Developing a clinical algorithm for early management of cervical spine injury in child trauma victims

Triage tools for detecting cervical spine injury in paediatric trauma patients

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.

Cervical Collar Clearance in Obtunded Children Presenting Without a Known Traumatic Mechanism: Is Imaging Necessary?

BACKGROUND

Obtunded pediatric patients are often placed in cervical collars (c-collars) to protect their cervical spine (c-spine) while injury is being ruled out, even without a known traumatic injury. The goal of this study was to determine the necessity of c-collars in this population by determining the rate of c-spine injury among patients with suspected non-traumatic mechanisms of loss of consciousness.

METHODS

A single institution, ten-year retrospective chart review was conducted including all obtunded patients admitted to the Pediatric Intensive Care Unit without a known traumatic event. Patients were categorized into five groups based on etiology of obtundation: respiratory, cardiac, medical/metabolic, neurologic, and other. Comparisons were made between those placed in a c-collar and a control group who were not, using Wilcoxon rank sum test for continuous measures, and Chi-square or Fisher's exact test for categorical measures.

RESULTS

464 patients were included, of which 39 (8.41%) were placed in a c-collar. There was a significant difference in whether a patient was placed in a c-collar based on diagnosis category (p < 0.001). Those placed in a-c-collar were more likely to undergo imaging studies than the control group (p < 0.001). The overall incidence of c-spine injury in this patient population in our study was zero.

CONCLUSION

Cervical collar placement and radiographic evaluation is not necessary in obtunded pediatric patients who present without a known traumatic mechanism as the overall risk of injury is low. Consideration for collar placement should be given in cases when trauma cannot be definitively ruled out at initial evaluation.

LEVELS OF EVIDENCE

III.

A Retrospective Look at a Cervical Spine Clearance Protocol in Pediatric Trauma Patients at a Level-1 Trauma Center

BACKGROUND

Adult studies have demonstrated the efficacy of written protocols for clearance of the cervical spine. However, less than half of recently surveyed pediatric trauma centers report using a documented protocol. Little data exists on such protocols in pediatric populations, but interest remains because of potential reductions in radiation exposure, time to clearance, hospital stay, and specialist referral. However, missed injury can have devastating consequences. The purpose of this study is to examine the efficacy in detecting injury of an implemented cervical spine clearance protocol at a level-1 pediatric trauma hospital.

METHODS

A retrospective review was performed on pediatric patients presenting as activated traumas to the emergency department of a single level-1 pediatric trauma hospital between May 2010 and October 2018. This institution has utilized a written cervical spine clearance protocol throughout this time. Presence of cervical spine injury, documented clearance, cervical spine imaging, and follow-up documentation were reviewed for any missed injuries.

RESULTS

There were no missed cervical spine injuries. Five-hundred sixty-three clinically significant cervical spine injuries were identified, representing 16.5% of patients. Of these, 96 were fractures, dislocations, or ligamentous injuries, representing 2.8% of all patients. Most cervical spine clearances were performed by trauma surgery. Advanced imaging of the cervical spine was ordered for 43.2% of patients overall and trended down over time.

CONCLUSION

Documented cervical spine clearance protocols are effective for detection of significant injury in pediatric trauma patients. This study suggests these protocols minimize risk of missed injury and may prevent unnecessary radiation exposure, delayed clearance, prolonged hospitalization, or unnecessary specialist referral.

CLINICAL RELEVANCE

Utilization of a standard written protocol for cervical spine clearance likely prevents missed injury and helps to minimize radiation exposure in pediatric populations. Further research is needed on evaluation and management of pediatric cervical spine trauma.

Development of a New Emergency Medicine Spinal Immobilization Protocol for Pediatric Trauma Patients and First Applicability Test on Emergency Medicine Personnel

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.

Variation in pediatric cervical spine imaging across trauma centers-A cause for concern?

BACKGROUND

Traumatic pediatric cervical spine injury can be challenging to diagnose, and the clinical algorithms meant to aid physicians differ from adult trauma protocols. Despite the existence of standardized guidelines, imaging decisions may vary according to physician education, subjective assessment, and experience with pediatric trauma patients. Our study investigates the rates of pediatric posttraumatic cervical spine imaging across trauma centers, hypothesizing that more specialized centers will have lower rates of advanced cervical spine imaging.

METHODS

The 2015 to 2016 Trauma Quality Improvement Program database was reviewed for patients younger than 18 years- to assess rates of cervical spine imaging on presentation across different trauma centers. Propensity stratification logistic regression was performed controlling for patient- and center-specific variables. p Values less than 0.05 were considered significant.

RESULTS

Of 110,769 pediatric trauma patients, 35.2% were female, and the average age was 9.6 years. Overall, 3.6% had cervical spine computed tomography (CT) and less than 1% had cervical spine MRI or X-ray. Compared with all others, Level I trauma centers were significantly less likely to use cervical spine CT for the initial evaluation of younger (≤14 years) but not older trauma patients (adjusted odds ratio [AOR], 0.89; 95% confidence interval [CI], 0.80-0.99; AOR, 0.97; 95% CI, 0.87-1.09); Level I centers had higher odds of cervical spine MRI use, but only for patients 14 years or younger (AOR, 1.63; 95% CI, 1.09-2.44). Pediatric-designated trauma centers had significantly lower odds of cervical spine CT (≤14 years: AOR, 0.70; 95% CI, 0.63-0.78; >14 years: AOR, 0.67; 95% CI, 0.67-0.75) and higher odds of cervical spine X-ray (≤14 years: AOR, 4.75; 95% CI, 3.55-6.36; >14 years: AOR, 4.50; 95% CI, 2.72-7.45) for all ages, but higher odds of cervical spine MRI for younger patients only (≤14 years: AOR, 2.10; 95% CI, 1.38-3.21).

CONCLUSION

Level I and pediatric designations were associated with lower rates of cervical spine CT. Pediatric centers were also more likely to use cervical spine X-ray. This variability of imaging use further supports the need to disseminate and educate providers on pediatric-specific cervical spine evaluation guidelines.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Imaging of pediatric cervical spine trauma

While pediatric cervical spine injuries (CSI) are rare, they are associated with high morbidity and mortality and sometimes require expeditious surgical management. In this article, we aim to improve the diagnostic accuracy of pediatric CSI by reviewing normal pediatric cervical anatomy, typical pediatric CSI patterns, and common mimics of pediatric CSI. A literature review was conducted on pediatric CSI, its epidemiology, and the various imaging manifestations and mimics. The most common pediatric CSI occur in the upper cervical spine owing to the higher fulcrum and larger head at a young age, namely prior to age 9 years, while lower CSI occur more frequently in patients older than 9 years. While various craniocervical measurements may be utilized to identify craniocervical disruption, soft tissue injuries may be the only manifestation, thus making pediatric CSI difficult to diagnose on initial imaging. In the acute setting, CT cervical spine is an appropriate initial imaging modality for pediatric CSI evaluation. MRI serves as an additional tool to exclude or identify injuries when initial findings are equivocal. It is essential to recognize the unique anatomy and biomechanics of the pediatric spine and thus discern common pediatric CSI patterns and their mimics.

Cervical spine evaluation in pediatric trauma: A cost-effectiveness analysis

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.

[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]

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.

Clinical clearance and imaging for possible cervical spine injury in children in the emergency department: A retrospective cohort study

OBJECTIVES

While cervical spine injuries (CSIs) are rare in the paediatric population, presentations to EDs with possible neck injuries are common. Based on a lack of Australian data we set out to determine how many possible injuries are clinically cleared, what imaging is used on the remainder and the incidence and characteristics of confirmed paediatric CSIs.

METHODS

We undertook a retrospective electronic medical record review of children <18 years with potential CSIs at a large tertiary paediatric trauma centre in Victoria, Australia over a 12 month period (annual census 87 000). For possible injuries we extracted key epidemiologic, imaging and short-term outcome data.

RESULTS

During the study period, a total of 617 patients with potential neck injuries were seen in the ED (617/87 000, 0.7%). The median age was 11 years. The most common mechanisms of injury were falls (41%), motor vehicle injuries (28%) and sports-related injuries (24%). Four hundred and fourteen of 617 (67%) underwent neck imaging (345/414, 83% plain radiograph; 100/414, 24% computed tomography; 7/414, 1.6% magnetic resonance imaging). Twenty-three of 617 (4.1%) had radiologically documented CSIs. Two required operative interventions for their neck injuries.

CONCLUSION

While two-thirds of children with potential CSIs undergo radiological evaluation, actual injuries are rare (<4%). These data suggest that there is a potential for improved targeting of cervical spine imaging for trauma. The development of a clinical decision tool may help reduce neck radiography.

Cervical Spine Injury Risk Factors in Children With Blunt Trauma

BACKGROUND

Adult prediction rules for cervical spine injury (CSI) exist; however, pediatric rules do not. Our objectives were to determine test accuracies of retrospectively identified CSI risk factors in a prospective pediatric cohort and compare them to a de novo risk model.

METHODS

We conducted a 4-center, prospective observational study of children 0 to 17 years old who experienced blunt trauma and underwent emergency medical services scene response, trauma evaluation, and/or cervical imaging. Emergency department providers recorded CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks, multivariable odds ratios, and test characteristics for the retrospective risk model and a de novo model.

RESULTS

Of 4091 enrolled children, 74 (1.8%) had CSIs. Fourteen factors had bivariable associations with CSIs: diving, axial load, clotheslining, loss of consciousness, neck pain, inability to move neck, altered mental status, signs of basilar skull fracture, torso injury, thoracic injury, intubation, respiratory distress, decreased oxygen saturation, and neurologic deficits. The retrospective model (high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury) was 90.5% (95% confidence interval: 83.9%-97.2%) sensitive and 45.6% (44.0%-47.1%) specific for CSIs. The de novo model (diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress) was 92.0% (85.7%-98.1%) sensitive and 50.3% (48.7%-51.8%) specific.

CONCLUSIONS

Our findings support previously identified pediatric CSI risk factors and prospective pediatric CSI prediction rule development.

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.

Cervical spine trauma evaluation

Cervical spine trauma is a relatively rare but catastrophic event in sports. These critical situations depend on sports medicine personnel understanding every aspect of sideline care to ensure a safe and successful evaluation. This involves thorough preparation, vigilant observation of the sporting event to detect the possible mechanism of injury, and initiation of the appropriate action plan when a potentially catastrophic injury is suspected. Sideline management of cervical spine trauma requires the appropriate primary survey, with spine stabilization if necessary, secondary survey for concomitant injury, and, potentially, initiation of full spine stabilization with a spine board. In this chapter, our primary focus is discussion of the sideline evaluation of cervical spine trauma, and sideline practices designed to stabilize the athlete and minimize risk for further injury.

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.

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.

Absent congenital cervical pedicle nearly misdiagnosed as a facet dislocation: A case report

Background

Cervical spinal injury encompasses up to 1.5% of all pediatric injuries. Children, and more specifically infants, are a difficult subset of patients to obtain neurological exam in the setting of trauma, thus necessitating the use of cervical X-rays, CT scans, and MRI imaging.

Case description

A healthy, 15-month-old boy had an unwitnessed fall down a flight of stairs and received a CT scan of the head and cervical spine in the emergency department due to cephalohematoma and mechanism of injury. The patient was initially diagnosed with a unilateral facet dislocation but after additional imaging and rigorous interdisciplinary discussions, the patient was correctly diagnosed with a congenitally absent left C5 pedicle. Surgical intervention was not pursued and the patient was discharged home with close follow up.

Conclusion

In the acute trauma setting, congenital absent cervical pedicle can be difficult to differentiate from unilateral facet dislocation and may require the use of advanced imaging and close communication between the neurosurgery and radiology departments. Given the high morbidity and mortality involved in the repair of facet dislocation in a child, it is crucial to maintain high degree of clinical suspicion for absent spinal pedicle. In this case, the patient nearly underwent surgical intervention, but was ultimately able to be discharged home with no symptoms or deficits after correct diagnosis.

Identification of Risk Factors for Cervical Spine Injury from Pediatric Trauma Registry

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.

Implementation of pediatric cervical spine clearance guidelines at a combined trauma center: Twelve-month impact

BACKGROUND

Pediatric cervical spine clearance guidelines should reduce computed tomography (CT) usage in combined pediatric and adult trauma centers biased by adult CT clearance.

METHODS

Cervical spine clearance under age 15 years was compared 12 months before (128 patients) and after (105 patients) guideline implementation, emphasizing National Emergency X-Radiography Utilization Study (NEXUS) criteria when appropriate.

RESULTS

CT scans in patients clearable by NEXUS criteria decreased 23% (p = 0.01) and decreased by 16% in cases where radiography other than CT was indicated by guidelines (p = 0.01).

CONCLUSION

Guideline implementation can have an immediate effect in decreasing pediatric cervical spine CT usage and should improve across time.

LEVEL OF EVIDENCE

Care management study, level IV.

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.

Estimation of normal computed tomography measurements for the upper cervical spine in the pediatric age group

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.

Nuances in pediatric trauma

Pediatric trauma evaluation mimics adult stabilization in that it is best accomplished with a focused and systematic approach. Attention to developmental differences, anatomic and physiologic nuances, and patterns of injury equip emergency physicians to stabilize and manage pediatric injury.

Variability of prehospital spinal immobilization in children at risk for cervical spine injury

OBJECTIVE

This study aimed to compare prehospital spinal immobilization techniques applied to age-based cohorts of children with and without cervical spine injury (CSI) after blunt trauma.

METHODS

We compared prehospital spinal immobilization in 3 age-based cohorts of children with blunt trauma-related CSI transported to 1 of 17 participating hospitals. We also compared children younger than 2 years with CSI with those at risk for but without CSI after blunt trauma. We identified patients through query of billing and radiology databases. We compared immobilization methods using Fisher's exact test for homogeneity.

RESULTS

We identified 16 children younger than 2 years, 78 children 2 to 7 years old, and 221 children 8 to 15 years old with CSI, and 66 children younger than 2 years without CSI. There were no significant differences in spinal immobilization techniques applied to children younger than 2 years old with and without CSI (P = 0.34). Of the 82 children younger than 2 years, 34 (41%) were fully immobilized in a cervical collar and rigid long board. There was a significant difference between spinal immobilization techniques applied to children with CSI younger than 2 years and 8 to 15 years old (P < 0.01). Six (38%) children with CSI younger than 2 years were fully immobilized versus 49 (63%) children 2 to 7 years old and 175 (79%) children 8 to 15 years old.

CONCLUSIONS

In this retrospective, observational study involving several emergency departments and Emergency Medical Services systems, we found that full spinal immobilization is inconsistently applied to children younger than 2 years after blunt trauma regardless of the presence of CSI. Full spinal immobilization is applied more consistently to older children with CSI.

Cervical spine evaluation in pediatric trauma

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.

Clinical Guidelines for Delayed or Prolonged Transport: III. Spine Injury

Conventional emergency medical services (EMS) guidelines recommend that essentially every victim of any significant trauma be treated in the field as having an unstable spine injury. For example, any victim of any motor vehicle crash generally is assumed to have an unstable spine injury and is transported to the hospital in full-spine immobilization. This approach generally is reasonable and appropriate for the conventional EMS context of rapid transport, because patient symptoms and physical examination often are unreliable for the time period immediately following the event.

The specialized context of delayed or prolonged transport, however, requires a closer look at assessment criteria and treatment procedures for spine injury. Full-spine immobilization, if it is not required, can be unnecessarily difficult, impractical, impossible, and even dangerous during prolonged evacuation, especially in severe environments or when using improvized equipment. Prolonged transport also provides an opportunity to repeat patient surveys and to observe changes in the patient's condition over time.

Utility of plain radiographs in detecting traumatic injuries of the cervical spine in children

OBJECTIVE

The objective of this study was to estimate the sensitivity of plain radiographs in identifying bony or ligamentous cervical spine injury in children.

METHODS

We identified a retrospective cohort of children younger than 16 years with blunt trauma-related bony or ligamentous cervical spine injury evaluated between 2000 and 2004 at 1 of 17 hospitals participating in the Pediatric Emergency Care Applied Research Network. We excluded children who had a single or undocumented number of radiographic views or one of the following injuries types: isolated spinal cord injury, spinal cord injury without radiographic abnormalities, or atlantoaxial rotary subluxation. Using consensus methods, study investigators reviewed the radiology reports and assigned a classification (definite, possible, or no cervical spine injury) as well as film adequacy. A pediatric neurosurgeon, blinded to the classification of the radiology reports, reviewed complete case histories and assigned final cervical spine injury type.

RESULTS

We identified 206 children who met inclusion criteria, of which 127 had definite and 41 had possible cervical spine injury identified by plain radiograph. Of the 186 children with adequate cervical spine radiographs, 168 had definite or possible cervical spine injury identified by plain radiograph for a sensitivity of 90% (95% confidence interval, 85%-94%). Cervical spine radiographs did not identify the following cervical spine injuries: fracture (15 children) and ligamentous injury alone (3 children). Nine children with normal cervical spine radiographs presented with 1 or more of the following: endotracheal intubation (4 children), altered mental status (5 children), or focal neurologic findings (5 children).

CONCLUSIONS

Plain radiographs had a high sensitivity for cervical spine injury in our pediatric cohort.

Clinical prediction rules for children: a systematic review

CONTEXT

The degree to which clinical prediction rules (CPRs) for children meet published standards is unclear.

OBJECTIVE

To systematically review the quality, performance, and validation of published CPRs for children, compare them with adult CPRs, and suggest pediatric-specific changes to CPR methodology.

METHODS

Medline was searched from 1950 to 2011. Studies were selected if they included the development of a CPR involving children younger than 18 years. Two investigators assessed study quality, rule performance, and rule validation as methodologic standards.

RESULTS

Of 7298 titles and abstracts assessed, 137 eligible studies were identified. They describe the development of 101 CPRs addressing 36 pediatric conditions. Quality standards met in fewer than half of the studies were blind assessment of predictors (47%), reproducibility of predictors (18%), blind assessment of outcomes (42%), adequate follow-up of outcomes (36%), adequate power (43%), adequate reporting of results (49%), and 95% confidence intervals reported (36%). For rule performance, 48% had a sensitivity greater than 0.95, and 43% had a negative likelihood ratio less than 0.1. For rule validation, 76% had no validation, 17% had narrow validation, 8% had broad validation, and none had impact analysis performed. Compared with CPRs for adult health conditions, quality and rule validation seem to be lower.

CONCLUSIONS

Many CPRs have been derived for children, but few have been validated. Relative to adult CPRs, several quality indicators demonstrated weaknesses. Existing performance standards may prove elusive for CPRs that involve children. CPRs for children that are more assistive and less directive and include patients' values and preferences in decision-making may be helpful.

Variation in the self-reported use of computed tomography in clearing the cervical spine of pediatric trauma patients

OBJECTIVE

Cervical spine injury (CSI) in children can be life-threatening or associated with lifelong disabilities. Whereas screening computed tomography (CT) of the cervical spine is used in the evaluation of adult trauma patients, it has no additional benefit in children when compared with plain film radiography of the cervical spine. Despite this, CT use in the pediatric patient is increasing. We sought to compare the self-reported utilization of screening cervical spine CT among pediatric emergency medicine (PEM) physicians and general emergency medicine (non-PEM) physicians.

METHODS

Physicians completed an online survey consisting of a clinical vignette in which the respondents chose to evaluate a pediatric trauma patient for CSI using no imaging, plain films, or CT. Questions regarding the physician's attitudes, knowledge, and practice patterns for pediatric CSI were included.

RESULTS

Six hundred fifty-four physicians responded to the survey: 463 (70.8%) non-PEM and 191 (29.2%) PEM physicians. Both groups ordered radiographic imaging at a similar rate, although non-PEM physicians were 4 times more likely to utilize CT than PEM practitioners. Non-PEM physicians were more likely to overestimate the frequency of pediatric CSI. Pediatric emergency medicine physicians were more likely to state that they would never use CT as the initial modality for CSI screening.

CONCLUSIONS

In response to a clinical vignette, non-PEM physicians were more likely to self-report the use of screening CT in pediatric trauma patients than PEM physicians.

Unilateral cervical facet dislocation in a 9-year-old boy

Facet dislocations in children are rare. This article presents the youngest case of a unilateral facet dislocation described in the pediatric population. A 9-year-old boy sustained a flexion/axial loading injury to his cervical spine while wrestling with his friends, causing a unilateral facet dislocation at C4/5. Prereduction magnetic resonance imaging (MRI) demonstrated the absence of a diskal herniation or cord impingement and an intact posterior ligamentous complex. Due to the patient's young age, the decision was made to forgo a supervised awake closed reduction. Closed reduction was performed under general anesthesia with somatosensory-evoked potential and motor-evoked potential monitoring. Closed reduction was successfully achieved after Gardner-Wells tongs were applied and used to manually direct slow, steady in-line traction, along with slight flexion and posterior rotation of the dislocated side under direct fluoroscopy. The patient was immediately awakened from anesthesia and was found to have an intact sensory examination. He was immobilized in a cervical collar for 12 weeks. At 2-year follow-up, he remained asymptomatic without recurrence and had painless full range of motion of the cervical spine. Radiographs revealed a normally aligned cervical spine. Unilateral cervical facet dislocations and subluxations are the result of a distractionflexion force applied to the spine along with a rotational component. These are not uncommon injuries in the adult spine; however, in the young pediatric population, cervical facet dislocations are rare.

Current issues in the diagnosis of pediatric cervical spine injury

Cervical spine injury in pediatric trauma occurs rarely; however, there is significant potential for considerable morbidity when it does occur. Screening for cervical spine injuries has been shown to be most sensitive in adult trauma centers when combined with reliable physical examination findings. Because pediatric trauma patients suffer from a different range of injuries than adults, and often are not reliable due to age limitations or associated head injury, the same strategies employed in adult trauma do not always hold true in children. We look at the differences in adult and pediatric cervical spine anatomy and traumatic mechanisms, as well as the differences between cervical spine injury in infants/children and adolescents/teens. In addition, we examine the literature currently available in each population and derive consensuses on the issues that are important in managing the pediatric cervical spine. We hope to provide a framework that trauma centers can use to develop safe and effective cervical spine clearance protocols.

Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age

OBJECT

Cervical spine clearance after trauma in children 0-3 years of age is deceptively difficult. Young children may not be able to communicate effectively, and severe injuries may require intubation and sedation. Currently, no published guidelines are available to aid in decision-making in these complex situations. The purpose of this study was to determine whether a safe and effective protocol-driven system could be developed for clearance of the cervical spine in noncommunicative children between 0 and 3 years of age.

METHODS

Children 0-3 years of age, including intubated patients, who were admitted after trauma activation at Primary Children's Medical Center in Salt Lake City or the Children's Hospital of New York from 2002 to 2006 were managed according to a cervical spine clearance protocol. Data were collected in a prospective fashion. Radiographic and clinical methods of clearing the cervical spine, as well as the type and management of injuries, were recorded.

RESULTS

A total of 2828 pediatric trauma activations required cervical spine clearance during the study period. Of these, 575 (20%) were children <or= 3 years of age who were admitted to the hospital. To facilitate clearing the cervical spine in these children, plain radiographs (100%), CT studies (14%), and MR images (10%) were obtained. Nineteen ligamentous injuries (3.3%) and 9 fractures/dislocations (1.5%) were detected, with 4 patients requiring operative stabilization (0.7%). No late injuries have been detected.

CONCLUSIONS

The protocol used has been effective in detecting cervical spine injuries in noncommunicative children after trauma. The combination of clinical information and radiographic studies is essential for safely clearing the cervical spine in these complex situations. Clearance of the cervical spine without CT or MR imaging studies is possible in the majority of cases, even in very young patients.

`Clearing' the cervical spine in conscious trauma patients

This is a systematic review of published evidence regarding management of the cervical spine in conscious and co-operative trauma patients. We examine the literature in the following sections: clinical evaluation of the cervical spine; use of plain radiography; use of additional radiographic views; use of computed tomography; use of magnetic resonance imaging. Finally we consider the elderly and paediatric populations, particularly where there are significant differences compared to the general adult population. This paper also reviews the literature regarding non-medical assessment of the cervical spine. We conclude that there are well-validated decision rules available to guide the clinician, and that each imaging strategy has distinct advantages and disadvantages. Familiarity with these issues provides a sound basis for safe and effective decision-making.

Pediatric cervical spine trauma imaging: a practical approach

Cervical spine trauma in children is rare and the diagnosis can be challenging due to anatomical and biomechanical differences as compared to adults. A variety of algorithms have been used in adults to accurately diagnose injuries, but have not been fully studied in pediatric patients. In this article we review suggested imaging protocols and the general characteristics, types of injuries, and measurements used to diagnose cervical spine injuries in children.

Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

STUDY DESIGN

Best evidence synthesis.

OBJECTIVE

To critically appraise and synthesize the literature on assessment of neck pain.

SUMMARY OF BACKGROUND DATA

The published literature on assessment of neck pain is large and of variable quality. There have been no prior systematic reviews of this literature.

METHODS

The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders conducted a critical review of the literature (published 1980-2006) on assessment tools and screening protocols for traumatic and nontraumatic neck pain.

RESULTS

We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain.

CONCLUSION

The scientific evidence supports screening protocols in emergency care for low-risk patients; and CT-scans for high-risk patients with blunt trauma to the neck. In nonemergency neck pain without radiculopathy, the validity of most commonly used objective tests is lacking. There is support for subjective self-report assessment in monitoring patients' course, response to treatment, and in clinical research.

Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

STUDY DESIGN

Best evidence synthesis.

OBJECTIVE

To critically appraise and synthesize the literature on assessment of neck pain.

SUMMARY OF BACKGROUND DATA

The published literature on assessment of neck pain is large and of variable quality. There have been no prior systematic reviews of this literature.

METHODS

The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders conducted a critical review of the literature (published 1980-2006) on assessment tools and screening protocols for traumatic and nontraumatic neck pain.

RESULTS

We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain.

CONCLUSION

The scientific evidence supports screening protocols in emergency care for low-risk patients; and CT-scans for high-risk patients with blunt trauma to the neck. In nonemergency neck pain without radiculopathy, the validity of most commonly used objective tests is lacking. There is support for subjective self-report assessment in monitoring patients' course, response to treatment, and in clinical research.

Effect of emergency department care on outcomes in pediatric trauma: what approaches make a difference in quality of care?

Deriving evidence-based best practice for each phase or setting of trauma care is necessary to maximize best outcomes. There is a paucity of studies examining the association of provider training on pediatric trauma outcomes. Pivotal decisions (whether and where to transfer, diagnostic workup, and initial resuscitation) occur in this setting, yet there is little evidence relating to best practices in those areas. Classic process-performance measures such as time intervals during care (e.g., time to computerized tomography scan, time to operating room, etc.) or utilization measures (American College of Surgeons designation) are commonly used in the trauma center certification process, yet process-outcome links relevant to children are lacking. Although great advances have been made in the trauma care delivered to children, scientific proof is lacking and much more needs to be done to establish the evidence-based need to deliver the highest quality of pediatric trauma care.

Imaging of cervical spine injuries of childhood

Cervical spine injuries of children, though rare, have a high morbidity and mortality. The pediatric cervical spine is anatomically and biomechanically different from that of adults. Hence, the type, level and outcome of cervical spine injuries in children are different from those seen in adults. Normal developmental variants seen in children can make evaluation of the pediatric cervical spine challenging. This article reviews the epidemiology of pediatric cervical spine trauma, normal variants seen in children and specific injuries that are more common in the pediatric population. We also propose an evidence-based imaging protocol to avoid unnecessary imaging studies and minimize radiation exposure in children.

Cervical spine clearance after trauma in children

OBJECT

Currently, no diagnostic or procedural standards exist for clearing the cervical spine in children after trauma. The establishment of protocols has been shown to reduce the time required to accomplish clearance and reduce the number of missed injuries. The purpose of this study was to determine if reeducation and initiation of a new protocol based on the National Emergency X-Radiography Utilization Study criteria could safely increase the number of pediatric cervical spines cleared by nonneurosurgical personnel.

METHODS

The authors collected and reviewed data regarding cervical spine clearance in children (age range 0-18 years) who presented to the emergency department at Primary Children's Medical Center in Salt Lake City, Utah, between 2001 and 2006 after sustaining significant trauma. Radiographic and clinical methods of clearing the cervical spine, as well as the type and management of injuries, were determined for two periods: Period I (January 2001-December 2003) and Period II (January 2004-February 2006). Between 2001 and 2003, 95% of 936 cervical spines were cleared by the neurosurgical service. Twenty-one ligamentous injuries (2.2%) and 12 fracture/dislocations (1.3%) were detected, and five patients (0.5%) required operative stabilization. Since January 2004, 585 (62.4%) of 937 cervical spines have been cleared by nonneurosurgical personnel. Twelve ligamentous injuries (1.3%) and 14 fracture/dislocations (1.5%) were identified, and four patients (0.4%) required operative stabilization. No late injuries were detected in either time period.

CONCLUSIONS

The protocol outlined in the paper has been effective in detecting cervical spine injuries in children after trauma and has increased the number of cervical spines cleared by nonneurosurgical personnel by nearly 60%. Reeducation with the establishment of protocols can safely facilitate clearance of the cervical spine after trauma by nonneurosurgical personnel.