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Three Part Question

In [unconscious children with suspected c-spine injury] are there [radiological protocols] to [clear the c-spine]?

Clinical Scenario

A 7 year old boy is brought into your ED following a road traffic collision while on his push bike. He was not wearing a helmet. He has sustained a head injury and has been intubated and ventilated in preparation for transfer for imaging. You know that his c-spine collar is associated with decubitus ulcers and increased ICP. You wonder if there are any evidence based protocols for clearing his c-spine at the same time.

Search Strategy

MEDLINE OVID 1950-Feburary 2010
[exp Cervical Vertebrae OR cervical vertebrae.mp] AND [Spinal Injuries OR spinal injury.mp] AND [exp Unconsciousness OR unconsciousness.mp] OR [obtunded.mp] LIMIT to (English language and “all child (0-18 years)”)

Search Outcome

19 papers were found, of which 4 were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Frank, JB et al 2002 USA	102 intubated children with suspected cervical spin injury. 51 managed with standard care, then next 51 managed with new protocol with early MRI.	Retrospective case analysis, then prospective analysis after new intervention. Level III	Time to c-spine clearance	5.1 days in preprotocol group; 3.2 days in protocol group	No consideration of potentially missed injuries. No long term follow-up. Not randomised controlled trial.
			Time to ICU discharge	9.2 days in preprotocol group; 7.3 days in protocol group
Flynn JM et al 2002 USA	237 children underwent MRI after cervical spine injury within 3 days of injury, of which 25 were ‘intubated, obtunded or uncooperative’.	Assessing result of new protocol. No comparison made. Level V.	No missed c-spine injuries.	3 were found to have c-spine injuries. 22 were ‘cleared’ with no subsequent problems in the subsequent 5 years	Small numbers. Not randomised controlled trial/no comparisons made.
Lee, SL et al. 2003 USA	12 intubated patients with suspected cervical spine injury. 6 managed with standard care, then next 6 managed with ‘consensus protocol’ involving early MRI	Retrospective case analysis, then prospective analysis after new intervention. Level III	No missed c-spine injuries	No c-spine injuries were missed.	Small numbers. Not randomised controlled trial.
			Time to ICU discharge.	40 hours in standard care group; 19.4 hours in protocol group
Scarrow AM et al 1999 USA	17 obtunded or comatose patients were assessed with a protocol involving dynamic fluoroscopy with somatosensory evoked potential monitoring; if there were abnormalities MRI was done.	Assessing results of new protocol. No comparison made. Level V	Protocol can reliably rule out c-spine injury.	Protocol could not reliably rule out c-spine injury.	Small numbers. Study protocol not consistently followed by researchers.

Comment(s)

There is no direct answer to the question, and all of the studies admit that there is much more work to be done in this area. More widespread use of MRI can help clinicians be more confident about ruling out cervical spine injury in the unconscious child, but there is no long term follow up data on this. This type of scanning is time-consuming and problematic in ventilated patients, and currently is not a viable option as first line imaging in ED patients.

Clinical Bottom Line

There is no evidence-based protocol to clear the c-spine in the unconscious child. A case-by-case approach and consideration of MRI scanning is warranted.

References

1. Frank JB et al The efficacy of magnetic resonance imaging in pediatric cervical spine clearance. Spine 2002; 27: 1176-1179
2. Flynn JM et al The efficacy of magnetic resonance imaging in the assessment of pediatric cervical spine injuries. Journal of Pediatric Orthopaedics 2002; 22: 573-577
3. Lee SL et al A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results. Journal of Pediatric Surgery 2003; 38: 358-362
4. Scarrow AM et al Cervical spine evaluation in obtunded or comatose pediatric trauma patients: a pilot study Pediatric Neurosurgery 1999; 30: 163-175.