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Three Part Question

In [pediatric trauma patients] are [historical factors and physical exam] effective in [predicting cervical spine injury]?

Clinical Scenario

A 2 year old boy is brought to your emergency department after a motor vehicle crash. He was wearing a seatbelt and the parents do not think he lost consciousness. No one else in the car was injured. On exam, the child is quite upset and you are unable to determine whether there is cervical tenderness. You do notice some bruising over his torso. There are no neurologic deficits on exam and he is able to ambulate. Should you obtain cervical spine imaging to rule-out injury?

Search Strategy

Medline 1948-09/11 using OVID interface, Cochrane Library (2011), PubMed clinical queries
[(exp spinal injuries/diagnosis OR exp cervical vertebral/injury) AND (pediatric.mp)]. Limit to English language.

Search Outcome

A total of 162 papers were identified, four prospective studies were relevant to the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Leonard JC, Kuppermann N, Olsen C, et al. 2011 Aug USA	Children younger than 16 years, presenting after blunt trauma,and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury (CSI). Three control groups of children free of CSI were created: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) age-matched cases which received out-of-hospital emergency medical services.	Case-control study	The records of 540 children with CSI were reviewed and compared to case controls. Eight factors were found to be associated with CSI.	The eight factors associated with CSI are: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, medical and genetic conditions predisposing to CSI, diving, and high-risk motor vehicle crash. Having one or more factors was 98% sensitive and 26% specific for CSI.	This was a retrospective chart review and is subject to ascertainment and sampling bias as well as possible missing data.
Viccellio P, Simon H, Pressman BD, Shah MN, et al. 2001 Aug USA	This was a sub-study of the National Emergency X-Radiology Utilization Study (NEXUS) of patients < 18 years old (3,065) who presented after blunt trauma to participating emergency departments and underwent clinical evaluation before radiographic imaging.	A multi-center prospective observational study	Of the 3,065 pediatric patients evaluated, only 30 (0.98%) had CSI.	The NEXUS criteria: midline cervical tenderness, altered level of alertness, evidence of intoxication, neurologic abnormality, and presence of painful distracting injury, correctly identified all pediatric CSI victims (sensitivity: 100%; 95% confidence interval (CI): 87.8%–100%) and correctly designated 603 patients as low risk for CSI (negative predictive value: 100%; 95% CI: 99.4%–100%).	Small number of children with cervical spine injury in this series, particularly in the youngest age groups.
Anderson RC, Kan P, Vanaman M, Rubsam J, Hansen KW, Scaife ER 2010 Mar USA	Trauma patients 0 - 3 years old from two institutions (New York, Utah) between 2002 and 2006.	Prospective case-series for evaluation of a cervical spine clearance protocol.	This protocol consisted of plain radiographs for all pediatric trauma patients, if inadequate or suspicious, a CT scan was performed. If normal, clearance of the cervical spine was attempted by full active and/or passive ROM without the appearance of pain. If abnormal physical exam or high-energy injury, a MRI was perfomed. For uncertain MRI results, a flexion-extension x-ray under fluoroscopy was performed.	Of 575 pediatric trauma patients, there were 19 ligamentous injuries, 4 fractures, and 5 dislocations. There were no missed CSI. This was verified by telephone follow-up at 3 months in New York, and a lack of intervention by pediatric neurosurgeons in Salt Lake City, Utah.	Only pediatric patients that were part of a trauma activation were included. There were only a small number of CSI in this patient population. Some injuries may have been missed in Utah because it was assumed that if these patients didn't follow up at the same hospital, then they had no injury. In addition, they did not comment on whether or not they had 100% success of telephone follow-up in New York.
Hoffman JR, Mower, WR, Wolfsone AB, et al. 2000, July 13 USA	34,069 blunt trauma patients of all ages (1 - 101) who underwent radiographic imaging of the cervical spine.	Prospective, observational study.	The clinical decision rule of being low-risk for CSI was applied. These criteria were: no posterior midline neck tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no clinically apparent distracting injury.	The decision instrument identified all but 8 of the 818 patients who had cervical spine injury (Sens: 99%, CI: 98 - 99.8 %).	No specific information was given regarding the number of pediatric patients evaluated, or how many had cervical spine injury. Some patients may have had cervical spine injury but were not radiographed and thus not included in the study.

Comment(s)

Cervical spine injury in pediatric patients is an infrequent, but potentially devastating condition. The four relevant papers described similar variations for the evaluation of this particular patient population. The risk factors associated with this type of injury were high energy collision, dangerous mechanism, abnormal neurologic exam, predisposing medical or genetic conditions, altered mental status, distracting injury, midline neck pain or tenderness. However, all four studies were limited by a small number of non-verbal patients and were hesitant to fully recommend their approach to clearing the cervical spine of these patients.

Clinical Bottom Line

While cervical spine clearance in older children is similar to adults, caution should be used in applying these principles in younger pediatric trauma patients.

References

1. Leonard JC, Kuppermann N, Olsen C, et al. Factors Associated With Cervical Spine Injury in Children After Blunt Trauma. Ann Emerg Med 2011 Aug;58(2):145-55
2. Viccellio P, Simon H, Pressman BD, Shah MN et al. A prospective multicenter study of cervical spine injury in children Pediatrics 2001 Aug; 108(2): e20:
3. Anderson RC, Kan P, Vanaman M, Rubsam J, Hansen KW, Scaife ER Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age Journal of Neurosurgery: Pediatrics 2010 Mar; 5(3):292-6:
4. Hoffman JR, Mower, WR, Wolfsone AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma New England Journal of Medicine 2000, July 13; 343 (2), 94 - 99