Objectives and hypotheses
Are the objectives of the study clearly stated?
Yes. Authors are trying to determine if the risk factors for isolated head injury are identical to multiple head trauma. Also they investigate whether the same indications for radiographic evaluation of suspected cervical spine injuries apply.
Is the study design suitable for the objectives?
Yes. Study is designed to identify the significant risk factors for radiographic evaluation of cervical spine among children with isolated head injuries
Who / what was studied?
268 paediatric patients with isolated head injuries admitted to the Paediatric Intensive Care Unit at Children's Hospital Medical Centre in Cincinati, Ohio between 1 January 1985- 31 December 1990
Was a control group used if appropriate?
Were outcomes defined at the start of the study?
Yes. From each patient record the following information was obtained: age, sex, specific type(s) of head and neck injury, mechanism of injury, signs and symptoms of neck injury and results of radiographic image of the neck
Patients were then divided into low risk group of CSI (capable of verbal communication and no neck tenderness) and high risk groups (unable to communicate and complained of neck pain or tenderness)
Was this the right sample to answer the objectives?
The sample may not be representative because all patients were taken from the Paediatric Intensive Care Unit of a single hospital and only children with isolated head injuries took part in the study.
Is the study large enough to achieve its objectives? Have sample size estimates been performed?
Only 215(80%) of 268 patients underwent cervical spine radiographs and only 10 had sustained concurrent neck injury. Number of patients therefore used for this study is relatively small.
Were all subjects accounted for?
As mentioned in 2.6 only 80% of paediatric patients were accounted for.
Were all appropriate outcomes considered?
Yes all appropriate outcomes were considered for each individual case.
Has ethical approval been obtained if appropriate?
This retrospective study was approved by the Director of the PICU and the Institutional Review Board.
Measurement and observation
Is it clear what was measured, how it was measured and what the outcomes were?
Yes. Authors divided the children in two group based: 1. on ability to verbalise and no complain of neck pain or tenderness 2. unable to verbalize (preverbal <2years old, significant brain stem injury, inconsolable, Alcohol/Substance abuse) and/or neck pain. CS radiographs confirmed CSI.
Was the assessment of outcomes blinded?
Was follow up sufficiently long and complete?
Five year Follow up did not show any asymptomatic neck injuries since the original head trauma.
Are the measurements valid?
Yes, measurements used in this study were based on current recommendations for c-spine imaging
Are the measurements reliable?
Not exactly as the measurements in this study such as the ability to verbalise and presence of neck pain or tenderness were largerly based on physician's discretion.
Are the measurements reproducible?
This was a retrospective study so measurements taken for each individual are readily available on patients record.
Presentation of results
Are the basic data adequately described?
Yes basic data is extensively and clearly tabulated in tables
Are the results presented clearly, objectively and in sufficient detail to enable readers to make their own judgement?
Yes all the results are tabulated in detail and clearly in tables and in turn enable the reader to come up with his own conclusions
How large are the effects within a specified time?
Are the results internally consistent, i.e. do the numbers add up properly?
Are the data suitable for analysis?
Sample data was relatively small, came from a single hospital. Also CSI sample was also small making statistical analysis not very strong.
Are the methods appropriate to the data?
For the data obtained a chi-square analysis was applied to determine whether the difference in the odds ratio between the two groups was significant.
Are any statistics correctly performed and interpreted?
Yes as mentioned above.
Are the results discussed in relation to existing knowledge on the subject and study objectives?
Yes the discussion commented on the results obtained and their significance by relating to current knowledge
Is the discussion biased?
No, authors state that as this was a retrospective study there were potential limitations such as errors in chart documentation and examination was based on physician level of experience. Also they comment on their findings and make appropriate deductions based on the findings.
Are the author's conclusions justified by the data?
Yes, author's conclusions are solely based on the findings of this study
What level of evidence has this paper presented? (using CEBM levels)
Retrospective Cohort Study. Class III
Does this paper help me to answer my problem?
Yes, this paper proved very helpful. It provided a clear message regarding the recommendations for radiographic evaluation of suspected cervical spine injuries.
Can any necessary change be implemented in practice?
Although the study is old (1994) , a new review published recently (Neuroscience (2002), Vol. 50, Supplement 3, S85-S99) , incorporates the findings of this study into new guidelines for the radiographic evaluation of suspected CSI
What aids to implementation exist?
The current lack of diagnostic guidelines makes the findings of this study to be readily taken up, and as I already mentioned in 8.1 they have been incorporated into new guidelines for the radiographic evaluation of suspected CSI
What barriers to implementation exist?
Fear of missing a cervical spine injury.
Are the study patients similar to your own?
No, our patients are not ICU patients and may have either sustained multiple or isolated head trauma and they present to A&E.
Does the paper give any conclusions that will affect what you will offer or tell your patient?
Yes, this paper suggests that radiographic imaging indications (inability to verbalize and neck pain/tenderness) for suspected CSI are the same for both paediatric patients with isolated head injuries as do multiple trauma victims