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Duncan AJ, Ahmeti M. Pediatric C-spine Clearance by CT: A Retrospective Cohort Study. Cureus 2024; 16:e67832. [PMID: 39323696 PMCID: PMC11423953 DOI: 10.7759/cureus.67832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2024] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND Pediatric cervical spinal injury (CSI) remains a significant concern following blunt trauma, with mortality rates as high as 48%. Current protocols involve cervical immobilization and clearance through multidetector computed tomography (MDCT) scans, followed by magnetic resonance imaging (MRI) or clinical examination. However, prolonged collar use poses risks, necessitating timely clearance. This study assessed the efficacy of MDCT in pediatric CSI clearance. METHODS A retrospective cohort study, spanning January 2019 to January 2023, included pediatric patients under 18 undergoing cervical CT scans. RESULTS MDCT sensitivity was evaluated, with 13.8% positive scans, detecting clinically significant injuries. MRI identified no additional injuries, affirming MDCT reliability. The average clearance time was 24.9 hours, impacting hospitalization durations. Mortality unrelated to CSI was excluded. CONCLUSION These results align with recent studies advocating cervical collar removal based on negative MDCT, emphasizing its potential to decrease the time that patients remain in C-collars and expedite hospital courses, including therapy and discharge. The study encourages consideration of MDCT-based protocols for timely pediatric CSI clearance, promoting patient care efficiency and informed medical decision-making.
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Affiliation(s)
- Anthony J Duncan
- General Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks, USA
| | - Mentor Ahmeti
- Department of Surgery, Sanford Medical Center, Fargo, USA
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Tavender E, Eapen N, Wang J, Rausa VC, Babl FE, Phillips N. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev 2024; 3:CD011686. [PMID: 38517085 PMCID: PMC10958760 DOI: 10.1002/14651858.cd011686.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy. OBJECTIVES To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions. SELECTION CRITERIA We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach. MAIN RESULTS We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.
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Affiliation(s)
- Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
| | - Nitaa Eapen
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Junfeng Wang
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Vanessa C Rausa
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Australia
- Biomechanics and Spine Research Group, Centre for Children's Health Research, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, Australia
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Stephenson KJ, Bullard KL, Wyrick DL, Ramakrishnaiah RH, Albert GW, Maxson RT. Can you see with CT? Is cervical spine computed tomographic imaging sufficient in pediatric trauma? Am J Surg 2023:S0002-9610(23)00097-1. [PMID: 36922323 DOI: 10.1016/j.amjsurg.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Traumatic cervical spine injury (CSI) is fundamentally different in children, and imaging recommendations vary; however, prompt diagnosis is necessary. METHODS We conducted a retrospective cohort study, evaluating children who presented after traumatic injury from 7/1/2012 to 12/31/2019 receiving a cervical spine CT. Evaluation of the incidence and clinical significance of CSI undetected on CT subsequently diagnosed on MRI was conducted. Additionally, all with CSI underwent image review to evaluate for potential overlooked, but visible pathology. RESULTS 1487 children underwent a cervical spine CT, revealing 52 with CSI. 237 underwent MRI due to an abnormal CT or continued clinical concern. Ultimately, three were discovered to have clinically significant CSI missed on CT. In all cases, retrospective review demonstrated a retroclival hematoma when soft tissue windows were formatted in sagittal and coronal views. CONCLUSIONS A normal CT may be sufficient to rule-out clinically significant CSI. However, the presence of a retroclival hematoma must be evaluated.
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Affiliation(s)
- Krista J Stephenson
- Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR, 72202, United States.
| | - Kori L Bullard
- College of Medicine, University of Arkansas for Medical Sciences, 5301 W Markham St, Slot 520, Little Rock, AR, 72205, United States
| | - Deidre L Wyrick
- Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR, 72202, United States
| | - Raghu H Ramakrishnaiah
- Department of Pediatric Neuroradiology, Arkansas Children's Hospital, 1 Children's Way, Slot 105, Little Rock, AR, 72202, United States
| | - Gregory W Albert
- Division of Pediatric Neurosurgery, Arkansas Children's Hospital, 1 Children's Way, Slot 838, Little Rock, AR, USA
| | - R Todd Maxson
- Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR, 72202, United States
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Cerillo JL, Becsey AN, Sanghadia CP, Root KT, Lucke-Wold B. Spine Bracing: When to Utilize-A Narrative Review. BIOMECHANICS (BASEL, SWITZERLAND) 2023; 3:136-154. [PMID: 36949902 PMCID: PMC10029751 DOI: 10.3390/biomechanics3010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Spinal bracing is a common non-surgical technique that allows clinicians to prevent and correct malformations or injuries of a patient's spinal column. This review will explore the current standards of practice on spinal brace utilization. Specifically, it will highlight bracing usage in traumatic injuries, pregnancy, pediatrics, osteoporosis, and hyperkyphosis; address radiological findings concurrent with brace usage; and provide an overview of the braces currently available and advancements in the field. In doing so, we aim to improve clinicians' understanding and knowledge of bracing in common spinal pathologies to promote their appropriate use and improve patient outcomes.
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Affiliation(s)
- John L. Cerillo
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Clearwater, FL 33759, USA
| | | | - Chai P. Sanghadia
- Department of Molecular and Cellular Biology, University of Arizona, Tucson, AZ 85721, USA
| | - Kevin T. Root
- College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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Muacevic A, Adler JR. Implementation of National Emergency X-Radiography Utilization Study (NEXUS) Criteria in Pediatrics: A Systematic Review. Cureus 2022; 14:e30065. [PMID: 36238421 PMCID: PMC9547612 DOI: 10.7759/cureus.30065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2022] [Indexed: 11/05/2022] Open
Abstract
Since its introduction in 1992, the National Emergency X-Radiography Utilization Study (NEXUS) criteria have been used in trauma to decide whether a patient requires radiographic imaging. The tool is important in reducing radiation exposure. However, applying the NEXUS criteria for cervical spine imaging in pediatric patients is poorly supported compared to their use in adults. The objective of this review was to examine the effectiveness of using the NEXUS criteria in the diagnostic management of pediatric cervical spine injuries (CSI). The following databases were searched for studies focused on applying the NEXUS criteria for CSI in pediatric patients: Cochrane, PubMed, Google Scholar, EMBASE, ELSEVIER, and ScienceDirect. Additional studies were found through reference lists of primary sources and previous systematic and meta-analyses. The search focused on randomized controlled trials (RCTs), cohort studies, retrospective studies, prospective studies, and other uncontrolled trials published from 2000 to 2022. There were seven included studies with a total of 4502 pediatric patients. Five of the included studies were retrospective studies, while the remaining were prospective and case studies. Our results show that the sensitivity ranged from 43% to 100%, while the specificity ranged from 12.93% to 96%. The sensitivity increased with age, with those under the age of two or under the age of eight reporting poorer outcomes than the older pediatric patients. One study also shows that the proportion of patients undergoing cervical spine CT increased from 18% to 61% in the initial period before the implementation of clearance guidelines. The implementation of guidelines led to a 23% decrease in CT scans clearable by NEXUS criteria after 12 months. One of the studies reported that NEXUS criteria were a cost-effective option when used along with X-rays and CT. Overall, the studies do not strongly support the application of the NEXUS criteria to image pediatric patients for CSI. In conclusion, there is weak support in the literature for applying the NEXUS criteria in determining the need for cervical spine imaging in pediatric trauma patients. The practice and research implications of the findings are also discussed.
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An S, Hyun SJ. Pediatric Spine Trauma. J Korean Neurosurg Soc 2022; 65:361-369. [PMID: 35462522 PMCID: PMC9082124 DOI: 10.3340/jkns.2021.0282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/25/2022] [Indexed: 11/27/2022] Open
Abstract
Pediatric spine has growth potential with incomplete ossification, and also unique biomechanics which have important implications for trauma patients. This article intends to review various aspects of pediatric spine trauma including epidemiology, anatomy and biomechanics, and clinically relevant details of each type of injury based on the location and mechanism of injury. With the appropriate but not superfluous treatment, pediatric spine trauma patients can have better chance of recovery. Therefore, as a spine surgeon, understanding the general concept for each injury subtype together with the debate and progress in the field is inevitable.
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Nolte PC, Liao S, Kuch M, Grützner PA, Münzberg M, Kreinest M. Development of a New Emergency Medicine Spinal Immobilization Protocol for Pediatric Trauma Patients and First Applicability Test on Emergency Medicine Personnel. Pediatr Emerg Care 2022; 38:e75-e84. [PMID: 32604393 DOI: 10.1097/pec.0000000000002151] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to (i) develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) perform an applicability test on emergency medicine personnel. METHODS A structured search of the literature published between 1980 and 2019 was performed in MEDLINE using PubMed. Based on this literature search, a new Emergency Medicine Spinal Immobilization Protocol for pediatric trauma patients (E.M.S. IMMO Protocol Pediatric) was developed. Parameters found in the literature, such as trauma mechanism and clinical findings that accounted for a high probability of spinal injury, were included in the protocol. An applicability test was administered to German emergency medicine personnel using a questionnaire with case examples to assess correct decision making according to the protocol. RESULTS The E.M.S. IMMO Protocol Pediatric was developed based on evidence from published literature. In the applicability test involving 44 emergency medicine providers revealed that 82.9% of participants chose the correct type of immobilization based on the protocol. A total of 97.8% evaluated the E.M.S. IMMO Protocol Pediatric as helpful. CONCLUSIONS Based on the current literature, the E.M.S. IMMO Protocol Pediatric was developed in accordance with established procedures used in trauma care. The decision regarding immobilization is made on based on the cardiopulmonary status of the patient, and life-threatening injuries are treated with priority. If the patient presents in stable condition, the necessity for full immobilization is assessed based upon the mechanisms of injury, assessment of impairment, and clinical examination.
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Affiliation(s)
- Philip C Nolte
- From the Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | | | - Matthias Kuch
- Pediatric Emergency Department, Karlsruhe City Clinic, Karlsruhe
| | - Paul A Grützner
- From the Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | | | - Michael Kreinest
- From the Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
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8
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Phillips N, Rasmussen K, McGuire S, Abel KA, Acworth J, Askin G, Brady R, Walsh M, Babl FE. Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort. Emerg Med J 2021; 38:330-337. [PMID: 34449409 DOI: 10.1136/emermed-2020-210325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 12/31/2020] [Accepted: 01/24/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Clinical decision rules (CDRs) are commonly used to guide imaging decisions in cervical spine injury (CSI) assessment despite limited evidence for their use in paediatric populations. We set out to determine CSI incidence, imaging rates and the frequency of previously identified CSI risk factors, and thus assess the projected impact on imaging rates if CDRs were strictly applied as a rule in our population. METHODS A single-centre prospective observational study on all aged under 16 years presenting for assessment of possible CSI to a tertiary paediatric emergency department over a year, commencing September 2015. CDR variables from the National Emergency X-Radiography Utilization Study (NEXUS) rule, Canadian C-Spine rule (CCR) and proposed Paediatric Emergency Care Applied Research Network (PECARN) rule were collected prospectively and applied post hoc. RESULTS 1010 children were enrolled; 973 had not received prior imaging. Of these, 40.7% received cervical spine imaging; 32.4% X-rays, 13.4% CT scan and 3% MRI. All three CDRs identified the five children (0.5%) with CSI who had not received prior imaging. If CDRs were strictly applied as a rule for imaging, projected imaging rates in our setting would be as follows: NEXUS-44% (95% CI 41% to 47.4%), CCR-at least 48.4% (95% CI 45.3% to 51.7%) and PECARN-68% (95% CI 65.1% to 71.1%). CONCLUSION CSIs were rare (0.5% of our cohort), however, 40% of children received imaging. CDRs have been designed to guide imaging decisions; if strictly applied as a rule for imaging, the CDRs assessed in this study would increase imaging rates. Projected rates differ considerably depending on the CDR applied. These findings highlight the need for a validated paediatric-specific cervical spine imaging CDR.
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Affiliation(s)
- Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia .,Child Health Research Centre, University of Queensland, South Brisbane, Queensland, Australia
| | - Katie Rasmussen
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Sally McGuire
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Kerrie-Ann Abel
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Jason Acworth
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Geoffrey Askin
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia.,Orthopaedics (Spinal service), Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia.,Biomechanics and Spine Research Group, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Robyn Brady
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Mark Walsh
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia.,Medical Imaging (Radiology), Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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McCollum N, Guse S. Neck Trauma: Cervical Spine, Seatbelt Sign, and Penetrating Palate Injuries. Emerg Med Clin North Am 2021; 39:573-588. [PMID: 34215403 DOI: 10.1016/j.emc.2021.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pediatric cervical spine, blunt cerebrovascular, and penetrating palate injuries are rare but potentially life-threatening injuries that demand immediate stabilization and treatment. Balancing the risk of a missed injury with radiation exposure and the need for sedation is critical in evaluating children for these injuries. Unfortunately, effective clinical decision tools used in adult trauma cannot be uniformly applied to children. Careful risk stratification based on history, mechanism and examination is imperative to evaluate these injuries judiciously in the pediatric population. This article presents a review of the most up-to-date literature on pediatric neck trauma.
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Affiliation(s)
- Nichole McCollum
- Division of Emergency Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
| | - Sabrina Guse
- Division of Emergency Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA; George Washington School of Medicine and Health Sciences, 2300 I St NW, Washington, DC 20052, USA
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10
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Garg B, Ahuja K. C-spine clearance in poly-trauma patients: A narrative review. J Clin Orthop Trauma 2021; 12:66-71. [PMID: 33716430 PMCID: PMC7920196 DOI: 10.1016/j.jcot.2020.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 11/26/2022] Open
Abstract
The incidence of cervical spine injury in patients with polytrauma is 3.7%. Early identification and management of cervical spine injuries in these patients play a crucial role in preventing secondary cervical spine and cord injuries. C-spine clearance assumes a pivotal role in reducing the morbidity and mortality associated with cervical spine injury. Despite the availability of various validated management algorithms and protocols for C-spine clearance, there are several controversies regarding C-spine clearance, such as the ideal protocol and imaging modality, clearance of obtunded patients and management of patients that lie out of the described protocols and rules. The current article aims to provide a comprehensive review of the relevant literature and address the prevalent controversies.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Kaustubh Ahuja
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Rishikesh, 249203, Uttarakhand, India
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Abstract
OBJECTIVES Injuries are one of the most common causes of pediatric emergency department (ED) visit. The aim of this study was to investigate the relationship between the intensity of pain at the ED visit of children presenting with an extremity injury and the risk of fracture. METHODS We conducted a retrospective study, considering all patients presenting to the ED of a children's hospital in Italy, with an accidental extremity injury, between May and December 2015. We selected all children aged 8 to 17 years who underwent an x-ray. Children with major, multiple, or nonextremity injuries were excluded. Age, sex, spontaneous and palpation pain, local swelling, time between injury, and medical evaluation were recorded. Sensibility and specificity of spontaneous and palpation pain in detecting a fracture were calculated. RESULTS We reviewed 994 medical records; of these, 344 (34.6%) reported a fracture. Children's median age was 12 years (interquartile range [IQR], 10-14). Median spontaneous pain at the ED visit was not significantly different between children with and without a fracture: 4.0 (1.0-6.0) and 5 (1.0-6.0), respectively (P = 0.129). Children with mild palpation pain and children without an increase of pain of at least 2 points between spontaneous and palpation pain were fractured in 3.2% and 0.97% of cases, respectively. CONCLUSIONS In this series, pain intensity in children with a minor extremity injury was not a good marker of fracture. Nevertheless, children with mild palpation pain or with a mild increase of pain between spontaneous and palpation pain had a low risk of fracture.
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12
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Overmann KM, Robinson BRH, Eckman MH. Cervical spine evaluation in pediatric trauma: A cost-effectiveness analysis. Am J Emerg Med 2019; 38:2347-2355. [PMID: 31870674 DOI: 10.1016/j.ajem.2019.11.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 11/26/2019] [Accepted: 11/30/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The emergent evaluation of children with suspected traumatic cervical spine injuries (CSI) remains a challenge. Pediatric clinical pathways have been developed to stratify the risk of CSI and guide computed tomography (CT) utilization. The cost-effectiveness of their application has not been evaluated. Our objective was to examine the cost-effectiveness of three common strategies for the evaluation of children with suspected CSI after blunt injury. METHODS We developed a decision analytic model comparing these strategies to estimate clinical outcomes and costs for a hypothetical population of 0-17 year old patients with blunt neck trauma. Strategies included: 1) clinical pathway to stratify risk using NEXUS criteria and determine need for diagnostic testing; 2) screening radiographs as a first diagnostic; and 3) immediate CT scanning for all patients. We measured effectiveness with quality-adjusted life years (QALYs), and costs with 2018 U.S. dollars. Costs and effectiveness were discounted at 3% per year. RESULTS The use of the clinical pathway results in a gain of 0.04 QALYs and a cost saving of $2800 compared with immediate CT scanning of all patients. Use of the clinical pathway was less costly and more effective than immediate CT scan as long as the sensitivity of the clinical prediction rule was greater than 87% and when the sensitivity of x-ray was greater than 84%. CONCLUSION A strategy using a clinical pathway to first stratify risk before further diagnostic testing was less costly and more effective than either performing CT scanning or screening cervical radiographs on all patients.
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Affiliation(s)
- Kevin M Overmann
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, USA; Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA.
| | - Bryce R H Robinson
- Department of Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, 325 Ninth Ave, Seattle, WA, USA.
| | - Mark H Eckman
- Department of Internal Medicine, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, USA.
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Hassan N, Butler C, DeCou J, Crumb T, Flohr S, Reischman D, Junewick J. Pediatric cervical spine injuries on CT: difference in accuracy of interpretations by pediatric versus non-pediatric radiologists. Emerg Radiol 2019; 27:185-190. [PMID: 31820269 DOI: 10.1007/s10140-019-01743-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/01/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To retrospectively compare the accuracy of interpretation of initial cervical computerized tomography (CCT) by a non-pediatric radiologist (NPR) versus a pediatric radiologist (PR). METHODS IRB approval and consent waiver were granted to review all injured children from 2010 to 2014 in the trauma registry with CT and magnetic resonance imaging (MRI) of the cervical spine. Patients with negative CCT who subsequently had positive MRI from a single institution comprised the study group. Patients with negative CCT and MRI, matched by age, gender, and severity scores, comprised the control group. The CCTs from both groups were initially interpreted at the time of service by a NPR. Subsequently, a single PR with 20 years of experience blinded to clinical/imaging data reinterpreted these CCT examinations. CT interpretations were then compared with MRI results and evaluated for statistical significance using SSPS software. The data analysis utilized summary statistics, two-tailed binomial test, and univariate χ2 test. Significance for all comparisons was assessed at P < 0.05. RESULTS The study group was comprised of the 21 patients with negative CCT and positive MRI. Of the cohort included, 76% (16) were male and 24% (5) were female. The age range was 1 month-17 years, with a mean age of 9.7 years. CCT interpretation by NPR had a specificity of 91.7% (sensitivity 71.2%, positive predictive value 81.3%, and negative predictive value 86.3%) compared with results of MRI. Six of the 21 negative CCTs were interpreted by the PR as positive, mainly craniocervical junction injuries, and confirmed by MRI (28.6%, P < .001 compared with the NPR); no control CCT was interpreted by the PR as positive (sensitivity 100%, positive predictive value 100%, and negative predictive value 58.3%). CONCLUSION In our retrospective study, a pediatric radiologist has improved recognition of pediatric cervical spine injuries on CT compared with non-pediatric radiologist.
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Affiliation(s)
- Nabil Hassan
- Division of Pediatric Critical Care, OSF Healthcare Children's Hospital of Illinois, 530 NE Glen Oak Ave, Peoria, IL, 61637, USA
| | - Chloe Butler
- Mercy Medical Center, P.O. Box 14584, Des Moines, IA, 50306-3584, USA
| | - James DeCou
- Department of Surgery, Helen DeVos Children's Hospital, 100 Michigan St. NE, Grand Rapids, MI, 49503, USA
| | - Teri Crumb
- Department of Surgery, Helen DeVos Children's Hospital, 100 Michigan St. NE, Grand Rapids, MI, 49503, USA
| | - Stephanie Flohr
- Department of Surgery, Helen DeVos Children's Hospital, 100 Michigan St. NE, Grand Rapids, MI, 49503, USA
| | - Diann Reischman
- Department of Epidemiology, Grand Valley State University, A-1-178 Mackinac Hall, Allendale, MI, 49401, USA
| | - Joseph Junewick
- Advanced Radiology Services PC, Grand Rapids, MI, USA. .,Michigan State University College of Human Medicine, Grand Rapids, MI, USA. .,Department of Radiology, Helen DeVos Children's Hospital, 100 Michigan Street, Grand Rapids, MI, 49503, USA.
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[Development and first application testing of a new protocol for preclinical spinal immobilization in children : Assessment of indications based on the E.M.S. IMMO Protocol Pediatric]. Unfallchirurg 2019; 123:289-301. [PMID: 31768566 DOI: 10.1007/s00113-019-00744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND To protect the spine from secondary damage, spinal immobilization is a standard procedure in prehospital trauma management. Immobilization protocols aim to support emergency medicine personnel in quick decision making but predominantly focus on the adult spine; however, trauma mechanisms and injury patterns in adults differ from those in children and applying adult prehospital immobilization protocols to pediatric patients may be insufficient. Adequate protocols for children with spinal injuries are currently unavailable. OBJECTIVE The aim of this study was (i) to develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) to perform a first analysis of the quality of results if the protocol is used by emergency personnel. MATERIAL AND METHODS Based on a structured literature search a new immobilization protocol was developed. Analysis of the quality of results was performed by a questionnaire containing four case scenarios in order to assess correct decision making. The decision about spinal immobilization was made without and with the utilization of the protocol. RESULTS The E.M.S. IMMO Protocol Pediatric was developed based on the literature. The analysis of the quality of results was performed involving 39 emergency medicine providers. It could be shown that if the E.M.S. IMMO Protocol Pediatric was used, the correct type of immobilization was chosen more frequently. A total of 38 out of 39 participants evaluated the protocol as helpful. CONCLUSION The E.M.S. IMMO Protocol Pediatric provides decision-making support whether pediatric spine immobilization is indicated with respect to the cardiopulmonary status of the patient. In a first analysis, the E.M.S. IMMO Protocol Pediatric improves decision making by emergency medical care providers.
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Xun H, Lopez J, Darrach H, Redett RJ, Manson PN, Dorafshar AH. Frequency of Cervical Spine Injuries in Pediatric Craniomaxillofacial Trauma. J Oral Maxillofac Surg 2019; 77:1423-1432. [DOI: 10.1016/j.joms.2019.02.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/19/2019] [Accepted: 02/19/2019] [Indexed: 11/25/2022]
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Gopinathan NR, Viswanathan VK, Crawford AH. Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts. Indian J Orthop 2018; 52:489-500. [PMID: 30237606 PMCID: PMC6142799 DOI: 10.4103/ortho.ijortho_607_17] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Nirmal Raj Gopinathan
- Department of Orthopedic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vibhu Krishnan Viswanathan
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alvin H Crawford
- Department of Pediatric Orthopedics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, Schep NWL, van Rijn RR. Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database Syst Rev 2017; 12:CD011686. [PMID: 29215711 PMCID: PMC6486014 DOI: 10.1002/14651858.cd011686.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Annelie Slaar
- WestfriesgasthuisDepartment of RadiologyMaelsonstraat 3HoornNoord HollandNetherlands1624 NP
| | - M M Fockens
- University of AmsterdamAcademic Medical CenterAmsterdamNetherlands
| | - Junfeng Wang
- Academic Medical CenterDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Mario Maas
- Academic Medical CenterDepartment of RadiologyUniversity of AmsterdamMeibergdreefAmsterdamNetherlands
| | - David J Wilson
- St Lukes HospitalDepartment of RadiologyLatimer RoadHeadingtonOxfordUKOX3 7PF
| | - J Carel Goslings
- Academic Medical CenterTrauma Unit, Department of SurgeryMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Niels WL Schep
- Academic Medical CenterDepartment of Surgery/Trauma UnitMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Rick R van Rijn
- Academic Medical Center AmsterdamDepartment of RadiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
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Cassar-Pullicino VN, Leone A. Imaging in paediatric spinal injury. TRAUMA-ENGLAND 2017. [DOI: 10.1177/1460408617725781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | - Antonio Leone
- Institute of Radiology, School of Medicine, Catholic University, Rome, Italy
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20
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Saragiotto BT, Michaleff ZA. The Canadian C-Spine Rule. J Physiother 2016; 62:170. [PMID: 27161303 DOI: 10.1016/j.jphys.2016.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 02/22/2016] [Accepted: 04/06/2016] [Indexed: 10/21/2022] Open
Affiliation(s)
- Bruno Tirotti Saragiotto
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Zoe A Michaleff
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia; Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
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Davies J, Cross S, Evanson J. Radiological assessment of paediatric cervical spine injury in blunt trauma: the potential impact of new NICE guidelines on the use of CT. Clin Radiol 2016; 71:844-53. [PMID: 27234435 DOI: 10.1016/j.crad.2016.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 03/28/2016] [Accepted: 04/29/2016] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- J Davies
- Radiology Department, Royal London Hospital, Whitechapel Road, London E1 1BB, UK.
| | - S Cross
- Radiology Department, Royal London Hospital, Whitechapel Road, London E1 1BB, UK
| | - J Evanson
- Radiology Department, Royal London Hospital, Whitechapel Road, London E1 1BB, UK
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Chaudhry AS, Prince J, Sorrentino C, Fasanya C, McGinn J, Atanassov KD, Bloom S, Price M. Identification of Risk Factors for Cervical Spine Injury from Pediatric Trauma Registry. Pediatr Neurosurg 2016; 51:167-74. [PMID: 26992002 DOI: 10.1159/000444192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/21/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cervical spine injuries are rare in children. Our goal is to establish guidelines for cervical spine clearance that are practical for our pediatric population, and, in the process, to reduce the risk of radiation exposure from unnecessary advanced imaging. METHODS We retrospectively reviewed the records from the registries of two pediatric trauma centers from the past 11 years (January 2002 to June 2013). Patients aged 1 month to 17 years, who had a CT scan of the cervical spine due to trauma indication for possible cervical spine injury, were evaluated. RESULTS Three risk factors were identified as being significant for the presence of a cervical spine injury. Patients who sustained a cervical spine injury were more likely to be male (p = 0.0261), were more severely injured with a higher injury severity score (ISS 16.39 ± 15.79 injured vs. 8.7 ± 9.4 uninjured), and presented with neck tenderness (p = 0.0001). CONCLUSION In our study, significant cervical spine injury is related to male gender, higher ISS and neck tenderness.
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Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, Schep NWL, van Rijn RR. Triage tools for detecting cervical spine injury in pediatric trauma patients. Hippokratia 2015. [DOI: 10.1002/14651858.cd011686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Annelie Slaar
- Academic Medical Center (AMC); Department of Radiology; Amsterdam Netherlands 1105 AZ
| | | | - Junfeng Wang
- Academic Medical Center; Department of Clinical Epidemiology, Biostatistics and Bioinformatics; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Mario Maas
- Academic Medical Center; Department of Radiology; University of Amsterdam Meibergdreef Amsterdam Netherlands
| | - David J Wilson
- St Lukes Hospital; Department of Radiology; Latimer Road Headington Oxford UK OX3 7PF
| | - J Carel Goslings
- Academic Medical Center; Trauma Unit, Department of Surgery; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Niels WL Schep
- Academic Medical Center; Department of Surgery/Trauma Unit; Meibergdreef 9 Amsterdam Netherlands 1105AZ
| | - Rick R van Rijn
- Academic Medical Center Amsterdam; Department of Radiology; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
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Vachhrajani S, Sen AN, Satyan K, Kulkarni AV, Birchansky SB, Jea A. Estimation of normal computed tomography measurements for the upper cervical spine in the pediatric age group. J Neurosurg Pediatr 2014; 14:425-33. [PMID: 25127096 DOI: 10.3171/2014.7.peds13591] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Upper cervical spine injuries in the pediatric age group have been recognized as extremely unstable from ligamentous disruption and as potentially lethal. Few measurement norms have been published for the pediatric upper cervical spine to help diagnose this pathological state. Instead, adult measurement techniques and results are usually applied inappropriately to children. The authors propose using high-resolution reconstructed CT scans to define a range of normal for a collection of selected upper cervical spine measurements in the pediatric age group. METHODS Sagittal and coronal reformatted images were obtained from thin axial CT scans obtained in 42 children (< 18 years) in a 2-month period. There were 25 boys and 17 girls. The mean age was 100.9 months (range 1-214 months). Six CT scans were obtained for nontrauma indications, and 36 were obtained as part of a trauma protocol and later cleared for cervical spine injury. Six straightforward and direct linear distances-basion-dental interval (BDI); atlantodental interval (ADI); posterior atlantodental interval (PADI); right and left lateral mass interval (LMI); right and left craniocervical interval (CCI); and prevertebral soft-tissue thickness at C-2-that minimized logistical and technical distortions were measured and recorded. Statistical analysis including interobserver agreement, age stratification, and sex differences was performed for each of the 6 measurements. RESULTS The mean ADI was 2.25 ± 0.24 mm (± SD), the mean PADI was 18.3 ± 0.07 mm, the mean BDI was 7.28 ± 0.10 mm, and the mean prevertebral soft tissue width at C-2 was 4.45 ± 0.43 mm. The overall mean CCI was 2.38 ± 0.44 mm, and the overall mean LMI was 2.91 ± 0.49 mm. Linear regression analysis demonstrated statistically significant age effects for PADI (increased 0.02 mm/month), BDI (decreased 0.02 mm/month), and CCI (decreased 0.01 mm/month). Similarly significant effects were found for sex; females demonstrated on average a smaller CCI by 0.26 mm and a smaller PADI by 2.12 mm. Moderate to high interrater reliability was demonstrated across all parameters. CONCLUSIONS Age-dependent and age-independent normal CT measurements of the upper cervical spine will help to differentiate physiological and pathological states in children. The BDI appears to change significantly with age but not sex; on the other hand, the LMI and ADI appear to be age-independent measures. This preliminary study suggests acceptable levels of interrater reliability, and further expanded study will aim to validate these measurements to produce a profile of normal upper cervical spine measurements in children.
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Affiliation(s)
- Shobhan Vachhrajani
- Division of Neurosurgery, Department of Surgery, Hospital for Sick Children, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada ; and
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Rozzelle CJ, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Ryken TC, Theodore N, Walters BC, Hadley MN. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery 2013; 72 Suppl 2:205-26. [PMID: 23417192 DOI: 10.1227/neu.0b013e318277096c] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Curtis J Rozzelle
- Division of Neurological Surgery, Children's Hospital of Alabama, University of Alabama at Birmingham, AL 35294, USA
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Diagnosis of cervical spine injuries in children: a systematic review. Eur J Trauma Emerg Surg 2013; 39:653-65. [DOI: 10.1007/s00068-013-0295-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 04/26/2013] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE This article will review the current literature as it relates to imaging of the child suspected to have cervical spine injury (CSI) and the imaging findings of pediatric CSI, focusing on strategies to minimize radiation dose while maximizing diagnostic yield. CONCLUSION Although CSI is uncommon in children, the clinical implications of failure to correctly diagnose CSI are significant. Clinical decision rules proven effective in predicting CSI in adults cannot be uniformly applied to children.
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Abstract
PURPOSE OF REVIEW We present data from recently conducted research regarding the diagnosis of blunt cervical spine injury (CSI) in children. RECENT FINDINGS Research in the prehospital setting to evaluate the need for cervical spine immobilization in children, regardless of clinical findings or mechanism of injury, suggests that low-risk prediction rules may be safely utilized by prehospital providers, although more data is needed. Their size, developing skeleton and unique anatomy leave children vulnerable to particular injury patterns, namely cephalad bony fractures and ligamentous and spinal cord injuries without radiographic abnormality. Low-risk clinical prediction rules have been developed but need to be further validated. For those children at higher risk of CSI, diagnostic imaging strategies are evolving, with computed tomography and MRI becoming more prominent. SUMMARY Evidence in the management of children with CSI has expanded in recent years, but further large prospective studies are needed. We present a review of some recent developments influencing clinical practice.
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Abstract
Increasing evidence from adult trauma patients has allowed the formation of some international consensus on clearance protocols. The evidence for paediatric trauma remains more fragmented, making the creation of definitive protocols difficult. Spinal injury in children differs from that in adults by injury distribution and prevalence, as well as anatomical and radiological differences. This complicates the process of clearance of the cervical spine in children. The evidence for clearance can be considered in terms of three groups of patients – the alert and asymptomatic child, the conscious child with high-risk criteria and the unconscious or obtunded child. This systematic review summarises the available evidence to clarify the current best practice for each group of patients.
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Affiliation(s)
- Lynn Hutchings
- The Kadoorie Centre for Critical Care Research, The Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The University of Oxford, Oxford, UK
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The appropriate use of CT: quality improvement and clinical decision-making in pediatric emergency medicine. Pediatr Radiol 2011; 41 Suppl 2:498-504. [PMID: 21847729 DOI: 10.1007/s00247-011-2102-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 02/14/2011] [Indexed: 10/17/2022]
Abstract
An increasing number of patients presenting to a shrinking number of hospital emergency departments has contributed to challenges to providing high-quality care, specifically care that is safe, efficient and effective. These challenges are magnified by trends in CT utilization with uncertain implications for care delivery. The utility of CT poses challenges to the pediatric emergency medicine physician to balance risk with potential benefit. We describe the process of evidence-based clinical decision-making to define the appropriate use of CT studies. Strategies for minimizing CT utilization in managing appendicitis, traumatic brain injury and cervical spine injuries are described. Clinical scores, clinical decision rules and evidence-based guidelines can assist the clinician in providing high-quality care through effective utilization of CT.
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Evaluation of diagnosis techniques used for spinal injury related back pain. PAIN RESEARCH AND TREATMENT 2011; 2011:478798. [PMID: 22110925 PMCID: PMC3195805 DOI: 10.1155/2011/478798] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 04/11/2011] [Indexed: 11/24/2022]
Abstract
Back pain is a prevalent condition affecting much of the population at one time or the other. Complications, including neurological ones, can result from missed or mismanaged spinal abnormalities. These complications often result in serious patient injury and require more medical treatment. Correct diagnosis enables more effective, often less costly treatment methods. Current diagnosis technologies focus on spinal alterations. Only approximately 10% of back pain is diagnosable, with current diagnostic technologies. The objective of this paper is to investigate and evaluate based on specific criteria current diagnosis technique. Nine diagnostic techniques were found in the literature, namely, discography, myelography, single photon emission computer tomography (SPECT), computer tomography (CT), combined CT & SPECT, magnetic resonance imaging (MRI), upright and kinematic MRI, plain radiography and cineradiography. Upon review of the techniques, it is suggested that improvements can be made to all the existing techniques for diagnosing back pain. This review will aid health service developers to focus on insufficient areas, which will help to improve existing technologies or even develop alternative ones.
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Bond MC, Lemkin DL, Brady W. The orthopedic literature 2009. Am J Emerg Med 2010; 29:943-53. [PMID: 20934830 DOI: 10.1016/j.ajem.2010.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2010] [Accepted: 06/27/2010] [Indexed: 10/19/2022] Open
Affiliation(s)
- Michael C Bond
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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