Developing a Spinal Clearance Protocol for Unconscious Pediatric Trauma Patients

Abstract

There is a need for an evidence-based protocol for the clearance of the spine in the obtunded and high-risk pediatric trauma patient. High-resolution CT with sagittal and coronal reconstructions should be the basis for cervical spinal clearance, in combination with the interpretation of films by an expert radiologist. All spinal regions should be imaged, and clearance should be formally documented. The role of magnetic resonance imaging in routine clearance remains controversial. Multicenter prospective studies are needed to develop consensus for an evidenced-based protocol for clearance in this high-risk group.

Imaging investigations in Spine Trauma: The value of commonly used imaging modalities and emerging imaging modalities

“…52,53 These are better visualised with MRI. [52][53][54][55][56][57] Therefore some guidelines advise primary imaging screening with radiographs followed by MRI rather than CT, if deemed necessary. 20 Older studies have found as many as 7% of significant neck injuries missed with CT. 58 However some authors argue that spinal injury without CT abnormality in children is very rare and that CT should be the investigation of choice just like in adults.…”

“…20 Older studies have found as many as 7% of significant neck injuries missed with CT. 58 However some authors argue that spinal injury without CT abnormality in children is very rare and that CT should be the investigation of choice just like in adults. 54 Flexion/extension radiographs, either dynamic or static, in obtunded patients should now be obsolete. They do not reliably show instability and risk worsening neurological compromise.…”

“…In children MRI is even more important as often injuries affect the soft tissue only, rather than bone. 53,54,57,93 In the past cervical spine clearance protocols based on radiographs combined with MRI have also been investigated and found to be sensitive for all relevant injuries. 94 However, this approach is nowadays reserved for paediatric imaging.…”

“…Finally, it is not universally agreed how trauma spine imaging in children should be performed, whether and if so which role CT plays, or whether radiographs supplemented by MRI are the imaging investigations of choice. 10,20,[52][53][54] The issues outlined above result in some variation in currently published spine trauma clearance guidelines.…”

Management of Pediatric Cervical Spine and Spinal Cord Injuries

“…Hutchings et al 17 reviewed c-spine clearance methods retrospectively in 115 consecutive obtunded major trauma patients ,16 years of age. No protocol was used during the 7-year study period.…”