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Three Part Question

In [children under 3 years old with suspected Cervical spine injury] are [there good Clinical decision rules] to [clear the cervical spine]?

Clinical Scenario

A 3-year-old boy is brought to your ED after falling top to bottom of stairs at home. Parents witnessed his landing and he did not lose consciousness. The child is distressed, and only his mother is able to have a reasonable rapport with him. Would having Clinical Decision Rule (CDR) help in clearing C-spine clinically, to avoid imaging?

Search Strategy

Medline 1950- October 2012, and Embase 1980- October 2012
Search criteria were “Spinal Injuries,” “spine cord injuries,” “spinal fractures,” “cervical vertebrae,” “clearance,” “clearing,” “infant,” ”baby,” ”babies,” ”newborn,” ”pediatric,” ”paediatric,” ”child,” ”teen,” ”neonate,” adolescent”. Limits that were applied were Languages: English and Humans.

Search Outcome

A total of 135 papers were identified; four 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
Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR; NEXUS Group. August 2001 USA	Sub-study of the National Emergency X- Radiology Utilization Study (NEXUS) of patients < 18 years old (3,065) who presented after blunt trauma to EDs, and underwent clinical evaluation before radiographic imaging.	A multi- centre prospective observational study	Of the 3,065-paediatric patients evaluated, only 30 (0.98%) had Cervical spine injury	The NEXUS criteria had a sensitivity of 100% in these 30 patients	The 30 children with spinal injury were throughout all age groups (only four under 9 and none under 2)
Masiakos P.T., Pieretti-Vanmarcke R., Velmahos G.C., Nance M.L., Islam S., Falcone R.A., Wales P.W., September 2009 USA	Trauma registries from 22 (level I or II) trauma centres were reviewed for 10-year period (1995 to 2005). Blunt trauma patients younger than 3 years were identified.	A multi centre retrospective study.	Four clinical predictors of Cervical spine injury were identified: GCS <14 (scored 3), GCS Eye score of 1(scored 2), motor vehicle crash (scored 2), and age 2 years or older (scored 1). A score of <2 had a negative predictive value of 99.93% in ruling out Cervical spine injury	Of 12,537 patients younger than 3 years, C-spine injury was identified in 83 patients (0.66%), 8 of who had spinal cord injury. A total of 8,707 patients (69.5% of all patients) scored <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study.	Scoring system needs prospective validation. No formal follow-up to identify potential missed cases.
Anderson R.C.E., Peter K., Vanaman M., Rubsam J., Hansen K.W., Scaife E.R., Brockmeyer D.L. March 2010 USA	Trauma patients 0 - 3 years old from two institutions (USA) 2002 - 2006.	Prospective case-series for evaluation of a cervical spine clearance protocol.	To determine whether a safe protocoled system could clear the cervical spine in non-communicative children between 0 and 3 years of age. 1) Plain radiographs for all paediatric trauma patients (good gold standard) 2) If inadequate or suspicious, a CT scan was performed. 3) If normal, clearance of the cervical spine was attempted 4) Normal radiological study but abnormal neurological exam or high- energy injury, a MR Imaging obtained.	Of 575 paediatric trauma patients, there were 19 ligamentous injuries, 4 fractures, and 5 dislocations. There were no missed CSI.To facilitate clearing the C-spine in these children, plain radiographs (100%), CT studies (14 %), and MR images (10%) were obtained.	Only paediatric patients that were part of trauma activation were included.
Chung S., Mikrogianakis A., Wales P.W., Dirks P., Shroff M., Singhal A., Grant V., Hancock B.J., Cre April 2011 Canada	Children younger than 18 years with neck injury.	Literature review.	Trauma Association of Canada Paediatric committee designed a CDR based on consensus.	A consensus was reached on two pathways to evaluate the paediatric cervical spine: 1) patients with a reliable clinical examination and 2) a patient with an unreliable examination.	This is a consensus clinical desicion rule (CDR), not tested on a sample population.

Comment(s)

This is a common situation: a child has a potential neck injury and is distressed; yet you do not feel confident clinically clearing the spine. Our search revealed 3 large series [1, 2, 3], which are relevant. One study [2] used a pragmatic 4 clinical predictors method [GCS <14, GCS Eye score of 1, motor vehicle crash, and age 2 years or older] to help in reducing radiation exposure in children under 3 years of age with C-spine injury. Consensus guidelines exist, but are not targeted at the younger age group, and heavily rely on examination findings.

Clinical Bottom Line

In practice all three Clinical Decision Rules appear to work well, and fit with the personal practice of many experienced doctors.

References

1. Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR; NEXUS Group. A Prospective Multicenter Study of Cervical Spine Injury in Children Pediatrics- Official Journal of American Academy of Pediatrics August 2001
2. Masiakos P.T., Pieretti-Vanmarcke R., Velmahos G.C., Nance M.L., Islam S., Falcone R.A., Wales P.W., Brown R.L. Clinical Clearance of the Cervical Spine in Blunt Trauma Patients Younger Than 3 Years: A Multi-Center Study of the American Association for the Surgery of Trauma Journal of Trauma - Injury, Infection and Critical Care September 2009
3. Anderson R.C.E., Peter K., Vanaman M., Rubsam J., Hansen K.W., Scaife E.R., Brockmeyer D.L. Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age. Journal of Neurosurgery: Pediatrics March 2010
4. Chung S., Mikrogianakis A., Wales P.W., Dirks P., Shroff M., Singhal A., Grant V., Hancock B.J., Creery D., Atkinson J., St-Vil D., Crevier L., Yanchar N., Hayashi A., Mehta V., Carey T., Dhanani S., Trauma association of canada pediatric subcommittee National pediatric cervical spine evaluation pathway: Consensus guidelines Journal of Trauma - Injury, Infection and Critical Care April 2011