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Tavender E, Eapen N, Wang J, Rausa VC, Babl FE, Phillips N. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev 2024; 3:CD011686. [PMID: 38517085 PMCID: PMC10958760 DOI: 10.1002/14651858.cd011686.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy. OBJECTIVES To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions. SELECTION CRITERIA We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach. MAIN RESULTS We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.
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Affiliation(s)
- Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
| | - Nitaa Eapen
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Junfeng Wang
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Vanessa C Rausa
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Australia
- Biomechanics and Spine Research Group, Centre for Children's Health Research, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, Australia
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Haddad E, Al Khoury Salem H, Dohin B. Diagnosis and treatment of cervical spine injuries in children. Orthop Traumatol Surg Res 2024; 110:103762. [PMID: 37992867 DOI: 10.1016/j.otsr.2023.103762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/28/2023] [Accepted: 05/11/2023] [Indexed: 11/24/2023]
Abstract
Cervical spine injuries in children are a common reason for emergency room visits, while bone, ligament or spinal cord cervical lesions are relatively rare (1-1.5% of severe trauma in children) and mainly involve the upper cervical spine. The main causes are sports injuries, accidents at home and traffic accidents. Clinical triage is needed to avoid unnecessary radiation exposure from imaging. We propose a protocol to optimize the diagnosis and treatment. In children, conservative treatment using rigid immobilization (cervical collar or halo-vest) is the preferred option in stable and/or minimally displaced injuries. Frequent clinical and radiological monitoring is required to ensure the patient's condition does not deteriorate due to inappropriate or poorly tolerated treatment. In these cases, surgical treatment can be proposed as second-line treatment. Internal fixation is indicated as the first-line treatment if the injury is unstable or a neurological deficit is present. The fixation methods must be adapted to the pediatric population by taking into account the vertebral volume and residual growth potential. Intraoperative CT scans or neuronavigation can make the surgical procedure safer and easier. Clinical, radiographic and CT scan monitoring should continue until the end of growth in a child who underwent surgical treatment to quickly detect any mechanical complications or sagittal imbalance due to poor craniocervical or cervicothoracic alignment. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Elie Haddad
- Service de chirurgie pédiatrique du Pr. SCALABRE, centre hospitalo-universitaire de Saint-Étienne, hôpital Nord, avenue Albert-Raimond, 42270 Saint-Priest-en-Jarez, France.
| | - Hassan Al Khoury Salem
- Service de chirurgie pédiatrique du Pr. SCALABRE, centre hospitalo-universitaire de Saint-Étienne, hôpital Nord, avenue Albert-Raimond, 42270 Saint-Priest-en-Jarez, France.
| | - Bruno Dohin
- Service de chirurgie pédiatrique du Pr. SCALABRE, centre hospitalo-universitaire de Saint-Étienne, hôpital Nord, avenue Albert-Raimond, 42270 Saint-Priest-en-Jarez, France.
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Luckhurst CM, Wiberg HM, Brown RL, Bruch SW, Chandler NM, Danielson PD, Draus JM, Fallat ME, Gaines BA, Haynes JH, Inaba K, Islam S, Kaminski SS, Kang HS, Madabhushi VV, Murray J, Nance ML, Qureshi FG, Rubsam J, Stylianos S, Bertsimas DJ, Masiakos PT. Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study. JAMA Surg 2023; 158:1126-1132. [PMID: 37703025 PMCID: PMC10500431 DOI: 10.1001/jamasurg.2023.4213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/16/2023] [Indexed: 09/14/2023]
Abstract
Importance There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients. Objective To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model. Design, Setting, and Participants This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022. Exposure Blunt trauma. Main Outcomes and Measures Primary outcome was CSI. The primary and secondary objectives were predetermined. Results The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915). Conclusion and Relevance This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.
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Affiliation(s)
- Casey M. Luckhurst
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston
| | | | - Rebeccah L. Brown
- Division of Pediatric Surgery at Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Steven W. Bruch
- Division of Pediatric Surgery at University of Michigan Medical Center, Ann Arbor
| | - Nicole M. Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Paul D. Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - John M. Draus
- Division of Pediatric Surgery at Kentucky Children’s Hospital, Lexington
| | - Mary E. Fallat
- Division of Pediatric Surgery at Norton Children’s Hospital, Louisville, Kentucky
| | - Barbara A. Gaines
- Division of Pediatric Surgery at University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jeffrey H. Haynes
- Department of Pediatric Surgery, Children’s Hospital of Richmond at Virginia Commonwealth University Health, Richmond
| | - Kenji Inaba
- Division of Trauma, Emergency Surgery, and Surgical Critical Care at University of Southern California Medical Center, Los Angeles
| | - Saleem Islam
- Division of Pediatric Surgery at University of Florida Health, Gainesville
| | - Stephen S. Kaminski
- Department of Surgery at Santa Barbara Cottage Hospital, Santa Barbara, California
| | - Hae Sung Kang
- Department of Surgery, Virginia Commonwealth University Health, Richmond
| | | | - Jason Murray
- Department of Surgery, University of Texas Health Tyler, Tyler
| | - Michael L. Nance
- Division of Pediatric Surgery at Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Faisal G. Qureshi
- Division of Pediatric Surgery at Children’s Medical Center Dallas, Dallas, Texas
| | - Jeanne Rubsam
- Division of Pediatric Surgery at Morgan Stanley Children’s Hospital of New York-Presbyterian, New York
| | - Steven Stylianos
- Division of Pediatric Surgery at Morgan Stanley Children’s Hospital of New York-Presbyterian, New York
| | | | - Peter T. Masiakos
- Division of Pediatric Surgery, Massachusetts General Hospital, Boston
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Schatteman S, Jaremko J, Jans L, Herregods N. Update on Pediatric Spine Imaging. Semin Musculoskelet Radiol 2023; 27:566-579. [PMID: 37816365 DOI: 10.1055/s-0043-1771333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
The spine is often difficult to evaluate clinically in children, increasing the importance of diagnostic imaging to detect a wide variety of spinal disorders ranging from congenital abnormalities to severe infections. Clinical history and physical examination can help determine whether imaging is needed and which imaging technique would be best. The most common cause for back pain, even in children, is muscular strain/spasm that does not require any imaging. However, red flags such as pain at age < 5 years, constant pain, night pain, radicular pain, pain lasting > 4 weeks, or an abnormal neurologic examination may require further investigation. Imaging can be of great value for diagnosis but must be interpreted along with the clinical history, physical examination, and laboratory findings to achieve an accurate diagnosis. We discuss imaging for the most common and/or important spine pathologies in children: congenital and developmental pathologies, trauma, infectious processes, inflammatory causes, and tumors.
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Affiliation(s)
- Stijn Schatteman
- Department of Radiology and Nuclear Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jacob Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Lennart Jans
- Department of Radiology and Nuclear Medicine, Ghent University Hospital, Ghent, Belgium
| | - Nele Herregods
- Department of Radiology and Nuclear Medicine, Ghent University Hospital, Ghent, Belgium
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Kalanjiyam GP, Kanna RM, Rajasekaran S. Pediatric spinal injuries- current concepts. J Clin Orthop Trauma 2023; 38:102122. [PMID: 36846073 PMCID: PMC9945789 DOI: 10.1016/j.jcot.2023.102122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/03/2023] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
| | - Rishi Mugesh Kanna
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, India
| | - S. Rajasekaran
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, India
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6
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Prasher S, Landes C. The cervical spine in paediatric radiology. Br J Hosp Med (Lond) 2022; 83:1-9. [DOI: 10.12968/hmed.2022.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Accurate radiological assessment of the cervical spine is vital in the management of the child presenting with trauma. Compared to an adult's spine, the significant differences in the developmental anatomy (variants or synchondrosis), biomechanics and fracture patterns in the paediatric cervical spine makes assessment difficult, even for experienced radiologists. This review discusses the unique biomechanical factors, developmental anatomy, patterns of injury and imaging strategy in the paediatric population.
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Affiliation(s)
- Sparsh Prasher
- Department of Radiology, Alder Hey Childrens Hospital, Liverpool, UK
| | - Caren Landes
- Department of Radiology, Alder Hey Childrens Hospital, Liverpool, UK
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7
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Muacevic A, Adler JR. Implementation of National Emergency X-Radiography Utilization Study (NEXUS) Criteria in Pediatrics: A Systematic Review. Cureus 2022; 14:e30065. [PMID: 36238421 PMCID: PMC9547612 DOI: 10.7759/cureus.30065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2022] [Indexed: 11/05/2022] Open
Abstract
Since its introduction in 1992, the National Emergency X-Radiography Utilization Study (NEXUS) criteria have been used in trauma to decide whether a patient requires radiographic imaging. The tool is important in reducing radiation exposure. However, applying the NEXUS criteria for cervical spine imaging in pediatric patients is poorly supported compared to their use in adults. The objective of this review was to examine the effectiveness of using the NEXUS criteria in the diagnostic management of pediatric cervical spine injuries (CSI). The following databases were searched for studies focused on applying the NEXUS criteria for CSI in pediatric patients: Cochrane, PubMed, Google Scholar, EMBASE, ELSEVIER, and ScienceDirect. Additional studies were found through reference lists of primary sources and previous systematic and meta-analyses. The search focused on randomized controlled trials (RCTs), cohort studies, retrospective studies, prospective studies, and other uncontrolled trials published from 2000 to 2022. There were seven included studies with a total of 4502 pediatric patients. Five of the included studies were retrospective studies, while the remaining were prospective and case studies. Our results show that the sensitivity ranged from 43% to 100%, while the specificity ranged from 12.93% to 96%. The sensitivity increased with age, with those under the age of two or under the age of eight reporting poorer outcomes than the older pediatric patients. One study also shows that the proportion of patients undergoing cervical spine CT increased from 18% to 61% in the initial period before the implementation of clearance guidelines. The implementation of guidelines led to a 23% decrease in CT scans clearable by NEXUS criteria after 12 months. One of the studies reported that NEXUS criteria were a cost-effective option when used along with X-rays and CT. Overall, the studies do not strongly support the application of the NEXUS criteria to image pediatric patients for CSI. In conclusion, there is weak support in the literature for applying the NEXUS criteria in determining the need for cervical spine imaging in pediatric trauma patients. The practice and research implications of the findings are also discussed.
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Chu ECP, Wong AYL. Cervicogenic Dizziness in an 11-Year-Old Girl: A Case Report. Adolesc Health Med Ther 2021; 12:111-116. [PMID: 34866956 PMCID: PMC8636150 DOI: 10.2147/ahmt.s341069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/19/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Eric Chun-Pu Chu
- New York Chiropractic and Physiotherapy Centre, Hong Kong SAR, People’s Republic of China
- Correspondence: Eric Chun-Pu Chu New York Chiropractic and Physiotherapy Centre, 41/F Langham Place Office Tower, 8 Argyle Street, Hong Kong SAR, People’s Republic of ChinaTel +852-3594-7844Fax +852-3594-6193 Email
| | - Arnold Yu-Lok Wong
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, People’s Republic of China
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9
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Konovalov N, Peev N, Zileli M, Sharif S, Kaprovoy S, Timonin S. Pediatric Cervical Spine Injuries and SCIWORA: WFNS Spine Committee Recommendations. Neurospine 2020; 17:797-808. [PMID: 33401857 PMCID: PMC7788416 DOI: 10.14245/ns.2040404.202] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/07/2020] [Indexed: 11/19/2022] Open
Abstract
Cervical trauma in children have variations from the adults mainly due to anatomic differences. An optimal diagnostic and treatment strategy is critical, particularly when there is a lack of standardized protocols for the management of such cases. This review paper examines the diagnostic and treatment options of pediatric cervical trauma and Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). A literature search for the last 10 years were conducted using key words. Case reports, experimental studies, papers other than English language were excluded. Up-to-date information on pediatric cervical trauma and SCIWORA were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of WFNS Spine Committee. The statements were voted and reached a consensus using Delphi method. This review reflects different aspects of contemporary pediatric cervical trauma decision-making and treatment, and SCIWORA. The mainstay of SCIWORA treatment is nonsurgical with immobilization, avoidance of risky activities. Prognosis generally depends on the initial neurological status and magnetic resonance imaging. Due to a significant discrepancy in the literature on diagnostic and management, future randomized controlled trials are needed to aid in generating standardized protocols.
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Affiliation(s)
- Nikolay Konovalov
- Burdenko Institute Department of Neurosurgery, Moscow, Russian Federation
| | - Nikolay Peev
- Department of Neurosurgery, Belfast Health and Social Care Trust, Northern Ireland, Belfast, UK
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University, Izmir, Turkey
| | - Salman Sharif
- Neurosurgery Liaquat National Hospital & Medical College, Karachi Pakistan, Karachi, Pakistan
| | - Stanislav Kaprovoy
- Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
| | - Stanislav Timonin
- Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
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10
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Ten Brinke JG, Slinger G, Slaar A, Saltzherr TP, Hogervorst M, Goslings JC. Increased and unjustified CT usage in paediatric C-spine clearance in a level 2 trauma centre. Eur J Trauma Emerg Surg 2020; 47:781-789. [PMID: 33108476 PMCID: PMC8187214 DOI: 10.1007/s00068-020-01520-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/26/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Joost G Ten Brinke
- Department of Surgery, Gelre Hospital, Apeldoorn, The Netherlands. .,Trauma Unit, Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, The Netherlands.
| | | | - Annelie Slaar
- Department of Radiology, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | | | - Mike Hogervorst
- Department of Surgery, Gelre Hospital, Apeldoorn, The Netherlands
| | - J Carel Goslings
- Department of Trauma Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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11
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Wang MX, Beckmann NM. Imaging of pediatric cervical spine trauma. Emerg Radiol 2020; 28:127-141. [PMID: 32601894 DOI: 10.1007/s10140-020-01813-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/19/2020] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Mindy X Wang
- Department of Diagnostic and Interventional Imaging, Memorial Hermann, Houston, TX, USA.
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA.
| | - Nicholas M Beckmann
- Department of Diagnostic and Interventional Imaging, Memorial Hermann, Houston, TX, USA
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA
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Gupta S, Hauser BM, Zaki MM, Xu E, Cote DJ, Lu Y, Chi JH, Groff M, Khawaja AM, Harris MB, Smith TR, Zaidi HA. Morbidity after traumatic spinal injury in pediatric and adolescent sports-related trauma. J Neurosurg Spine 2019; 32:642-648. [PMID: 31881536 PMCID: PMC7383358 DOI: 10.3171/2019.10.spine19712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 10/14/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sports injuries present a considerable risk of debilitating spinal injury. Here, the authors sought to profile the epidemiology and clinical risk of traumatic spinal injuries (TSIs) in pediatric sports injuries. METHODS The authors conducted a retrospective cohort analysis of pediatric patients who had experienced a sports-related TSI, including spinal fractures and spinal cord injuries, encoded in the National Trauma Data Bank in the period from 2011 to 2014. RESULTS Included in the analysis were 1723 cases of pediatric sports-related TSI, which represented 3.7% of all pediatric sports-related trauma. The majority of patients with TSI were male (81%), and the median age was 15 years (IQR 13-16 years). TSIs arose most often from cycling accidents (47%) and contact sports (28%). The most frequently fractured regions were the thoracic (30%) and cervical (27%) spine. Among patients with spinal cord involvement (SCI), the cervical spine was involved in 60% of cases.The average length of stay for TSIs was 2 days (IQR 1-5 days), and 32% of the patients required ICU-level care. Relative to other sports-related trauma, TSIs without SCI were associated with an increased adjusted mean length of stay by 1.8 days (95% CI 1.6-2.0 days), as well as the need for ICU-level care (adjusted odds ratio [aOR] 1.6, 95% CI 1.3-1.9). Also relative to other sports-related trauma, TSIs with SCI had an increased length of stay by 2.1 days (95% CI 1.8-2.6 days) and the need for ICU-level care (aOR 3.6, 95% CI 2.6-4.8).TSIs without SCI were associated with discharge to or with rehabilitative services (aOR 1.7, 95% CI 1.5-2.0), as were TSIs with SCI (aOR 4.0, 95% CI 3.2-4.9), both relative to other sports-related trauma. Among the patients with TSIs, predictors of the need for rehabilitation at discharge were having a laminectomy or fusion, concomitant lower-extremity injury, head injury, and thoracic injury. Although TSIs affected 4% of the study cohort, these injuries were present in 8% of patients discharged to or with rehabilitation services and in 17% of those who died in the hospital. CONCLUSIONS Traumatic sports-related spinal injuries cause significant morbidity in the pediatric population, especially if the spinal cord is involved. The majority of TSI cases arose from cycling and contact sports accidents, underscoring the need for improving education and safety in these activities.
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Affiliation(s)
- Saksham Gupta
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Blake M. Hauser
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Mark M Zaki
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Edward Xu
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - David J. Cote
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
- Channing Division of Network Medicine, Department of Medicine/Brigham and Women’s Hospital, Harvard Medical School/Boston/MA/USA
| | - Yi Lu
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - John H. Chi
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Michael Groff
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Ayaz M. Khawaja
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
- Channing Division of Network Medicine, Department of Medicine/Brigham and Women’s Hospital, Harvard Medical School/Boston/MA/USA
| | - Mitchel B. Harris
- Department of Orthopedics/Massachusetts General Hospital, Harvard Medical School/Boston/MA/USA
| | - Timothy R. Smith
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Hasan A. Zaidi
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
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McAllister AS, Nagaraj U, Radhakrishnan R. Emergent Imaging of Pediatric Cervical Spine Trauma. Radiographics 2019; 39:1126-1142. [DOI: 10.1148/rg.2019180100] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Aaron S. McAllister
- From the Department of Radiology, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205, and Department of Radiology, The Ohio State University, Columbus, Ohio (A.S.M.); Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital, Cincinnati, Ohio (U.N.); and Department of Radiology and Imaging Sciences, Riley Hospital for Children at Indiana University Health, Indianapolis, Ind (R.R.)
| | - Usha Nagaraj
- From the Department of Radiology, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205, and Department of Radiology, The Ohio State University, Columbus, Ohio (A.S.M.); Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital, Cincinnati, Ohio (U.N.); and Department of Radiology and Imaging Sciences, Riley Hospital for Children at Indiana University Health, Indianapolis, Ind (R.R.)
| | - Rupa Radhakrishnan
- From the Department of Radiology, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205, and Department of Radiology, The Ohio State University, Columbus, Ohio (A.S.M.); Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital, Cincinnati, Ohio (U.N.); and Department of Radiology and Imaging Sciences, Riley Hospital for Children at Indiana University Health, Indianapolis, Ind (R.R.)
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George MP, Kim WG, Lee EY. Tales from the Night:: Emergency MR Imaging in Pediatric Patients after Hours. Magn Reson Imaging Clin N Am 2019; 27:409-426. [PMID: 30910105 DOI: 10.1016/j.mric.2019.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Overnight in-house radiology has rapidly become an important part of contemporary practice models, and is increasingly the norm in pediatric radiology. MR imaging is an indispensable first-line and problem-solving tool in the pediatric population. This has led to increasingly complex MR imaging being performed "after hours" on pediatric patients. This article reviews the factors that have led to widespread overnight subspecialty radiology and the associated challenges for overnight radiologists, and provides an overview of up-to-date imaging techniques and imaging findings of the most common indications for emergent MR imaging in the pediatric population.
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Affiliation(s)
- Michael P George
- Department of Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Wendy G Kim
- Department of Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Edward Y Lee
- Division of Thoracic Imaging, Department of Radiology, Boston Children's Hospital, Harvard Medical School, 330 Longwood Avenue, Boston, MA 02115, USA
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Posttraumatic Anatomical Injuries of the Craniovertebral Junction and Treatment Implications: Part I. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019. [PMID: 30610336 DOI: 10.1007/978-3-319-62515-7_42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Please check the hierarchy of the section headings and correct if necessary.
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16
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Abstract
Acute onset of neurological signs and symptoms referable to the spine including difficulty walking, bowel and bladder dysfunction, and paresthesias in the extremities may be manifestations of pediatric spine emergency. Trauma is the most common etiology for a pediatric spinal emergency. Because a history of trauma is often available, the role of imaging involves detection of spinal injuries. Other pathologies such as infection, inflammation, vascular, and neoplasms may lead to pediatric spinal emergencies that also require imaging for assistance in determining the etiology and appropriate management.
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Affiliation(s)
- Katie Suzanne Traylor
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Stephen F Kralik
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Rupa Radhakrishnan
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202.
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Gopinathan NR, Viswanathan VK, Crawford AH. Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts. Indian J Orthop 2018; 52:489-500. [PMID: 30237606 PMCID: PMC6142799 DOI: 10.4103/ortho.ijortho_607_17] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The clinical presentation and diagnostic workup in pediatric cervical spine injuries (CSI) are different from adults owing to the unique anatomy and relative immaturity. The current article reviews the existing literature regarding the uniqueness of these injuries and discusses the current guidelines of radiological evaluation. A PubMed search was conducted using keywords "paediatric cervical spine injuries" or "paediatric cervical spine trauma." Six hundred and ninety two articles were available in total. Three hundred and forty three articles were considered for the review after eliminating unrelated and duplicate articles. Further screening was performed and 67 articles (original articles and review articles only) related to pediatric CSI were finally included. All articles were reviewed for details regarding epidemiology, injury patterns, anatomic considerations, clinical, and radiological evaluation protocols. CSIs are the most common level (60%-80%) for pediatric Spinal Injuries (SI). Children suffer from atlantoaxial injuries 2.5 times more often than adults. Children's unique anatomical features (large head size and highly flexible spine) predispose them to such a peculiar presentation. The role of National Emergency X-Ray Utilization Study, United State (NEXUS) and Canadian Cervical Spine Rule criteria in excluding pediatric cervical injury is questionable but cannot be ruled out completely. The minimum radiological examination includes 2- or 3-view cervical X-rays (anteroposterior, lateral ± open-mouth odontoid views). Additional radiological evaluations, including computerized tomography (CT) and magnetic resonance imaging (MRI) are obtained in situations of abnormal physical examination, abnormal X-rays, inability to obtain adequate X-rays, or to assess cord/soft-tissue status. The clinical criteria for cervical spine injury clearance can generally be applied to children older than 2 years of age. Nevertheless, adequate caution should be exercised before applying these rules in younger children. Initial radiographic investigation should be always adequate plain radiographs of cervical spine. CT and MRI scans should only be performed in an appropriate group of pediatric patients.
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Affiliation(s)
- Nirmal Raj Gopinathan
- Department of Orthopedic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vibhu Krishnan Viswanathan
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alvin H Crawford
- Department of Pediatric Orthopedics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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18
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Abstract
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.
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19
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Diagnosis of atlanto-occipital dissociation: Standardised measurements of normal craniocervical relationship in finless porpoises (genus Neophocaena) using postmortem computed tomography. Sci Rep 2018; 8:8474. [PMID: 29855530 PMCID: PMC5981431 DOI: 10.1038/s41598-018-26866-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 05/21/2018] [Indexed: 11/22/2022] Open
Abstract
Due to the different craniocervical structures in humans and cetaceans, a standardised method assessing the normal craniocervical relationship in cetaceans is lacking, causing difficulties in defining the presence of atlanto-occipital dissociation (AOD) in cetaceans. The present study aimed to 1) describe a novel standardised method of determining the normal craniocervical relationships, and 2) define the 95% accuracy range of the normal craniocervical relationship in finless porpoises (genus Neophocaena), that allowed AOD diagnosis. Fifty-five out 83 stranded or by-caught finless porpoise carcasses were analyzed in term of their craniocervical relationship in dorsal-ventral and medial-lateral dimension, using postmortem computed tomography measurements. The normal craniocervical relationship in both dorsal-ventral (mean BD/OV: 0.87 ± 0.24 [2 SD]) and medial-lateral dimension (mean VR/VL: 0.98 ± 0.17 [2 SD]) was first defined. The 95% accuracy ranges of the normal craniocervical relationship in dorsal-ventral (0.63–1.11) and medial-lateral dimension (0.82–1.15) were proposed. The baseline ranges could facilitate AOD assessment, and provide an objective means of record for AOD related injury and death of cetaceans caused by anthropogenic trauma. The technique developed may be applied to live cetaceans with abnormal craniocervical relationship to aid diagnosis and guide corrective therapy.
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20
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Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, Schep NWL, van Rijn RR. Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database Syst Rev 2017; 12:CD011686. [PMID: 29215711 PMCID: PMC6486014 DOI: 10.1002/14651858.cd011686.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population. OBJECTIVES To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma. SEARCH METHODS We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility. SELECTION CRITERIA We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy. MAIN RESULTS Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity. AUTHORS' CONCLUSIONS There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.
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Affiliation(s)
- Annelie Slaar
- WestfriesgasthuisDepartment of RadiologyMaelsonstraat 3HoornNoord HollandNetherlands1624 NP
| | - M M Fockens
- University of AmsterdamAcademic Medical CenterAmsterdamNetherlands
| | - Junfeng Wang
- Academic Medical CenterDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Mario Maas
- Academic Medical CenterDepartment of RadiologyUniversity of AmsterdamMeibergdreefAmsterdamNetherlands
| | - David J Wilson
- St Lukes HospitalDepartment of RadiologyLatimer RoadHeadingtonOxfordUKOX3 7PF
| | - J Carel Goslings
- Academic Medical CenterTrauma Unit, Department of SurgeryMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Niels WL Schep
- Academic Medical CenterDepartment of Surgery/Trauma UnitMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Rick R van Rijn
- Academic Medical Center AmsterdamDepartment of RadiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
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Hale AT, Alvarado A, Bey AK, Pruthi S, Mencio GA, Bonfield CM, Martus JE, Naftel RP. X-ray vs. CT in identifying significant C-spine injuries in the pediatric population. Childs Nerv Syst 2017; 33:1977-1983. [PMID: 28656384 DOI: 10.1007/s00381-017-3448-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 05/01/2017] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Andrew T Hale
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.
| | - Abraham Alvarado
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Amita K Bey
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Sumit Pruthi
- Department of Radiology, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Gregory A Mencio
- Division of Orthopedic Surgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Christopher M Bonfield
- Division of Neurological Surgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Jeffrey E Martus
- Division of Orthopedic Surgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Robert P Naftel
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.,Division of Neurological Surgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
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Özbek Z, Özkara E, Vural M, Arslantaş A. Treatment of cervical subaxial injury in the very young child. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1193-1198. [PMID: 29086032 DOI: 10.1007/s00586-017-5316-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/31/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Infant's cervical spine has serious differences compared to other pediatric age groups and adults. Anatomical and biomechanical constitution of an infant is unique, and the pediatric spine gradually begins to resemble the structure of the adult spine after age 10. In addition, clinical presentation of the cervical spinal traumas has many distinctions from birth to the end of adolescence. In young children, cervical spine traumas are mainly localized in the upper cervical region. Trauma localized in subaxial cervical region and fracture-dislocations are rare in infants. CASE REPORT Here, we present a case history of a 7-month-old infant with surgically treated severe subaxial flexion-distraction injury. Neurologic examination revealed complete loss of motor function below C5. A whole-body CT was taken and we observed that C5-6 dislocated anteriorly approximately one vertebra size and also unilateral facet joint was locked. The patient was intubated and closed reduction was attempted with fluoroscopy under general anesthesia, but it was unsuccessful. Whereupon C5-6 microdiscectomy was performed with the anterior approach and fixation was provided with the craniofacial miniplate. Despite anterior stabilization, exact posterior alignment could not been achieved so, posterior approach was added to the surgery. At 12 month follow-up, the patient improved from quadriparesis to paraparesis and we achieved a satisfactory radiological outcome.
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Affiliation(s)
- Zühtü Özbek
- Department of Neurosurgery, School of Medicine, Eskisehir Osmangazi University, 26480, Eskisehir, Turkey.
| | - Emre Özkara
- Department of Neurosurgery, School of Medicine, Eskisehir Osmangazi University, 26480, Eskisehir, Turkey
| | - Murat Vural
- Department of Neurosurgery, School of Medicine, Eskisehir Osmangazi University, 26480, Eskisehir, Turkey
| | - Ali Arslantaş
- Department of Neurosurgery, School of Medicine, Eskisehir Osmangazi University, 26480, Eskisehir, Turkey
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Safir S, Rasouli J, Steinberger J, Skovrlj B, Doshi A, Margetis K, Ghatan S. Absent congenital cervical pedicle nearly misdiagnosed as a facet dislocation: A case report. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2017; 9:20-23. [PMID: 28713667 PMCID: PMC5508796 DOI: 10.1016/j.inat.2016.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Scott Safir
- Department of Surgery, Mount Sinai Health System, New York, NY 10029, United States
| | - Jonathan Rasouli
- Department of Neurological Surgery, Mount Sinai Health System, New York, NY 10029, United States
| | - Jeremy Steinberger
- Department of Neurological Surgery, Mount Sinai Health System, New York, NY 10029, United States
| | - Branko Skovrlj
- Department of Neurological Surgery, Mount Sinai Health System, New York, NY 10029, United States
| | - Amish Doshi
- Department of Radiology, Mount Sinai Health System, New York, NY 1029, United States
| | - Konstantinos Margetis
- Department of Neurological Surgery, Mount Sinai Health System, New York, NY 10029, United States
| | - Saadi Ghatan
- Department of Neurological Surgery, Mount Sinai Health System, New York, NY 10029, United States
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Shah K, Tikoo A, Kothari MK, Nene A. Current Concepts in Pediatric Cervical Spine Trauma. Open Orthop J 2017; 11:346-352. [PMID: 28603566 PMCID: PMC5447926 DOI: 10.2174/1874325001711010346] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 07/10/2016] [Accepted: 07/15/2016] [Indexed: 12/23/2022] Open
Abstract
Background: Pediatric spinal trauma is rare and challenging entity. Although cervical spine is commonly affected, it is often missed on routine imaging investigations. Therefore better understanding of growing spine and its patho-physiology is crucial. Methods: Articles related to pediatric cervical trauma were searched on Pubmed and other online research data banks. We have summarized unique anatomy of pediatric spine, investigations followed by common injury patterns, their diagnostic challenges and management. Results: Immature spine follows typical injury patterns, so thorough knowledge of its presentation should be known. Primary physicians should be able to perform initial assessment based on clinical examination and investigations for early diagnosis. High index of suspicion and strategic approach leads to early diagnosis and prevents further morbidity and mortality. Conclusion: Spinal injuries in children are rare and typical. They are often missed and can have fatal consequences. Thorough understanding of pediatric anatomy and injury patterns helps in early diagnosis.
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Affiliation(s)
- Kunal Shah
- Wockhardt Hospitals, 1877, Dr. Anand Rao Nair Road, Mumbai Central (E), Mumbai- 400 011, India
| | - Agnivesh Tikoo
- Wockhardt Hospitals, 1877, Dr. Anand Rao Nair Road, Mumbai Central (E), Mumbai- 400 011, India
| | - Manish K Kothari
- Wockhardt Hospitals, 1877, Dr. Anand Rao Nair Road, Mumbai Central (E), Mumbai- 400 011, India
| | - Abhay Nene
- Wockhardt Hospitals, 1877, Dr. Anand Rao Nair Road, Mumbai Central (E), Mumbai- 400 011, India
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Re: Radiological assessment of paediatric cervical spine injury in blunt trauma: the potential impact of new NICE guideline on the use of CT. Clin Radiol 2017; 72:262-263. [DOI: 10.1016/j.crad.2016.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 10/30/2016] [Accepted: 10/31/2016] [Indexed: 11/22/2022]
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Affiliation(s)
- Bari Dane
- Department of Radiology, NYU Langone Medical Center/Bellevue Hospital, New York, NY
| | - Mark P Bernstein
- Department of Radiology, NYU Langone Medical Center/Bellevue Hospital, New York, NY.
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Davies J, Cross S, Evanson J. Radiological assessment of paediatric cervical spine injury in blunt trauma: the potential impact of new NICE guidelines on the use of CT. Clin Radiol 2016; 71:844-53. [PMID: 27234435 DOI: 10.1016/j.crad.2016.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 03/28/2016] [Accepted: 04/29/2016] [Indexed: 12/29/2022]
Abstract
AIM To determine the potential effect of changes to the National Institute for Health and Care Excellence (NICE) guidelines to the use of computed tomography (CT) in the assessment of suspected paediatric cervical spine (c-spine) injury. MATERIAL AND METHODS A 5 year retrospective study was conducted of c-spine imaging in paediatric (<10 years) patients presenting following blunt trauma at a Level 1 trauma centre in London. All patients under the age of 10 years who underwent any imaging of the c-spine following blunt trauma were included. Clinical data relating to the presenting signs and symptoms were obtained from the retrospective review of electronic records and paper notes. This was then applied to the previous NICE guideline (CG56) and to the new NICE guideline (CG176). Patients with incomplete data were excluded. RESULTS Two hundred and seventy-eight patients <10 years underwent imaging of the c-spine following blunt trauma. Two hundred and seventy (97.12%) examinations had complete data and were included in further analysis. One hundred and forty-nine (55.19%) met the criteria for a CT of the c-spine under NICE CG56, whereas 252 (93.33%) met the updated NICE CG176 criteria for c-spine CT. Five (1.85%) patients had a c-spine injury and met the criteria under both CG56 and CG176 NICE guidelines. CONCLUSION Recent changes to NICE Head Injury Guidelines relating to radiological assessment of paediatric c-spine following blunt trauma are likely to result in an increased usage of CT as the initial radiological investigation over plain radiographs, without an apparent increase in specificity in the present series.
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Affiliation(s)
- J Davies
- Radiology Department, Royal London Hospital, Whitechapel Road, London E1 1BB, UK.
| | - S Cross
- Radiology Department, Royal London Hospital, Whitechapel Road, London E1 1BB, UK
| | - J Evanson
- Radiology Department, Royal London Hospital, Whitechapel Road, London E1 1BB, UK
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Jacob R, Cox M, Koral K, Greenwell C, Xi Y, Vinson L, Reeder K, Weprin B, Huang R, Booth TN. MR Imaging of the Cervical Spine in Nonaccidental Trauma: A Tertiary Institution Experience. AJNR Am J Neuroradiol 2016; 37:1944-1950. [PMID: 27231224 DOI: 10.3174/ajnr.a4817] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 03/21/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Cervical MR imaging has demonstrated a utility for detecting soft tissue injury in nonaccidental trauma. The purpose of this study was to identify the incidence and types of cervical spine injury on MR imaging in nonaccidental trauma and to correlate cervical spine injury with parenchymal injury on brain MR imaging and findings on head CT. MATERIALS AND METHODS A retrospective review of children diagnosed with nonaccidental trauma in a tertiary referral pediatric hospital over 8 years was performed. Inclusion criteria were children younger than 5 years of age, a confirmed diagnosis of nonaccidental trauma, and cervical spine MR imaging within 1 week of presentation. Brain and cervical spine MR imaging, head CT, cervical radiographs, and skeletal surveys were reviewed. RESULTS There were 89 patients included in this study (48 males; mean age, 9.1 months [range, 1-59 months]). Cervical spine injury on MR imaging was found in 61 patients (69%). Ligamentous injury was seen in 60 patients (67%), with interspinous ligaments being most commonly involved. Abnormal capsular fluid (atlanto-occipital and atlantoaxial) was present in 28 patients (32%). Cervical spine injury on MR imaging was significantly associated with parenchymal restricted diffusion on brain MR imaging and parenchymal injury on head CT (P = .0004 and P = .0104, respectively). Children with restricted diffusion on brain MR imaging were 6.22 (point estimate) times more likely to have cervical spine injury on MR imaging. CONCLUSIONS There is a high incidence of cervical spine injury in pediatric nonaccidental trauma. Positive findings may affect management and suggest a traumatic etiology.
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Affiliation(s)
- R Jacob
- From the Departments of Radiology (R.J., K.K., Y.X., T.N.B.)
| | - M Cox
- Pediatrics (M.C., K.R., B.W., R.H.)
| | - K Koral
- From the Departments of Radiology (R.J., K.K., Y.X., T.N.B.)
| | | | - Y Xi
- From the Departments of Radiology (R.J., K.K., Y.X., T.N.B.)
| | | | - K Reeder
- Pediatrics (M.C., K.R., B.W., R.H.)
| | - B Weprin
- Pediatrics (M.C., K.R., B.W., R.H.).,Neurological Surgery (B.W.), Children's Health, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas
| | - R Huang
- Pediatrics (M.C., K.R., B.W., R.H.)
| | - T N Booth
- From the Departments of Radiology (R.J., K.K., Y.X., T.N.B.)
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Rebollo Polo M. Management of pediatric central nervous system emergencies: a review for general radiologists. RADIOLOGIA 2016; 58 Suppl 2:142-50. [PMID: 27138031 DOI: 10.1016/j.rx.2016.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/15/2016] [Accepted: 03/28/2016] [Indexed: 10/21/2022]
Abstract
TEACHING OBJECTIVES To review the most common and most important diseases and disorders of the central nervous system (CNS) in pediatric emergencies, discussing the indications for different imaging tests in each context. DISCUSSION In pediatric patients, acute neurologic symptoms (seizures, deteriorating level of consciousness, focal neurologic deficits, etc.) can appear in diverse clinical situations (trauma, child abuse, meningoencephalitis, ischemia…). It is important to decide on the most appropriate neuroimaging diagnostic algorithm for each situation and age group, as well as to know the signs of the most typical lesions that help us in the etiological differential diagnosis. Pediatric patients' increased vulnerability to ionizing radiation and the possible need for sedation in studies that require more time are factors that should be taken into account when indicating an imaging test. It is essential to weigh the risks and benefits for the patient and to avoid unnecessary studies.
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Affiliation(s)
- M Rebollo Polo
- Hospital Universitario Maternoinfantil Sant Joan de Dèu, Esplugues de Llobregat, Barcelona, España.
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Baumann F, Ernstberger T, Neumann C, Nerlich M, Schroeder GD, Vaccaro AR, Loibl M. Pediatric Cervical Spine Injuries: A Rare But Challenging Entity. ACTA ACUST UNITED AC 2016; 28:E377-84. [PMID: 26165728 DOI: 10.1097/bsd.0000000000000307] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Injuries to the cervical spine in pediatric patients are uncommon. A missed injury can have devastating consequences in this age group. Because of the lack of routine in diagnosis and management of pediatric cervical spine injuries (PCSI), each of these cases represents a logistic and personal challenge. METHODS By means of clinical cases, we demonstrate key points in diagnostics and treatment of pediatric spine injuries. We highlight typical pediatric injury patterns and more adult-like injuries. RESULTS The most common cause of injury is blunt trauma. There is an age-related pattern of injuries in pediatric patients. Children under the age of 8 frequently sustain ligamentous injuries in the upper cervical spine. After the age of 8, the biomechanics of the cervical spine are similar to adults, and therefore, bony injuries of the subaxial cervical spine are most likely to occur. Clinical presentation of PCSI is heterogeneous. Younger children can neither interpret nor communicate neurological abnormalities, which make timely and accurate diagnosis difficult. Plain radiographs are often misinterpreted. We find different types of injuries at different locations, because of different biomechanical properties of the immature spine. We outline that initial management is crucial for long-term outcome. CONCLUSIONS Knowledge of biomechanical properties and radiographic presentation of the immature spine can improve the awareness for PCSI. Diagnosis and management of pediatric patients after neck trauma can be demanding. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Florian Baumann
- *Department of Trauma Surgery, Regensburg University Medical Center, Regensburg, Germany †The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Chaudhry AS, Prince J, Sorrentino C, Fasanya C, McGinn J, Atanassov KD, Bloom S, Price M. Identification of Risk Factors for Cervical Spine Injury from Pediatric Trauma Registry. Pediatr Neurosurg 2016; 51:167-74. [PMID: 26992002 DOI: 10.1159/000444192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/21/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cervical spine injuries are rare in children. Our goal is to establish guidelines for cervical spine clearance that are practical for our pediatric population, and, in the process, to reduce the risk of radiation exposure from unnecessary advanced imaging. METHODS We retrospectively reviewed the records from the registries of two pediatric trauma centers from the past 11 years (January 2002 to June 2013). Patients aged 1 month to 17 years, who had a CT scan of the cervical spine due to trauma indication for possible cervical spine injury, were evaluated. RESULTS Three risk factors were identified as being significant for the presence of a cervical spine injury. Patients who sustained a cervical spine injury were more likely to be male (p = 0.0261), were more severely injured with a higher injury severity score (ISS 16.39 ± 15.79 injured vs. 8.7 ± 9.4 uninjured), and presented with neck tenderness (p = 0.0001). CONCLUSION In our study, significant cervical spine injury is related to male gender, higher ISS and neck tenderness.
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Eran A, Yousem DM, Izbudak I. Asymmetry of the Odontoid Lateral Mass Interval in Pediatric Trauma CT: Do We Need to Investigate Further? AJNR Am J Neuroradiol 2015; 37:176-9. [PMID: 26381552 DOI: 10.3174/ajnr.a4492] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 05/18/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE Odontoid lateral mass interval asymmetry can be within the normal spectrum or the result of traumatic atlantoaxial injury. We sought to set radiographic guidelines for further investigation of odontoid lateral mass interval asymmetry in cervical spine CT studies of pediatric trauma patients. MATERIALS AND METHODS Fourteen children with C1-2 ligamentous injury or atlantoaxial rotational fixation/subluxation were retrospectively identified. We identified an additional 56 children fulfilling the following inclusion criteria: 1) They underwent C-spine CT to exclude traumatic injury, and 2) C-spine clearance and follow-up. Those were matched for age, sex, and severity of traumatic insult with the injured group. Clinical data were collected, and we measured the following parameters: anterior atlantodental interval; odontoid lateral mass interval; and the rotation of the head, C1, and C2. RESULTS A significant difference (P < .001) was found between the groups in cervical tenderness and torticollis. There was a significant difference in the atlantodental interval value (3.3 ± 0.8 mm in injured and 2.2 ± 0.5 mm in noninjured). The directionality of head, C1, and C2 rotation was significantly (P < .05) more toward the same direction in the noninjured group. We found significant linear correlation between head rotation and ipsilateral odontoid lateral mass interval asymmetry only in the noninjured at C1-2. With multivariant analysis, the presence of cervical tenderness and an abnormal atlantodental interval were the most significant variables. CONCLUSIONS Odontoid lateral mass interspace asymmetry in the absence of cervical tenderness and with a normal atlantodental interval is likely in the normal range and need not be further investigated.
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Affiliation(s)
- A Eran
- From the Department of Radiology (A.E.), Rambam Health Care Campus, Haifa, Israel
| | - D M Yousem
- Department of Radiology (D.M.Y., I.I.), Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - I Izbudak
- Department of Radiology (D.M.Y., I.I.), Johns Hopkins Medical Institutions, Baltimore, Maryland
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Palasis S, Hayes LL. Acquired pathology of the pediatric spine and spinal cord. Pediatr Radiol 2015; 45 Suppl 3:S420-32. [PMID: 26346148 DOI: 10.1007/s00247-015-3328-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 12/21/2014] [Accepted: 02/24/2015] [Indexed: 12/13/2022]
Abstract
Pediatric spine pathology poses a diagnostic challenge for radiologists. Acquired spine pathology often yields nonspecific signs and symptoms in children, especially in the younger age groups, and diagnostic delay can carry significant morbidity. This review is focused on some of the more common diagnostic dilemmas we face when attempting to evaluate and diagnose acquired pediatric spine anomalies in daily practice. An understanding of some of the key differentiating features of these disease processes in conjunction with pertinent history, physical exam, and advanced imaging techniques can indicate the correct diagnosis.
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Affiliation(s)
- Susan Palasis
- Department of Radiology at Scottish Rite, Children's Healthcare of Atlanta, 1001 Johnson Ferry Road, Atlanta, GA, 30342, USA,
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Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, Schep NWL, van Rijn RR. Triage tools for detecting cervical spine injury in pediatric trauma patients. Hippokratia 2015. [DOI: 10.1002/14651858.cd011686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Annelie Slaar
- Academic Medical Center (AMC); Department of Radiology; Amsterdam Netherlands 1105 AZ
| | | | - Junfeng Wang
- Academic Medical Center; Department of Clinical Epidemiology, Biostatistics and Bioinformatics; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Mario Maas
- Academic Medical Center; Department of Radiology; University of Amsterdam Meibergdreef Amsterdam Netherlands
| | - David J Wilson
- St Lukes Hospital; Department of Radiology; Latimer Road Headington Oxford UK OX3 7PF
| | - J Carel Goslings
- Academic Medical Center; Trauma Unit, Department of Surgery; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Niels WL Schep
- Academic Medical Center; Department of Surgery/Trauma Unit; Meibergdreef 9 Amsterdam Netherlands 1105AZ
| | - Rick R van Rijn
- Academic Medical Center Amsterdam; Department of Radiology; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
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The benefit of neck computed tomography compared with its harm (risk of cancer). J Trauma Acute Care Surg 2015; 78:126-31. [PMID: 25539213 DOI: 10.1097/ta.0000000000000465] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to compare the benefit of neck computed tomography (CT) of identifying important cervical spine injuries (CSIs) with its harm of radiation exposure and cancer risk. METHODS A PubMed search for published studies relating to CSI in trauma, cervical spine imaging, CT, and cancer risk was conducted. Article abstracts were reviewed, and selected published studies relating to the study objective were retrieved. RESULTS Of 100,000 trauma patients, neck CT scans were obtained in 3,767 to 26,785 patients. Of 100,000 patients with trauma on whom a neck CT scan was performed, a CSI was identified in 2,470 to 33,898 patients. Clinically important CSI ranged from 4,724 to 27,119 per 100,000 CT scans. For every 100,000 neck CT scans performed, additional cancer cases occur in a low end estimate of a thyroid cancer cases to a high end estimate of 100 male and 700 female cancer cases. In females, cancer risks are higher than in males, and these are closer to, but still less than, the incidence of clinically important CSI found by CT. CONCLUSION CT's benefit of identifying important CSIs in the published studies exceeds its cancer harm risk. However, at their extremes, the numbers are disturbingly close. Limiting neck CT scanning to a higher-risk group would increase the gap between benefit and harm, whereas performing CT routinely on low-risk cases approaches a point where its harm equals or exceeds its benefit. LEVEL OF EVIDENCE Systematic review, level IV.
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Paediatric trauma imaging: Why do we need separate guidance? Clin Radiol 2014; 69:1209-13. [DOI: 10.1016/j.crad.2014.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 06/16/2014] [Accepted: 07/01/2014] [Indexed: 11/22/2022]
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The communication of the radiation risk from CT in relation to its clinical benefit in the era of personalized medicine: part 2: benefits versus risk of CT. Pediatr Radiol 2014; 44 Suppl 3:525-33. [PMID: 25304716 DOI: 10.1007/s00247-014-3087-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 05/06/2014] [Accepted: 06/12/2014] [Indexed: 01/19/2023]
Abstract
In order to personalize the communication of the CT risk, we need to describe the risk in the context of the clinical benefit of CT, which will generally be much higher, provided a CT scan has a well-established clinical indication. However as pediatric radiologists we should be careful not to overstate the benefit of CT, being aware that medico-legal pressures and the realities of health care economics have led to overutilization of the technology. And even though we should not use previously accumulated radiation dose to a child as an argument against conducting a clinically indicated scan (the "sunk-cost" bias), we should consider patients' radiation history in the diagnostic decision process. As a contribution to future public health, it makes more sense to look for non-radiating alternatives to CT in the much larger group of basically healthy children who are receiving occasional scans for widely prevalent conditions such as appendicitis and trauma than to attempt lowering CT use in the smaller group of patients with chronic conditions with a limited life expectancy. When communicating the CT risk with individual patients and their parents, we should acknowledge and address their concerns within the framework of informed decision-making. When appropriate, we may express the individual radiation risk, based on estimates of summated absorbed organ dose, as an order of magnitude rather than as an absolute number, and compare this with the much larger natural cancer incidence over a child's lifetime, and with other risks in medicine and daily life. We should anticipate that many patients cannot make informed decisions on their own in this complex matter, and we should offer our guidance while maintaining respect for patient autonomy. Proper documentation of the informed decision process is important for future reference. In concert with our referring physicians, pediatric radiologists are well-equipped to tackle the complexities associated with the communication of CT risk, a task that often falls upon us, and by becoming more involved in the diagnostic decision process we can add value to the health care system.
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Abstract
Care of the ill and injured child requires knowledge of unique pediatric anatomic and physiologic differences. Subtleties in presentation and pathophysiologic differences impact management. This article discusses pediatric resuscitation, the presentation and management of common childhood illness, pediatric trauma, and common procedures required in the critically ill child.
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Sun R, Skeete D, Wetjen K, Lilienthal M, Liao J, Madsen M, Lancaster G, Shilyansky J, Choi K. A pediatric cervical spine clearance protocol to reduce radiation exposure in children. J Surg Res 2013; 183:341-6. [PMID: 23357274 DOI: 10.1016/j.jss.2012.12.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 12/14/2012] [Accepted: 12/21/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND To minimize radiation exposure in children and reduce resource use, we implemented an age-specific algorithm to evaluate cervical spine injuries at a Level 1 trauma center. The effects of protocol implementation on computed tomography (CT) use in children (≤ 10 y) were determined. METHODS With institutional review board approval, we conducted a retrospective review using the institutional trauma registry. All pediatric patients (≤ 10 y) (n = 324) between January 2007 and present were reviewed. We excluded cases in which no imaging or outside imaging was performed. Patients were evaluated by physical exam alone, with the aid of plain radiograms or with cervical spine CT. All patients who required head CT also had CT of cervical spine to C3. We analyzed demographic, injury, and outcome data using STATA to perform chi-square and t-test, and to determine P value. P < 0.05 was defined as significant. We used the WinDose program to calculate the radiation-effective dose used in cervical spine CT. RESULTS There were 123 and 124 patients in the pre-protocol and post-protocol groups, respectively. Demographics, GCS, and injury analysis, specifically head-neck and face Injury Severity Scores showed no significant difference between groups. There was a 60% (P < 0.001) decrease in the use of full CTs after protocol implementation. We estimated that the protocol reduced the exposed area by 50% and decreased the radiation dose to the thyroid by > 80%. We extrapolated the combined effect results in a threefold reduction in radiation exposure. CONCLUSIONS Implementation of a cervical spine protocol led to a significant reduction in radiation exposure among children.
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Affiliation(s)
- Raphael Sun
- Department of Surgery, Division of Acute Care Surgery and Pediatric Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA.
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Matshes EW, Selanders L, Hatch G, Lew EO. Injuries of the Upper Cervical Spinal Column are Markers of Severe Forces in the First Two Years of Life. Acad Forensic Pathol 2012. [DOI: 10.23907/2012.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cervical spinal column injuries occur uncommonly in infants and young toddlers, and rarely in the upper cervical spine. Any injury, when discovered at forensic autopsy, must be interpreted within the context of a complete case investigation, and available science. When severe upper cervical spinal column injury is detected, such as atlanto-occipital dislocation (AOD), atlanto-axial dislocation (AAD) or spinal cord transection, forensic pathologists commonly regard such trauma as a marker of significant forces. This retrospective study evaluated 60 cases of accidental and homicidal deaths occurring in the first 24 months of life and investigated by a large metropolitan medical examiner jurisdiction. All cases with AOD, AAD or spinal cord transection occurred under documented accidental circumstances, and all of those cases involved severe forces, including being struck by or run over by a car. While such high cervical spinal column pathology is not unusual when an infant or young toddler is struck by or run over by a motor vehicle, or other accidental circumstance involving severe forces, this discovery in a case of apparent natural death or death following alleged short fall or other commonplace activity of daily living should be considered highly suspect.
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Affiliation(s)
- Evan W. Matshes
- Medical Investigator and Pediatric Forensic Pathology, Office of the Medical Investigator, Albuquerque NM
| | - Lori Selanders
- Academic Forensic Pathology Incorporated -Research Division, Calgary, AB, Canada (LS)
| | - Gary Hatch
- University of New Mexico - Radiology and Pathology, Albuquerque, NM (GH)
| | - Emma O. Lew
- Miami-Dade County Medical Examiner Department (EL)
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