Pediatric Cervical Spine Clearance

Herman, Martin J.; Brown, Kristin O.; Sponseller, Paul D.; Phillips, Jonathan H.; Petrucelli, Philip; Parikh, Darshan; Mody, Kush S.; Leonard, Julie C.; Moront, Matthew; Brockmeyer, Douglas L.; Anderson, Richard C. E.; Alder, Adam C.; Anderson, John T.; Bernstein, Robert; Booth, Timothy N.; Braga, Bruno Perocco; Cahill, Patrick J.; Joglar, Jeanne M; Martus, Jeffrey E.; Nesiama, Jo-Ann; Pahys, Joshua M.; Rathjen, Karl E.; Riccio, Anthony I.; Schulz, Jacob F.; Stans, Anthony A.; Shah, Manish I.; Warner, William C.; Yaszay, Burt

doi:10.2106/jbjs.18.00217

Cited by 61 publications

(2 citation statements)

References 28 publications

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“…12 13 ED clinicians are thus faced with the decision of which children should receive imaging and for whom it can be safely avoided. [14][15][16] To address these concerns, attempts have been made to risk stratify patients with blunt trauma, identifying those at higher risk of CSI, and thus in need of imaging, through the use of clinical decision rules (CDRs). The most well known of these are the US derived National Emergency X-Radiography Utilization Study Low Risk Criteria (NEXUS) 17 18 and the Canadian C-Spine rule (CCR).…”

Section: Introductionmentioning

confidence: 99%

Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort

et al. 2021

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BackgroundClinical decision rules (CDRs) are commonly used to guide imaging decisions in cervical spine injury (CSI) assessment despite limited evidence for their use in paediatric populations. We set out to determine CSI incidence, imaging rates and the frequency of previously identified CSI risk factors, and thus assess the projected impact on imaging rates if CDRs were strictly applied as a rule in our population.MethodsA single-centre prospective observational study on all aged under 16 years presenting for assessment of possible CSI to a tertiary paediatric emergency department over a year, commencing September 2015. CDR variables from the National Emergency X-Radiography Utilization Study (NEXUS) rule, Canadian C-Spine rule (CCR) and proposed Paediatric Emergency Care Applied Research Network (PECARN) rule were collected prospectively and applied post hoc.Results1010 children were enrolled; 973 had not received prior imaging. Of these, 40.7% received cervical spine imaging; 32.4% X-rays, 13.4% CT scan and 3% MRI. All three CDRs identified the five children (0.5%) with CSI who had not received prior imaging. If CDRs were strictly applied as a rule for imaging, projected imaging rates in our setting would be as follows: NEXUS-44% (95% CI 41% to 47.4%), CCR-at least 48.4% (95% CI 45.3% to 51.7%) and PECARN-68% (95% CI 65.1% to 71.1%).ConclusionCSIs were rare (0.5% of our cohort), however, 40% of children received imaging. CDRs have been designed to guide imaging decisions; if strictly applied as a rule for imaging, the CDRs assessed in this study would increase imaging rates. Projected rates differ considerably depending on the CDR applied. These findings highlight the need for a validated paediatric-specific cervical spine imaging CDR.

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Section: Introductionmentioning

confidence: 99%

Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort

et al. 2021

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“…A CT scan of the C-spine is only indicated in those patients for whom a fracture is seen on plain radiography or for whom there is clinical suspicion of CSI despite a negative result with plain radiography [20][21][22]. A CT scan of the C-spine is the primary imaging modality exclusively in patients who are haemodynamically unstable or who have a reduced level of consciousness [23,24]. The main reason for this is the increased risk of thyroid cancer: the relative risk from a CT scan is thought to be 13-25% higher than the risk from a plain radiograph [21,25,26], except for low dose CT.…”

Section: Introductionmentioning

confidence: 99%

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

Brinke

Slinger

Slaar³

et al. 2020

Eur J Trauma Emerg Surg

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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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Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years

Luckhurst,

Wiberg,

Brown

et al. 2023

JAMA Surg

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ImportanceThere is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients.ObjectiveTo develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model.Design, Setting, and ParticipantsThis cohort study included pediatric patients (&lt;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.ExposureBlunt trauma.Main Outcomes and MeasuresPrimary outcome was CSI. The primary and secondary objectives were predetermined.ResultsThe 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 RelevanceThis 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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Pediatric Cervical Spine Clearance

Cited by 61 publications

References 28 publications

Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort

Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort

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

Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years

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