Objectives and hypotheses
Are the objectives of the study clearly stated?
Yes. The aim of this study is to determine if the open-mouth odontoid view is necessary in the evaluation of the paediatric cervical spine.
Is the study design suitable for the objectives?
Yes. This is a multi-institutional, retrospective,uncontrolled Cohort study.
This is adequate for assessing the necessity of the open-mouth odontoid view in the evaluation of the paediatric cervical spine.
Who / what was studied?
All paediatric patients 16 years of age and under who sustained documented cervical spine injury during a 10-year period from 1987-1997.
51 children with cervical spine injury were identified from the medical records at 4 hospitals.
Was a control group used if appropriate?
No control group was used in this study.
Were outcomes defined at the start of the study?
Yes. Variables analyzed were the following:
Demographic patient data (age,sex)
Mechanism of Injury
Physical examination findings
Radiographic analysis that made the diagnosis
All other radiographic analysis ordered
The value of the odontoid view in making the diagnosis
Was this the right sample to answer the objectives?
Patients were divided in 2 age groups (0-8 and 9-16) based on the age at which the pediatric cervical spine is considered to attain adult characteristics.
Is the study large enough to achieve its objectives? Have sample size estimates been performed?
The sample size used in the study was too small
Although this is a multi-institutional study performed on all patients 16 years and under who sustained documented cervical spine injury during a 10 year period, only 15 children were contained in the 0-8 age group and 36 in the 9-16 age group
Were all subjects accounted for?
Yes all patients 16 years and under who sustained documented cervical spine injury during a 10 year period at all 4 hospitals were accounted for.
Were all appropriate outcomes considered?
Yes. All possible outcomes mentioned previously were considered in the study.
Has ethical approval been obtained if appropriate?
Measurement and observation
Is it clear what was measured, how it was measured and what the outcomes were?
Yes. All outcomes are clearly presented and tabulated in tables concerning
Mechanism of injury: Most common in both age groups MVA 35%
Gading System of Neurological Deficit: 67% intact, 13.4% complete lesions and 19.6% varied from mild to severe
Type of injury: 0-8 group most common subluxation 9-16 most common fracture
Site of Injury: 0-8 group most common upper cervical 9-16 most common C4-C7
Diagnosis of cervical spine injury:
AP/lateral x-rays 13/15 (87%) 23/36 (64%)
Odontoid x-ray 0/15 (0%) 1/36 (3%)
Other(MRI/CT) 2/15 (13%) 12/36 (33%)
Was the assessment of outcomes blinded?
Was follow up sufficiently long and complete?
Follow up was for a 10 year period
Are the measurements valid?
All measurement outcomes are valid
Radiographic tool that made the diagnosis is the one recommended by current guidelines (initial AP/ lateral x-rays followed by odontoid, CT, MRI etc) for evaluation of the paediatric cervical spine.
Are the measurements reliable?
Yes, but making the diagnosis depends on the level of experience of the radiologist and his practice years.
Are the measurements reproducible?
Yes measurements are reproducible as they were obtained from the medical records of the paediatric patients.
Presentation of results
Are the basic data adequately described?
Yes. 5 tables of results presented and results are extensively analyzed in the article
Are the results presented clearly, objectively and in sufficient detail to enable readers to make their own judgement?
Yes, results are presented very clearly and in sufficient detail in tables.
In addition they are extensively analyzed and presented to the reader enabling him/her to draw their own conclusions.
How large are the effects within a specified time?
Are the results internally consistent, i.e. do the numbers add up properly?
Yes all the numbers presented in the tables add up properly and so do the corresponding percentages.
Are the data suitable for analysis?
Although the data (0-8 age group = 15 children / 9-16 age group = 36 ) is relatively small for analysis the authors proceeded to analyse which type of cervical injury (upper vs lower) is more common for each group.
Are the methods appropriate to the data?
A chi-square analysis was performed to analyse any significant difference between upper vs lower cervical injury in each group.
Are any statistics correctly performed and interpreted?
Chi-square analysis was performed as arleady mentioned and showed that the 0-8 age group is more likely to have an upper cervical spine injury than a lower c-spine injury, where as the two injuries are almost even in the 9-16 age group.
However its use is questionable due to the very small sample data for each group and results obtained might be invalid.
Are the results discussed in relation to existing knowledge on the subject and study objectives?
Although the overall number of patients in this study is small, the current literature concerning the use of the odontoid peg view in paediatric patients suspected of cervical spine injury is very limited, and this is the largest current series of paediatric cervical spine injuries in the literature.
The authors do try to discuss the results in relation to some reported cases.
Is the discussion biased?
No the discussion is fair.
Are the author's conclusions justified by the data?
The authors conclude that based on the results the odontoid peg view is of little value in the evaluation of cervical injuries in the age group 0-8.
However, they do appreciate that the overall number of patients used in this study is small and their results may be representative of the whole population.
They also recommend the use of AP and lateral x-rays, followed by a CT in doubtful cases.
What level of evidence has this paper presented? (using CEBM levels)
Does this paper help me to answer my problem?
Yes, the odontoid view appears to be of little value in the age group 0-8 however this must be used with caution considering the small sample used in this study.
The use of AP and lateral x-rays, followed by a CT in doubtful cases appears to be the best strategy in the evaluation of paediatric patients with c-spine injuries.
Can any necessary change be implemented in practice?
The odontoid peg view proves of little value in the traditional three view approach in the age-group 0-8.
An alternative evaluation for clearing the paediatric cervical spine should be an initial AP and lateral x-rays followed by CT scan in cases of suspected c-spine injury.
What aids to implementation exist?
Prior to age of nine the paediatric cervical spine is anatomically distinct than the adult cervical spine and the odontoid view film is usually of poor quality.
Young patients usually cannot or will not cooperate with the opening of the mouth required to obtain this view and inserting some stenting device into the mouth might frighten the infant or toddler and can compromise airway control and provoke vomiting.
What barriers to implementation exist?
Fear of missing a cervical fracture as this may lead to neurological sequelae
The number of children used in this study is very small and may not be representative of the true paediatric population
Are the study patients similar to your own?
Despite the fact that these are American children who have sustained documented cervical spine injury, other demographics appear similar to UK children.
Does the paper give any conclusions that will affect what you will offer or tell your patient?
The odontoid peg view might be unnecessary in children less than 9 years with suspected c-spine injury.
AP and lateral x-rays should be performed followed by a CT scan in doubtful cases.