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

Abstract

Background: Safe and effective clearance of the pediatric cervical spine presents a challenging problem due to a myriad of reasons, which has often led to further imaging studies such as computed tomographic (CT) scans being performed, exposing the pediatric patient to significant radiation with a potential increased cancer risk. The goal of this study is to develop an effective algorithm for cervical spine clearance that minimizes radiation exposure. Methods: A cervical spine clearance protocol had been utilized in our institution from 2002 to 2011. In October 2012, the protocol was revised to provide indications for appropriate imaging by utilizing repeat “next day” physical examination. In 2014, the protocol was again revised with the desired goal of decreasing the use of CT scans through increased involvement of the Spine Service. A retrospective review was commenced using information from the Trauma Database from 2011 to 2014. Three groups were analyzed according to which protocol the patients were evaluated under: 2011, 2012, and 2014 protocols. Results: During the study period, 762 patients underwent cervical spine clearance; 259 (2011 protocol), 360 (2012 protocol), and 143 (2014 protocol). The average age of all patients was 8.8 years, with 28% of patients younger than 5 years of age. There were no missed or delayed diagnoses of cervical spine injury. The use of CT scans decreased during the study period from 90% (2011 protocol) to 42% (2012 protocol) to 28.7% (2014 protocol). There was an increase in time to removal of the cervical collar at 13 to 24 hours from 8% (2011 protocol) to 22% (2012 protocol) to 19% (2014 protocol). This was not associated with an increase in hospital length of stay, which averaged 2.51 days (2011 protocol), 2.45 days (2012 protocol), and 2.27 days (2014 protocol). Conclusions: Repeat “next day” clinical examinations and increased involvement of the Spine Service decreased radiation exposure without compromising the diagnosis of cervical spine injury or increasing the length of stay at a Level One Pediatric Trauma Center in this pilot study. Level of Evidence: Level 4—case series.

Variability of Pediatric Cervical Spine Clearance Protocols

“…The algorithm in Anderson et al30 pertained only to patients 0 to 3 years old and liberally imaged all patients at their initial triage point. The algorithm in Kavuri et al31 relied heavily on spine service consultation rather than clinical clearance by the trauma team. The 2 remaining protocols reported their experiences in unconscious patients only and therefore did not use any of the NEXUS criteria 20,21…”

“…Waddell and Connelly 24 combined an educational program for clinicians with the implementation of a protocol at their Level I pediatric trauma center, with a resultant 47% decrease in CT usage after both elements were implemented. Kavuri et al 31 revised their institutional protocol twice during the study period at their Level I pediatric trauma center, with the rate of CT usage decreasing after both revisions were implemented, from 90% initially to 42% to 28.7% after the first and second revision, respectively. Luehmann and colleagues found no change in the rate of CT usage before and after protocol implementation at their pediatric Level 2 trauma center.…”

The Fate of the Cervical Collar

“…Pediatric patients have been shown previously to have low rates of CSI. [5][6][7][8][9]13 Those without a diving/axial load mechanism, along with a normal mental status and intact neurologic examination, have even lower risk. 1,6 However, posterior cervical midline tenderness often prompts concern for CSI.…”

Detection of Ischemic Colitis on Routine Lower Endoscopy and Its Implications After Repair of Ruptured Abdominal Aortic Aneurysm

“…Ischemic colitis (IC) is a well-documented complication of abdominal aortic aneurysm surgery that portends poor outcomes. [1][2][3] The incidence of IC has decreased with the overall trend towards management of abdominal aortic aneurysms with the endovascular aneurysm repair (EVAR) approach compared to open surgical repair (OSR) [4][5][6][7] ; however, the incidence remains higher among patients who suffer a ruptured abdominal aortic aneurysm (rAAA) for both repair approaches. 8,9 Various clinical predictors of IC have been studied, [10][11][12] but the diagnostic test of choice is lower endoscopy (flexible sigmoidoscopy and colonoscopy) to establish the diagnosis and guide management.…”