Cervical Spine Evaluation in Obtunded or Comatose Pediatric Trauma Patients: A Pilot Study

Abstract

A uniformly accepted protocol for evaluation and clearance of the cervical spine of pediatric trauma patients with altered mental status does not currently exist. We sought to detect cervical spine injuries in this group with minimal risk. Patients were evaluated with standard three-view cervical spine radiographs and CT when necessary. Those patients without radiographic abnormality and altered mental status underwent flexion-extension of the cervical spine using fluoroscopy with somatosensory evoked potential (SSEP) monitoring. Those with abnormal movement by fluoroscopy or changes in SSEP underwent MRI. Fifteen patients were evaluated with this protocol. Two patients had movement on flexion-extension of the cervical spine and 5 had SSEP changes. Three patients had an MRI with only 1 showing injury. Five patients had residual hemiparesis. Evaluation of the cervical spine in obtunded or comatose pediatric trauma patients can be done safely with flexion-extension under fluoroscopy and SSEP monitoring. Further prospective studies are required to determine the efficacy of SSEP monitoring for cervical spine clearance in this select population.

Cervical Spine Injuries in Children, Part I: Mechanism of Injury, Clinical Presentation, and Imaging

“…To increase the sensitivity of detecting injuries in children, they suggested expanding the criteria and imaging the C-spine whenever the NEXUS criteria were present or there was significant mechanism of injury, a history of transient neurologic symptoms or physical evidence of neck trauma, significant trauma to the head or face, or the child was inconsolable (27). Other authors suggest imaging the spine whenever the patient has a Glasgow Coma Scale (GCS) score of Ͻ 14 (28). Clearly, there is no consensus on the appropriate criteria for determining when children require C-spine imaging in the ED.…”

Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening

“…It is assumed that instability will be demonstrated under real time imaging, and the test can be terminated before significant cord injury occurs. While this may not be unreasonable, the procedure could potentially be made safer by performing a preceding axial 'stretch test' [116] or monitoring somatosensory evoked potentials [185]. Most studies use criteria for instability similar to those defined by White & Panjabi [186] of 3 mm displacement of adjacent vertebrae or > 11°of angulation, but this is by no means standard.…”

Trauma Association of Canada Pediatric Subcommittee National Pediatric Cervical Spine Evaluation Pathway: Consensus Guidelines

“…GRADE recommendation: Conditional Literature Review: a. Scarrow et al 9 performed a pilot study reviewing 17 patients who underwent fluoroscopic FE maneuvers of the cervical spine with somatosensory-evoked potential (SSEP) monitoring. They documented the outcome in 15 patients and found that 7 had hemiparesis.…”