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

Abstract

Objectives While cervical spine injuries (CSIs) are rare in the paediatric population, presentations to EDs with possible neck injuries are common. Based on a lack of Australian data we set out to determine how many possible injuries are clinically cleared, what imaging is used on the remainder and the incidence and characteristics of confirmed paediatric CSIs. Methods We undertook a retrospective electronic medical record review of children <18 years with potential CSIs at a large tertiary paediatric trauma centre in Victoria, Australia over a 12 month period (annual census 87 000). For possible injuries we extracted key epidemiologic, imaging and short‐term outcome data. Results During the study period, a total of 617 patients with potential neck injuries were seen in the ED (617/87 000, 0.7%). The median age was 11 years. The most common mechanisms of injury were falls (41%), motor vehicle injuries (28%) and sports‐related injuries (24%). Four hundred and fourteen of 617 (67%) underwent neck imaging (345/414, 83% plain radiograph; 100/414, 24% computed tomography; 7/414, 1.6% magnetic resonance imaging). Twenty‐three of 617 (4.1%) had radiologically documented CSIs. Two required operative interventions for their neck injuries. Conclusion While two‐thirds of children with potential CSIs undergo radiological evaluation, actual injuries are rare (<4%). These data suggest that there is a potential for improved targeting of cervical spine imaging for trauma. The development of a clinical decision tool may help reduce neck radiography.

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

“…These data correspond with the findings of previous studies-performed both in level 1 trauma centres and other hospitals-which have also reported low incidences. The incidence varies from 0.3-3.7%, depending on the specific population studied [4][5][6][7]28]. Our study confirms that a child presenting at a level 2 trauma centre after blunt trauma is very unlikely to have relevant C-spine injury.…”

“…In the paediatric ED, a CT of the brain is by far the most commonly performed CT examination; the largest increase, however, has been reported for CT scans of the cervical spine and chest [32,33]. And although some studies report that the total volume of CT utilization in children seems to have declined over the last decade-possibly due to the widespread introduction of clinical decision tools [26,31,34]-others still report a stable, increased or unexpectedly high CT utilization rate in children suffering blunt trauma [28,35]. This suggests that protocols are still not being sufficiently implemented in daily practice, or that concurrent developments are hindering physicians' adherence to these protocols.…”