties and radiographic presentation of the immature spine can improve the awareness for PCSI. Diagnosis and management of pediatric patients after neck trauma can be demanding.

LEVEL OF EVIDENCE

Level IV.

Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits

OBJECTIVE

To assess variation in the use of computed tomography (CT) for pediatric injury-related emergency department (ED) visits.

STUDY DESIGN

This was a retrospective cohort study of visits to 14 network-affiliated EDs from November 2010 through February 2013. Visits were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Primary outcome was CT use. We used descriptive statistics and performed multivariable logistic regression to evaluate the association of patient and ED covariates on any and body region-specific CT use.

RESULTS

Of the 80 868 injury-related visits, 11.4% included CT, and 28.4% of those involved more than 1 CT. Across EDs, CT use ranged from 7.6% to 25.5% of visits and did not correlate with institutional Injury Severity Score (P = .33) or admission/transfer rates (P = .07). In multivariable analysis of nonpediatric EDs, trauma centers and nonacademic EDs were associated with CT use. Higher pediatric volume was associated with any CT use; however, there was an inverse relationship between volume and nonhead CT use. When the pediatric ED was included in multivariable modeling, the effect of level 1-3 trauma center designation remained, and the pediatric level 1 trauma center was less likely to use most body region-specific CTs.

CONCLUSION

There is wide variation in CT imaging for pediatric injury-related visits not attributable solely to case mix. Future work to optimize CT utilization should focus on additional factors contributing to imaging practices and interventions.

Asymmetry of the Odontoid Lateral Mass Interval in Pediatric Trauma CT: Do We Need to Investigate Further?

BACKGROUND AND PURPOSE

Odontoid lateral mass interval asymmetry can be within the normal spectrum or the result of traumatic atlantoaxial injury. We sought to set radiographic guidelines for further investigation of odontoid lateral mass interval asymmetry in cervical spine CT studies of pediatric trauma patients.

MATERIALS AND METHODS

Fourteen children with C1-2 ligamentous injury or atlantoaxial rotational fixation/subluxation were retrospectively identified. We identified an additional 56 children fulfilling the following inclusion criteria: 1) They underwent C-spine CT to exclude traumatic injury, and 2) C-spine clearance and follow-up. Those were matched for age, sex, and severity of traumatic insult with the injured group. Clinical data were collected, and we measured the following parameters: anterior atlantodental interval; odontoid lateral mass interval; and the rotation of the head, C1, and C2.

RESULTS

A significant difference (P < .001) was found between the groups in cervical tenderness and torticollis. There was a significant difference in the atlantodental interval value (3.3 ± 0.8 mm in injured and 2.2 ± 0.5 mm in noninjured). The directionality of head, C1, and C2 rotation was significantly (P < .05) more toward the same direction in the noninjured group. We found significant linear correlation between head rotation and ipsilateral odontoid lateral mass interval asymmetry only in the noninjured at C1-2. With multivariant analysis, the presence of cervical tenderness and an abnormal atlantodental interval were the most significant variables.

CONCLUSIONS

Odontoid lateral mass interspace asymmetry in the absence of cervical tenderness and with a normal atlantodental interval is likely in the normal range and need not be further investigated.

Management of traumatic spinal injuries in children and young adults

PURPOSE

Spinal injuries are rarely seen in pediatric patients and therapeutic options are still poorly defined. The present study is aimed to present our experience with a rather large series of children and young adults suffering from traumatic spinal injury.

PATIENTS AND METHODS

Between 1990 and 2010, 75 consecutive pediatric patients with spinal injuries were treated in our institution. Mean age was 15 years, ranging from 3 months to 21 years. Radiological findings, treatment strategies, and clinical outcome were evaluated retrospectively and compared with literature. Forty (53.3%) patients were treated conservatively and 35 patients (47%) surgically using anterior or posterior approaches. Subgroup analysis was performed depending on age groups, severity of neurological symptoms, and localization.

RESULTS

Main trauma mechanisms were fall in 24 patients (38%) and motor vehicle accidents in 21 patients (28%). Complete neurological deficits were present in 17 individuals (23%) and incomplete in 36 patients (48%). Fractures were most frequently localized at the cervical region (56%) with predilection of the C 5/6 segment. Odontoid fractures were seen in 10 (13%) patients. Fractures of the lumbar and thoracic region were rare. Level of injury or clinical course did not differ between the subgroups (≤15 years versus >15 years).

CONCLUSION

Nearly three fourths of all radiologically detected spinal injuries are located at the cervical spine. Complete neurological deficits after trauma was associated with a poor outcome, in particular for patients with injuries of the upper cervical spine. The use of autologous bone graft was associated with favorable long-term results and should be considered as the material of first choice for vertebral body and disc replacement.

Utility of complete trauma series radiographs in alert pediatric patients presenting to Emergency Department of a Tertiary Care Hospital

PURPOSE

To assess the utility of trauma series radiographs in the management of alert pediatric patients with traumatic injury and to ascertain whether it is necessary to acquire the entire trauma series in these children.

METHODS

A total of 176 consecutive children below the age of 15 years and having Glasgow Coma Scale score greater than 12, who presented to the emergency department of a tertiary care hospital with a history of recent trauma, were retrospectively reviewed. All the children had undergone a thorough clinical examination followed by complete trauma series radiographs, according to the American College of Surgery guidelines.

RESULTS

A total of 558 radiographs were reviewed by a consultant pediatric radiologist including 528 trauma series radiographs and 30 additional radiographs. Among the trauma series radiographs, 35 (6.63 %) had evidence of injury; 24 (4.54 %) and 11 (2.08 %) involving the chest and pelvic regions, respectively. All children with normal physical examination had normal cervical spine and chest radiographs. Among the 11 positive pelvic X-rays, only two had radiological signs of injury in the absence of localizing physical signs, and all these children were less than 3 years of age. In all the remaining cases, children had localizing signs on physical examination. Out of the 30 additional X-rays, 27 (90 %) had radiological evidence of injury.

CONCLUSIONS

The routine use of entire radiological trauma series in alert pediatric patients with a normal physical examination has a very low yield. In these children, the localizing signs and symptoms can help us in determining the specific radiological examination to be utilized.

Spinal cord injury in pediatric age in Spain. Reality of a national reference center

The aim of this study was to analyze the incidence and the main characteristics of ambulant children with spinal cord injury (SCI) treated at the Unit of Biomechanics and Technical Assistance, at the National Spinal Cord Injury Hospital in Toledo, Spain. To date, there are no detailed studies on the effects of this disease in children regarding their walking ability.

MATERIAL AND METHODS

A retrospective study was performed including all patients attending the unit between January 2006 and December 2013, who were aged 18 years or younger and who were outpatients able to walk independently for at least 10 m, with or without technical aids.

RESULTS

Forty-eight patients were included in this study (25 males and 23 females) aged between 2 and 18 years (mean age, 12 ± 2.31 years). The etiology of SCI ranged between congenital (33.33%), traumatic (29.16%), and neoplastic (8.33%), and the level of injury varied between cervical (31.25%), lumbar (29.16%), a non-spinal origin (20.83%), dorsal (16.66%), and sacral (2.08%). The mean score on the Barthel Index was 82.61, the mean value of the Functional Independence Measure (FIM) locomotion score was 6.4, and 29 patients did not require the use of walking aids (WISCI 20).

CONCLUSION

The findings of this study contribute to the knowledge regarding the situation of children with SCI in Spain. The incidence of pediatric SCI is very low; however, the provision of care remains a personal and social challenge.

Cervical spine imaging in hospitalized children with traumatic brain injury

OBJECTIVES

The purposes of this study, in children with traumatic brain injury (TBI), to describe cervical spine imaging practice, to assess for recent changes in imaging practice, and to determine whether cervical spine computed tomography (CT) is being used in children at low risk for cervical spine injury.

METHODS

The setting was children's hospitals participating in the Pediatric Health Information System database, from January 2001 to June 2011. Participants were children (younger than 18 y) with TBI who were evaluated in the emergency department, admitted to the hospital, and received a head CT scan on the day of admission. The primary outcome measures were cervical spine imaging studies. This study was exempted from institutional review board assessment.

RESULTS

A total of 30,112 children met study criteria. Overall, 52% (15,687/30,112) received cervical spine imaging. The use of cervical spine radiographs alone decreased between 2001 (47%) and 2011 (23%), with an annual decrease of 2.2% (95% confidence interval [CI], 1.1%-3.3%), and was largely replaced by an increased use of CT, with or without radiographs (8.6% in 2001 and 19.5% in 2011, with an annual increase of 0.9%; 95% CI, 0.1%-1.8%). A total of 2545 children received cervical spine CT despite being discharged alive from the hospital in less than 72 hours, and 1655 of those had a low-risk mechanism of injury.

CONCLUSIONS

The adoption of CT clearance of the cervical spine in adults seems to have influenced the care of children with TBI, despite concerns about radiation exposure.

Interobserver agreement in retrospective chart reviews for factors associated with cervical spine injuries in children

OBJECTIVES

The objective was to describe the interobserver agreement between trained chart reviewers and physician reviewers in a multicenter retrospective chart review study of children with cervical spine injuries (CSIs).

METHODS

Medical records of children younger than 16 years old with cervical spine radiography from 17 Pediatric Emergency Care Applied Research Network (PECARN) hospitals from years 2000 through 2004 were abstracted by trained reviewers for a study aimed to identify predictors of CSIs in children. Independent physician-reviewers abstracted patient history and clinical findings from a random sample of study patient medical records at each hospital. Interobserver agreement was assessed using percent agreement and the weighted kappa (κ) statistic, with lower 95% confidence intervals.

RESULTS

Moderate or better agreement (κ > 0.4) was achieved for most candidate CSI predictors, including altered mental status (κ = 0.87); focal neurologic findings (κ = 0.74); posterior midline neck tenderness (κ = 0.74); any neck tenderness (κ = 0.89); torticollis (κ = 0.79); complaint of neck pain (κ = 0.83); history of loss of consciousness (κ = 0.89); nonambulatory status (κ = 0.74); and substantial injuries to the head (κ = 0.50), torso/trunk (κ = 0.48), and extremities (κ = 0.59). High-risk mechanisms showed near-perfect agreement (diving, κ = 1.0; struck by car, κ = 0.93; other motorized vehicle crash, κ = 0.93; fall, κ = 0.92; high-risk motor vehicle collision, κ = 0.89; hanging, κ = 0.80). Fair agreement was found for clotheslining mechanisms (κ = 0.36) and substantial face injuries (κ = 0.40).

CONCLUSIONS

Most retrospectively assessed variables thought to be predictive of CSIs in blunt trauma-injured children had at least moderate interobserver agreement, suggesting that these data are sufficiently valid for use in identifying potential predictors of CSI.

Age-related differences in factors associated with cervical spine injuries in children

OBJECTIVES

The Pediatric Emergency Care Applied Research Network (PECARN) investigators previously identified risk factors associated with cervical spine injuries (CSIs) in children. Anatomic maturation and age-related variation in mechanisms of injury suggested the need to explore factors separately for younger versus older children. The purpose of this substudy was to investigate CSI risk factors in age subgroups within the PECARN study cohort.

METHODS

This was an age-stratified case-control analysis of children younger than 16 years presenting to 17 PECARN hospitals following blunt trauma between January 1, 2000 and December 31, 2004. Data were abstracted for children with CSIs and randomly selected CSI-free children. Age-stratified multivariable logistic regression was performed to identify factors associated with CSI within three age groups: younger than 2, 2 to 7, and 8 to 15 years. Sensitivity and specificity for CSI were estimated for both the age-specific and original (altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, predisposing conditions, diving, and high-risk motor vehicle crash [MVC]) models.

RESULTS

Among 540 children with CSIs, 27 were younger than 2 years, 140 were 2 to 7 years, and 373 were 8 to 15 years. Focal neurologic deficits and high-risk MVC were associated with CSIs in all age-specific models. Other age-specific factors included the following: younger than 2 years, none; 2 to 7 years, altered mental status, neck pain, torticollis; and 8 to 15 years, altered mental status, neck pain, diving. Age-specific models had comparable sensitivity to the original model among the older groups, but had lower sensitivity and higher specificity among the youngest children.

CONCLUSIONS

While this analysis supports the original PECARN model for CSI, there were subtle age variations in factors associated with CSIs in children that warrant future investigation.

The benefit of neck computed tomography compared with its harm (risk of cancer)

BACKGROUND

The purpose of this study was to compare the benefit of neck computed tomography (CT) of identifying important cervical spine injuries (CSIs) with its harm of radiation exposure and cancer risk.

METHODS

A PubMed search for published studies relating to CSI in trauma, cervical spine imaging, CT, and cancer risk was conducted. Article abstracts were reviewed, and selected published studies relating to the study objective were retrieved.

RESULTS

Of 100,000 trauma patients, neck CT scans were obtained in 3,767 to 26,785 patients. Of 100,000 patients with trauma on whom a neck CT scan was performed, a CSI was identified in 2,470 to 33,898 patients. Clinically important CSI ranged from 4,724 to 27,119 per 100,000 CT scans. For every 100,000 neck CT scans performed, additional cancer cases occur in a low end estimate of a thyroid cancer cases to a high end estimate of 100 male and 700 female cancer cases. In females, cancer risks are higher than in males, and these are closer to, but still less than, the incidence of clinically important CSI found by CT.

CONCLUSION

CT's benefit of identifying important CSIs in the published studies exceeds its cancer harm risk. However, at their extremes, the numbers are disturbingly close. Limiting neck CT scanning to a higher-risk group would increase the gap between benefit and harm, whereas performing CT routinely on low-risk cases approaches a point where its harm equals or exceeds its benefit.

LEVEL OF EVIDENCE

Systematic review, level IV.