A prospective multicenter study of cervical spine injury in children

PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study

BACKGROUND

Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department.

METHODS

In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330.

FINDINGS

Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays.

INTERPRETATION

Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments.

FUNDING

The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Pediatric neck pain of a 10-year-old child with cervical spinal tumor evaluated and managed in direct access physical therapy: a case report

INTRODUCTION

Differential diagnosis of pediatric neck pain requires age-appropriate communication and assessment tools. Recognizing these age-related nuances is critical, emphasizing the role of physical therapists in assessing and managing pediatric patients while ruling out severe pathologies.

CASE DESCRIPTION

A 10-year-old male presented to physical therapy with a five-week history of increasing neck pain. A thorough history and segmental cervical examination considering the patient's age and development, led to patient referral to the emergency department. This case underscores the significance of comprehensive evaluation in pediatric neck pain management.

OUTCOMES

The patient was diagnosed with Langerhans Cell Histiocytosis (LCH). LCH primarily affects children and is treated with chemotherapy. Chemotherapy reduced the tumor, revealing C2 vertebral body damage. The patient underwent C1-C3 fusion surgery, a standard procedure for atlanto-occipital region stabilization in children. The patient was advised to restrict motion for 6 months while monitoring for tumor growth.

DISCUSSION-CONCLUSION

Pediatric neck cancer presents diagnostic challenges due to varied symptoms, but research highlights specific indicators to assist with differential diagnosis. This case emphasizes the need to recognize the complexities of pediatric neck pain and perform a thorough age-appropriate evaluation.

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.

Diagnostic Excellence in Pediatric Spine Imaging: Using Contextualized Imaging Protocols

Contextual design and selection of MRI protocols is critical for making an accurate diagnosis given the wide variety of clinical indications for spine imaging in children. Here, we describe our pediatric spine imaging protocols in detail, tailored to specific clinical questions.

Pediatric cervical spine clearance: A 10-year evaluation of multidetector computed tomography at a level 1 pediatric trauma center

INTRODUCTION

Efficient and accurate evaluation of the pediatric cervical spine (c-spine) for both injury identification and posttraumatic clearance remains a challenge. We aimed to determine the sensitivity of multidetector computed tomography (MDCT) for identification of cervical spine injuries (CSIs) in pediatric blunt trauma patients.

METHODS

A retrospective cohort study was conducted at a level 1 pediatric trauma center from 2012 to 2021. All pediatric trauma patients age younger than 18 years who underwent c-spine imaging (plain radiograph, MDCT, and/or magnetic resonance imaging [MRI]) were included. All patients with abnormal MRIs but normal MDCTs were reviewed by a pediatric spine surgeon to assess specific injury characteristics.

RESULTS

A total of 4,477 patients underwent c-spine imaging, and 60 (1.3%) were diagnosed with a clinically significant CSI that required surgery or a halo. These patients were older, more likely to be intubated, have a Glasgow Coma Scale score of <14, and more likely to be transferred in from a referring hospital. One patient with a fracture on radiography and neurologic symptoms got an MRI and no MDCT before operative repair. All other patients who underwent surgery including halo placement for a clinically significant CSI had their injury diagnosed by MDCT, representing a sensitivity of 100%. There were 17 patients with abnormal MRIs and normal MDCTs; none underwent surgery or halo placement. Imaging from these patients was reviewed by a pediatric spine surgeon, and no unstable injuries were identified.

CONCLUSION

Multidetector computed tomography appears to have 100% sensitivity for detecting clinically significant CSIs in pediatric trauma patients, regardless of age or mental status. Forthcoming prospective data will be useful to confirm these results and inform recommendations for whether pediatric c-spine clearance can be safely performed based on the results of a normal MDCT alone.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

A Pediatric Cervical Spine Clearance Guideline Leads to Fewer Unnecessary Computed Tomography Scans and Decreased Radiation Exposure

OBJECTIVES

Physical examination and computed tomography (CT) are useful to rule out cervical spine injury (CSI). Computed tomography scans increase lifetime cancer risk in children from radiation exposure. Most CSI in children occur between the occiput and C4. We developed a cervical spine (C-spine) clearance guideline to reduce unnecessary CTs and radiation exposure in pediatric trauma patients.

METHODS

A pediatric C-spine clearance guideline was implemented in September 2018 at our Level 2 Pediatric Trauma Center. Guidance included CT of C1 to C4 to scan only high-yield regions versus the entire C-spine and decrease radiation dose. A retrospective cohort study was conducted comparing preguideline and postguideline of all pediatric trauma patients younger than 8 years screened for CSI from July 2017 to December 2020. Primary endpoints included the following: number of full C-spine and C1 to C4 CT scans and radiation dose. Secondary endpoints were CSI rate and missed CSI. Results were compared using χ 2 and Wilcoxon rank-sum test with P < 0.05 significant.

RESULTS

The review identified 726 patients: 273 preguideline and 453 postguideline. A similar rate of total C-spine CTs were done in both groups (23.1% vs 23.4%, P = 0.92). Full C-spine CTs were more common preguideline (22.7% vs 11.9%, P < 0.001), whereas C1 to C4 CT scans were more common post-guideline (11.5% vs 0.4%, P < 0.001). Magnetic resonance imaging utilization and CSIs identified were similar in both groups. The average radiation dose was lower postguideline (114 vs 265 mGy·cm -1 ; P < 0.001). There were no missed CSI.

CONCLUSIONS

A pediatric C-spine clearance guideline led to increasing CT of C1 to C4 over full C-spine imaging, reducing the radiation dose in children.

LEVEL OF EVIDENCE

Level IV, therapeutic.

The Fate of the Cervical Collar: An Observational Pilot Study Investigating Follow-up Care After Emergency Department Discharge in Children With Mild Traumatic Neck Injuries

OBJECTIVES

After evaluation and treatment of minor traumatic cervical spine injury (CSI), many children are discharged home in a rigid cervical orthosis (RCO). This study investigated their adherence to RCO treatment recommendations. The feasibility of telehealth cervical spine clearance was also explored.

METHODS

This was a prospective observational study of children 3 to 18 years old with mild CSI evaluated at a level I pediatric trauma center from December 1, 2019, through July 31, 2021. Before emergency department discharge, patients received RCO use instructions and recommendation for follow-up with in-person neurosurgery clinic visit, neurosurgery telehealth visit, or in-person primary care provider visit. The family was responsible for arranging follow-up. Primary outcomes included compliance with follow-up and collar use.

RESULTS

Ninety-eight children (mean age, 11.3 ± 4.1 years) were included. Overall, follow-up contact was available for 51 patients (52%). At 1-week follow-up with 36 children, 64% were collar compliant, 13 had no pain (38% remained in RCO), 14 had mild pain without limitations, 8 had pain with some limitations, and 1 had significant pain. At 2-week follow-up with 31 children, 9 (29%) were collar compliant, 23 had no pain, 7 had mild pain without limitations, and 1 with significant persistent pain was found to have an odontoid fracture requiring C1-2 fusion. Patients/families often discontinued the use of the collar without follow-up (47%). Approximately half utilized a recommended clinical follow-up option for clearance, most often in neurosurgery clinic or using a neurosurgery telehealth visit. The mean time to follow-up was 11.34 ± 4.9 days (range, 3-25 days), and mean collar compliance lasted 9.8 ± 5.7 days (range, 1-25 days). No child experienced any short-term complications related to RCO use.

CONCLUSIONS

In this pilot study, a substantial portion of children with mild CSIs discharged from the emergency department with an RCO did not adhere to compliance or follow-up recommendations. Persistent pain requires further evaluation.

Can you see with CT? Is cervical spine computed tomographic imaging sufficient in pediatric trauma?

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.

Spine Bracing: When to Utilize-A Narrative Review

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.

Pediatric spinal injuries- current concepts

Spinal injuries in children contribute to the highest mortality and morbidity among all pediatric injuries. Fortunately, these injuries are a rare clinical entity but pose a difficulty in diagnosis due to challenges in neurological evaluation of a child and varied radiological presentation. Anatomical and biomechanical aspects of developing musculoskeletal system, relative plasticity of the pediatric spine make children vulnerable to spine injuries. Though motor vehicle collisions are common, children also suffer non-accidental trauma, falls and sports injuries. More chances of cervical spine involvement, higher susceptibility of spinal cord to tensile forces and associated multisystem injuries result in devastating consequences in children compared to adults. Injuries like SCIWORA, vertebral apophyseal injuries, birth-related spinal cord injuries are more specific injuries in pediatric age group. A vigilant clinical, neurological and radiological evaluation is mandatory in all children with suspected spinal injuries. Normal radiological features like ossification centers, pseudosubluxation and physiological vertebral wedging should be carefully noted as they could be misinterpreted as injuries. While CT scans help in better understanding of the fracture pattern, Magnetic Resonance Imaging in children is beneficial especially in detecting SCIWORA and other soft tissue injuries. Management principles of these pediatric spinal injuries are similar to adults. Literature evidences support conservative management in injuries like SCIWORA, unless there is an ongoing spinal cord compression. As in adults, the role of high dose methylprednisolone is still controversial in pediatric spinal cord injuries. Stable spinal injuries can be managed conservatively using orthosis or halo. Instrumentation by both anterior and posterior techniques has been described, but it is challenging due to smaller anatomy and poor implant purchase. In addition to pedicle screw instrumentation, wiring techniques are very beneficial especially in younger children.

Cervical Spine Computed Tomography in Adolescent Blunt Trauma Patients: Are They Being Overutilized?

INTRODUCTION

Cervical spine computed tomography (CSCT) scans are used to evaluate cervical spine traumatic injuries; however, recent evidence demonstrates that adult trauma centers (ATCs) overutilize CSCT when evaluating adolescent patients. This leads to unnecessary radiation exposure. The aim of this study is to review a level 1 ATC's use of CSCT in the adolescent blunt trauma population.

METHODS

A retrospective chart review was conducted of a level 1 ATC's trauma database. Blunt trauma patients between the ages of 11 and 18 who receive a CSCT between January 2015 to December 2019 were included. The primary outcome was the prevalence of positive findings on CSCT scans. Data were analyzed using Fischer-Exact analysis and multivariate logistic regression where appropriate.

RESULTS

Three-hundred thirty-seven of 546 (61.7%) adolescent blunt trauma patients received CSCT. Of those, 68.2% (230) were male; the mean age was 16.6 ± 1.0 y old. Twenty-eight patients (8.3%) had a positive finding on CSCT. All patients with a positive CSCT failed the National Emergency X-Radiography Utilization study (NEXUS) criteria while 123 patients (36.5%) with a negative CSCT met NEXUS criteria.

CONCLUSIONS

CSCT was overutilized in our trauma center. There is a low positive CSCT scan rate among adolescent patients, which aligns with the current literature. All patients with positive CSCT passed NEXUS criteria suggesting that a quality improvement project focusing on the use of the NEXUS criteria to assess the risk of cervical spine injury could potentially reduce the use of CSCT scans by nearly 40%.

Implementation of National Emergency X-Radiography Utilization Study (NEXUS) Criteria in Pediatrics: A Systematic Review

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.

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.

The Initial Approach to the Multisystem Pediatric Trauma Patient

ABSTRACT

Trauma remains the leading cause of morbidity and mortality in children and youth 1 to 19 years old in the United States. Providing timely care with a systematic approach is essential for emergently addressing life-threatening injuries and ongoing assessment. The primary survey is focused on identifying and managing life-threatening injuries. The secondary survey is focused on identifying and managing other important injuries. Over the past decade, there have been important advances in the evidence supporting the management of multisystem trauma in the pediatric patient by the emergency medicine clinician. In addition, the emergence of diagnostics, such as point-of-care ultrasound, aids decision making in the evaluation and management of the pediatric trauma patient. The purpose of this article is to review the initial systematic diagnostic approach and the emergent management of multisystem injuries from blunt force trauma in children in the emergency department and provide insight into the aspects of care that are still evolving.

Pediatric Spine Trauma

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.

Assessment of cervical spine CT scans by emergency physicians: A comparative diagnostic accuracy study in a non-clinical setting

OBJECTIVES

To determine and compare the diagnostic accuracy of assessing injuries on cervical spine computed tomography (CT) scans by trained emergency physicians and radiologists, both in a non-clinical setting.

METHODS

In this comparative diagnostic accuracy study, 411 cervical spine CT scans, of which 120 contained injuries (fractures and/or dislocations), were divided into 8 subsets. Eight emergency physicians received focused training and assessed 1 subset each before and after training. Four radiologists assessed 2 subsets each. Diagnostic accuracy between both groups was compared. The reference standard used was a multiverified data set, assessed by radiologists, neurosurgeons, and emergency physicians. The neurosurgeons also classified whether an "injury in need of stabilizing therapy" (IST) was present.

RESULTS

Posttraining, the emergency physicians demonstrated increased sensitivity and specificity for identifying cervical spine injuries compared to pretraining: sensitivity 88% (95% confidence interval [CI] 80% to 93%) versus 80% (95% CI 72% to 87%) and specificity 89% (95% CI 85% to 93%) versus 86% (95% CI 81% to 89%). When comparing the trained emergency physicians to the group of radiologists, no difference in sensitivity was found, 88% (95% CI 80% to 83%); however, the radiologists showed a significantly higher specificity (P < 0.01): 99% (95% CI 96% to 100%). In the 12% (15 scans) with missed injuries, emergency physicians missed more ISTs than radiologists, 6 versus 4 scans; however, this difference was not significant (P = 0.45).

CONCLUSION

After focused training and in a non-clinical setting, no significant difference was found between emergency physicians and radiologists in ruling out cervical spine injuries; however, the radiologists achieved a significantly higher specificity.

Helmets Protect Pediatric Bicyclists From Head Injury and Do Not Increase Risk of Cervical Spine Injury

OBJECTIVES

Only 21 states have mandatory helmet laws for pediatric bicyclists. This study sought to determine the incidence of helmeted riders among pediatric bicyclists involved in a collision and hypothesized the risk of a serious head and cervical spine injuries to be higher in nonhelmeted bicyclists (NHBs) compared with helmeted bicyclists (HBs).

METHODS

The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for pediatric (age <16 years) bicyclists involved in a collision. Helmeted bicyclists were compared with NHBs. A serious injury was defined by an abbreviated injury scale grade of greater than 2.

RESULTS

From 3693 bicyclists, 3039 (82.3%) were NHBs. Compared with HBs, NHBs were more often Black (21.6% vs 3.8%, P < 0.001), Hispanic (17.5% vs 9.3%, P < 0.001), without insurance (4.6% vs 2.4%, P = 0.012), and had a higher rate of a serious head injury (24.6% vs 9.3%, P < 0.001). Both groups had similar rates of complications and mortality (P > 0.05). The associated risk of a serious head (odds ratio = 3.17, P < 0.001) and spine injury (odds ratio = 0.41, P = 0.012) were higher and lower respectively in NHBs. Associated risks for cervical spine fracture or cord injury were similar (P > 0.05).

CONCLUSIONS

Pediatric bicyclists involved in a collision infrequently wear helmets, and NHBs was associated with higher risks of serious head injury. However, the associated risk of serious spine injury among NHBs was lower. The associated risks for cervical spine fracture or cervical cord injuries were similar. Nonhelmeted bicyclists were more likely to lack insurance and to be Black or Hispanic. Targeted outreach programs may help decrease the risk of injury, especially in at-risk demographics.

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.

Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort

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.

Pediatric Cervical Spine Clearance and Immobilization Practice Among Prehospital Emergency Medical Providers: A Statewide Survey

OBJECTIVES

Pediatric cervical spine injuries are rare but potentially life threatening. Although published guidelines for assessment of such injuries exist, there is less uniformity in its implementation in out-of-hospital settings. Our purpose was to assess the knowledge and practice patterns for pediatric cervical spine immobilization among prehospital emergency medical services (EMS) providers in Arizona.

METHODS

A cross-sectional web-based survey was conducted (October-December 2018), using an electronic mailing list of certified EMS providers (ground and air) in Arizona. A 20-question structured web-based survey was developed and deployed.

RESULTS

One hundred eight EMS stations were contacted with the survey. Sixty-eight providers responded; majority were emergency medical paramedics (73.1%). Most of the stations surveyed did not have a pediatric trauma center (66.2%). When treating children younger than 3 years, half of the respondents stated they did not know of a specific cervical spine clearance criterion; 59.3% felt that cervical spine immobilization was required "sometimes," and 40.0% were unaware of the state's EMS pediatric cervical spine clearance algorithm; 93.9% of EMS providers felt that an age-based algorithm for cervical spine clearance in children would be useful.

CONCLUSIONS

In this statewide survey involving prehospital EMS providers, we found that pediatric cervical spine clearance and immobilization practices, even within a specific geographic location, remain inconsistent.

Neck Trauma: Cervical Spine, Seatbelt Sign, and Penetrating Palate Injuries

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.

Prehospital Factors Associated With Cervical Spine Injury in Pediatric Blunt Trauma Patients

BACKGROUND

The risk for cervical spine injury (CSI) must be assessed in children who sustain blunt trauma. The Pediatric Emergency Care Applied Research Network (PECARN) retrospectively derived CSI model identifies CSI risk in children based on emergency department (ED) provider observations. The objective of this pilot study was to determine the univariate association of emergency medical services (EMS) provider-observed historical, mechanistic, and physical examination factors with CSI in injured children. Secondarily, we assessed the performance of the previously identified eight PECARN CSI risk factors (PECARN model) based exclusively on EMS provider observation.

METHODS

We conducted a four-center, prospective observational study of children 0 to 17 years old who were transported by EMS after blunt trauma and underwent spinal motion restriction or trauma team activation in the ED. In the ED, EMS providers recorded their observations for a priori determined CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks and test characteristics for the PECARN model based solely on EMS provider observations.

RESULTS

Of 1,372 enrolled children, 25 (1.8%) had CSIs. Of the a priori determined CSI risk factors, seven factors had bivariable associations with CSIs: axial load, altered mental status, signs of basilar skull fracture, substantial torso injury, substantial thoracic injury, respiratory distress, and decreased oxygen saturation. The PECARN model (high-risk motor vehicle collision, diving mechanism, predisposing condition, neck pain, decreased neck mobility, altered mental status, neurologic deficits, and/or substantial torso injury) exhibited the following test characteristics when based on EMS provider observations: sensitivity = 96.0% (95% confidence interval [CI] = 88.3% to 100.0%); negative predictive value = 99.8% (95% CI = 99.4% to 100.0%); specificity = 38.5% (95% CI = 35.9% to 41.1%); and positive predictive value = 2.8% (95% CI = 1.7% to 3.9%).

CONCLUSION

EMS providers can identify risk factors associated with CSI in injured children who experience blunt trauma. These risk factors may be considered for inclusion in a pediatric CSI decision rule specific to the prehospital setting.

Pediatric cervical spine injury in the United States: Defining the burden of injury, need for operative intervention, and disparities in imaging across trauma centers

BACKGROUND

Pediatric cervical spine injury (PCSI) in children is rare. Incidence of PCSI requiring intervention is not known, and imaging practices for screening in United States trauma centers are not well described.

METHODS

The 2016 NTDB was queried for patients younger than 15 years with PCSI. Incidence of PCSI, operative interventions, and imaging rates were analyzed by age and ACS accreditation status.

RESULTS

Of 84,554 children, 873 (1.03%) had PCSI. Patients <4 years were less likely to have PCSI (0.68% vs. 1.1%, RR 0.59, p < 0.001). 165 children (0.20%) required an intervention for PCSI. 12.8% of all children were screened for PCSI with imaging, 9.3% with CT, and 3.2% with plain X-rays. In spite of similar injury and intervention rates, stand-alone pediatric trauma centers were less likely than others to image patients without PCSI (11% vs. 13% p < 0.001), less likely to utilize CT scan (5.8% vs. 10.6% p < 0.001) and more likely to utilize plain films (5.2% vs. 2.4% p < 0.001).

CONCLUSION

Despite exceedingly low rates of PSCI requiring intervention (0.2%), imaging rates for screening are significant. Stand-alone pediatric trauma centers outperform others in limiting unnecessary imaging.

LEVEL OF EVIDENCE

IV.

C-spine clearance in poly-trauma patients: A narrative review

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.

Pediatric Spine Trauma: A Brief Review

Pediatric spinal trauma is a broad topic with nuances specific to each anatomic region of the spinal column. The purpose of this report is to provide a brief review highlighting the most important and common clinical issues regarding the diagnosis and management of pediatric spine trauma. Detailed descriptions of imaging findings along with specific operative and nonoperative management of each fracture and dislocation type are beyond the scope of this review.

Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel

Background

Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments.

Objective

To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments.

Eligibility criteria

All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms.

Sources of evidence

PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles.

Charting methods

Evidence was searched according to clinically relevant topics and PICO questions.

Results

Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland.

Conclusions

Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.

Increased and unjustified CT usage in paediatric C-spine clearance in a level 2 trauma centre

PURPOSE

Cervical spine injury after blunt trauma in children is rare but can have severe consequences. Clear protocols for diagnostic workup are, therefore, needed, but currently not available. As a step in developing such a protocol, we determined the incidence of cervical spine injury and the degree of protocol adherence at our level 2 trauma centre.

METHODS

We analysed data from all patients aged < 16 years suspected of cervical spine injury after blunt trauma who had presented to our hospital during two periods: January 2010 to June 2012, and January 2017 to June 2019. In the intervening period, the imaging protocol for diagnostic workup was updated. Outcomes were the incidence of cervical spine injury and protocol adherence in terms of the indication for imaging and the type of imaging.

RESULTS

We included 170 children in the first study period and 83 in the second. One patient was diagnosed with cervical spine injury. Protocol adherence regarding the indication for imaging was > 80% in both periods. Adherence regarding the imaging type decreased over time, with 45.8% of the patients receiving a primary CT scan in the second study period versus 2.9% in the first.

CONCLUSION

Radiographic imaging is frequently performed when clearing the paediatric cervical spine, although cervical spine injury is rare. Particularly CT scan usage has wrongly been emerging over time. Stricter adherence to current protocols could limit overuse of radiographic imaging, but ultimately there is a need for an accurate rule predicting which children really are at risk of injury.

Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial

BACKGROUND

Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study.

OBJECTIVE

This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED.

METHODS

We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study.

RESULTS

Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario.

CONCLUSIONS

We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year).

TRIAL REGISTRATION

ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/16966.

Cervical spine clearance in unconscious pediatric trauma patients: a level l trauma center experience

PURPOSE

To radiographically assess cervical spine clearance in unconscious pediatric trauma patients.

METHODS

A retrospective cohort study was conducted to review pediatric patients with suspected cervical spinal injuries between 2005 and 2018 at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. All pediatric patients aged 15 years and less, who sustained trauma (motor vehicle accident, pedestrian, fall, all-terrain vehicle accident, and sports injures) and were intubated at the scene or in the emergency department, were included.

RESULTS

A total of 62 patients were included. The average age for children was 8 ± 3.9 years. The average Glasgow coma scale (GCS) for children at initial trauma was 7.6 + 3.7. The average injury severity score (ISS) was 24.1 + 17.7. The most frequent abnormal finding identified on CT scan was cervical spine straightening (N = 8; 13.1%). A total of 13 children had abnormal MRI findings, with the most common injury being ligamentous in nature (N = 13; 46.42%). The sensitivity and specificity of CT scan in cervical spine clearance in unconscious children are 84.8% and 100%, respectively.

CONCLUSION

Utilizing CT scans in clearing the cervical spine is of paramount importance to promptly detect possible injuries. The role of MRI in cervical spine clearance still cannot be undervalued, especially when the clinical suspicion for injury is high.

[Pediatric spine trauma-Results of a German national multicenter study including 367 patients]

BACKGROUND

In general, pediatric spinal injuries are rare. No reliable data on the epidemiology of spinal injuries in pediatric patients in Germany are available. Especially in pediatric patients, for whom the medical history, clinical examination and the performance of imaging diagnostics are difficult to obtain, all available information on a spinal injury must be taken into account.

OBJECTIVE

The aim of this study was to provide epidemiological data for pediatric patients with spinal trauma in Germany in order to enhance future decision-making for the diagnostics and treatment of these patients.

MATERIAL AND METHODS

Within the framework of a national multicenter study, data were retrospectively obtained from 6 German spine centers for 7 years between January 2010 and December 2016. In addition to the demographic data, the clinical databases were screened for specific trauma mechanisms, level of injury as well as accompanying injuries. Furthermore, diagnostic imaging and the treatment selected were also analyzed.

RESULTS

A total of 367 children (female: male = 1:1.2) with a total of 610 spinal injuries were included in this study. The mean age was 12 years (±3.5 years). The most frequent trauma mechanisms were falls from <3 m and traffic accidents. The imaging diagnostics were only rarely carried out with the child under anesthesia. Younger children (0-9 years old) suffered more injuries to the cervical spine, whereas injuries to the thoracic and lumbar spine were more frequently found in older children (>10 years old). The children frequently showed accompanying injuries to the head and the extremities. Accompanying spinal injuries mostly occurred in adjacent regions and only rarely in other regions. Around 75% of the children were treated conservatively.

CONCLUSION

The results were different from the knowledge obtained from adult patients with spinal trauma and describe the special circumstances for pediatric patients with spinal trauma. Despite certain limitations these facts may help to enhance future decision-making for the diagnostics and treatment of these patients.

Pediatric Spinal Traumas

INTRODUCTION

Although childhood trauma is a major cause of morbidity and mortality, the incidence of spinal trauma is significantly lower in children than in adults. Existing studies on pediatric spinal trauma (PST) largely concern cervical trauma because of its frequency of incidence. We aimed to obtain more information by examining all types of spinal trauma, and evaluating factors such as age, trauma type, injury type, and American Spinal Injury Association score and comparing them with data from the literature.

METHODS

We retrospectively reviewed 30 pediatric trauma patients with spinal pathology confirmed by spinal imaging.

RESULTS

The mean age was 166.4 months. Mean age for each mechanism of injury was: 142.7 months for a simple fall, 149.0 months for injury involving a foreign object, 163.5 months for a fall from a height, and 181.6 months for traffic accidents. There was no statistically significant difference in mean age for different mechanisms of injury (p = 0.372). The levels of the spinal injuries were: lumbar 53.3% (16), thoracic 26.6% (8), and cervical 20.0% (6). Mean age for each level of spinal injury was 113.3 months for the cervical area, 172.2 months for the thoracic area, and 183.3 months for the lumbar area. Mean age was found to be statistically significant (p = 0.000).

DISCUSSION

PST is uncommon and the type of trauma and the spinal level affected varies with age. Cervical trauma predominates at younger ages, but adult-like traumas begin to occur with increasing age. It should be considered that the risk of developing neurological deficits is higher in pediatric patients than in adults, and the risk of multisystem injury is also high.

Is spinal computed tomography necessary in pediatric trauma patients?

BACKGROUND

To investigate the prevalence of findings of spinal injury on computed tomography (CT) images of pediatric trauma patients and to define indicators for the possible presence of spinal injuries.

METHODS

Spinal CT for pediatric trauma patients (age ≤ 12 years) over a 2-year period was retrospectively evaluated for the presence of findings suggestive of spinal injury.

RESULTS

Of the 773 patients reviewed, 19 (2.4%) showed traumatic spinal lesions on their spinal CT images. These patients were significantly older than those without spinal lesions (mean age 7.9 ± 3.3 years vs 6.1 ± 3.3 years; P = 0.02). The prevalence of spinal trauma was significantly lower in patients aged 0-8 years than in those aged 9-12 years (P = 0.025). Spinal injury was significantly higher in female patients (P = 0.014). Most of the spinal injuries were located at the lumbar and sacral vertebral levels, and most did not cause neurological complications or require surgical treatment. Important indicators of the possible presence of spinal injuries were pain, tenderness, or ecchymosis over the spine, a low Glasgow Coma Scale score (≤12), head injury (for cervical injuries), or intrathoracic injuries and pelvic fractures (for lumbar and sacral injuries).

CONCLUSIONS

Most spinal CT examinations for the diagnosis of spinal injuries in children did not show positive findings. Thus, many children were exposed to an unnecessary high dose of radiation. New clinical evaluation criteria and indicators should be defined to diagnose spinal injuries and avoid unnecessary radiological examinations.

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.

Radiologic Imaging in Trauma Patients with Cervical Spine Immobilization at a Pediatric Trauma Center

BACKGROUND

Pediatric trauma patients with cervical spine (CS) immobilization using a cervical collar often require procedural sedation (PS) for radiologic imaging. The limited ability to perform airway maneuvers while CS immobilized with a cervical collar is a concern for emergency department (ED) staff providing PS.

OBJECTIVE

To describe the use of PS and analgesia for radiologic imaging acquisition in pediatric trauma patients with CS immobilization.

METHODS

Retrospective medical record review of all trauma patients with CS immobilization at a high-volume pediatric trauma center was performed. Patient demographics, imaging modality, PS success, sedative and analgesia medications, and adverse events were analyzed. Patients intubated prior to arrival to the ED were excluded.

RESULTS

A total of 1417 patients with 1898 imaging encounters met our inclusion criteria. A total of 398 patients required more than one radiographic imaging procedure. The median age was 8 years (range 3.8-12.75 years). Computed tomography of the head was used in 974 of the 1898 patients (51.3%). A total of 956 of the 1898 patients (50.4%) required sedatives or analgesics for their radiographic imaging, with 875 (91.5%) requiring a single sedative or analgesic agent, and 81 (8.5%) requiring more than one medication. Airway obstruction was the most common adverse event, occurring in 5 of 956 patients (0.3%). All imaging procedures were successfully completed.

CONCLUSION

Only 50% of CS immobilized, nonintubated patients required a single sedative or analgesic medication for their radiologic imaging. Procedural success was high, with few adverse events.

Management of cervical spine trauma in children

PURPOSE

Paediatric cervical spine injuries are fortunately a rare entity. However, they do have the potential for devastating neurological sequelae with lifelong impact on the patient and their family. Thus, management ought to be exceptional from the initial evaluation at the scene of the injury, through to definitive management and rehabilitation.

METHODS

We set out to review cervical spine injuries in children and advise on current best practice with regards to management.

RESULTS

Epidemiology, initial management at the scene of injury, radiological findings and pitfalls of cervical spine trauma are outlined. Strategies for conservative and surgical management are detailed depending on the pattern of injury. The management of spinal cord injuries without radiological abnormality (SCIWORA) and cranio-cervical arterial injuries is also reviewed.

CONCLUSIONS

Due to a paucity of evidence in these rare conditions, expert opinion is necessary to guide best practice management and to ensure the best chance of a good outcome for the injured child.

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.

Single-lateral cervical radiograph in pediatric trauma is equivalent to multiple views

BACKGROUND

Cervical spine injuries (CSI) are rare within the pediatric population. Due to the significant consequences of missed CSI, children are often imaged excessively. In an attempt to decrease imaging of the cervical spine in children, we reviewed abnormal cervical radiographs (XR) to determine if the diagnosis of CSI could be made using a single-lateral cervical radiograph (LAT). Furthermore, we reviewed cervical computed tomography (CT) and magnetic resonance imaging (MRI) to ensure there were no missed CSI.

METHODS

Electronic medical records of trauma patients treated at a Level I Pediatric Trauma Center with abnormal XR findings followed by confirmatory CT or MRI between 2012 and 2017 were reviewed. All abnormal imaging on XR was compared with the LAT. In addition, all abnormal CTs and MRIs were reviewed to ensure there were no false negative XR.

RESULTS

A total of 3,735 XR were performed with 26 abnormal interpretations. All bony CSI were visualized on LAT. Confirmatory imaging found 13 (50%) were false positive and 13 (50%) were true positive. Secondary analysis of CT identified 12 injuries with prior XR; 8 of 12 LAT identifying the injury and 4 of 12 false positive on CT. Secondary analysis of MRI identified nine injuries with prior XR; 5 of 9 LAT identifying the injury. The four false-negative reads on MRI were ligamentous injuries.

CONCLUSION

Radiographs are commonly performed when evaluating CSI. In our population, initial assessment with a single LAT was equivalent to a multiple view XR. On secondary review, the only false-negative LAT reports were due to ligamentous injuries. This data suggests limiting exposure to LAT would accomplish the goal of reducing imaging without missing bony CSI and when ligamentous injury is suspected MRI should be the confirmatory study rather than CT.

LEVEL OF EVIDENCE

Diagnostic Test, level III.

"Next Day" Examination Reduces Radiation Exposure in Cervical Spine Clearance at a Level 1 Pediatric Trauma Center: Preliminary Findings

BACKGROUND

Safe and effective clearance of the pediatric cervical spine presents a challenging problem due to a myriad of reasons, which has often led to further imaging studies such as computed tomographic (CT) scans being performed, exposing the pediatric patient to significant radiation with a potential increased cancer risk. The goal of this study is to develop an effective algorithm for cervical spine clearance that minimizes radiation exposure.

METHODS

A cervical spine clearance protocol had been utilized in our institution from 2002 to 2011. In October 2012, the protocol was revised to provide indications for appropriate imaging by utilizing repeat "next day" physical examination. In 2014, the protocol was again revised with the desired goal of decreasing the use of CT scans through increased involvement of the Spine Service. A retrospective review was commenced using information from the Trauma Database from 2011 to 2014. Three groups were analyzed according to which protocol the patients were evaluated under: 2011, 2012, and 2014 protocols.

RESULTS

During the study period, 762 patients underwent cervical spine clearance; 259 (2011 protocol), 360 (2012 protocol), and 143 (2014 protocol). The average age of all patients was 8.8 years, with 28% of patients younger than 5 years of age. There were no missed or delayed diagnoses of cervical spine injury. The use of CT scans decreased during the study period from 90% (2011 protocol) to 42% (2012 protocol) to 28.7% (2014 protocol). There was an increase in time to removal of the cervical collar at 13 to 24 hours from 8% (2011 protocol) to 22% (2012 protocol) to 19% (2014 protocol). This was not associated with an increase in hospital length of stay, which averaged 2.51 days (2011 protocol), 2.45 days (2012 protocol), and 2.27 days (2014 protocol).

CONCLUSIONS

Repeat "next day" clinical examinations and increased involvement of the Spine Service decreased radiation exposure without compromising the diagnosis of cervical spine injury or increasing the length of stay at a Level One Pediatric Trauma Center in this pilot study.

LEVEL OF EVIDENCE

Level 4-case series.

Cervical Spine Injury in Burned Trauma Patients: Incidence, Predictors, and Outcomes

Cervical spine injuries (CIs) carry significant morbidity and mortality; hence, cervical spine immobilization is used liberally in trauma patients, including burns. The incidence, predictors, and outcomes of CI in burn patients are unknown. A retrospective cohort from the National Trauma Data Bank between 2007 and 2012 included all burned patients with and without CI. Predictors of CI were identified by logistic regression. Outcomes with and without CI were compared with Wilcoxon rank sum test. A total of 94,964 patients were identified with burn injuries. The incidence of CI was 0.79% (n = 745). Mechanism of injury, age, and injury severity score (ISS) were significant predictors of CI. Odds of CI were 109.4 (95% CI: 61.2-195.3, P < .0001) for motor vehicle injury, 87.8 (95% CI: 47.0-164.0, P < .0001) for falls, 1.2 (95% CI: 0.6-2.3, P = .66) for fire/flame, and 2.4 (95% CI: 1.0-5.5, P < .0001) for explosion compared with reference of hot object/substance. For every year increase in age, there were 1.02 higher odds of CI (95% CI: 1.01-1.02, P < .0001). For each point increase in ISS, there were 1.05 higher odds of CI (95% CI: 1.04-1.05, P < .0001). Patients with CI had higher mortality (10.3% vs 2.9%, P < .0001), longer total length of stay (12.0 vs 2.0 days, P < .0001), intensive care unit length of stay (4.0 vs 0.0 days, P < .001), and ventilator days (1.0 vs 0.0 days, P < .0001). The incidence of CI in burn patients is low, especially when due to fire, flame, or scalds; however, CI is associated with higher mortality and worse outcomes.