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Three Part Question

In [alert children with suspected cervical trauma] is [clinical examination without cervical radiography] adequate to [exclude significant cervical injury]?

Clinical Scenario

An 11 year old boy is brought to the emergency department by paramedics after falling off his bicycle. They have immobilised his cervical spine with a hard collar. He has no visible external injury, is fully alert and co-operative and does not complain of any neck pain. You are aware of the “trend” for radiographic cervical spine imaging in virtually all blunt trauma patients, as unrecognised cervical spine injury can lead to disastrous neurological sequelae. However, you wonder whether imaging in this case is really necessary.

Search Strategy

Medline 1966-12/02 using the OVID interface.
[exp spinal cord injuries OR "cervical spine injur$".mp] AND [exp x-rays OR x-rays.mp OR radiograph$.mp] AND [Best BETs Paediatric filter] LIMIT to human AND English.

Search Outcome

Altogether, 298 papers were identified of which 2 were relevant. In addition NICE are undergoing a systematic review of head and cervical spine injury, and checking their search results, we found 1 additional paper that has not yet been indexed by Medline. These 3 papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Laham JL et al, 1994, USA	268 children aged 0-19, with apparent isolated head injuries defined by clinical and radiographic evidence in a single children’s hospital Low-risk criteria for c-spine injury: capable of verbal communication and no neck pain	Retrospective cohort study	Performance of low-risk criteria for excluding c-spine injury	No cervical spine injuries in the low risk group (n=135). 10 (7.5%) cervical injuries in the high risk group. (n=133) Sensitivity 100% Specificity 52%	The entry criteria of: significant head injury needing admission was made at the discretion of the PICU triage officer GCS was not consistently recorded in these children 215 children had cervical radiographs (80%)
Viccellio P, et al. 2001, USA	Multicenter evaluation of 3065 children (age <18) with suspected c-spine injury who underwent clinical evaluation prior to c-spine radiography Low-risk criteria (Nexus criteria) were defined as absence of: 1) midline cervical tenderness, 2) painful distracting injury, 3) altered alertness, 4) neurological deficit, and 5) intoxication	Prospective cohort study	Performance of low-risk criteria for excluding c-spine injury	No child in the low-risk group of 603 patients had a c-spine injury. Nexus criteria identified all cases of cervical injury diagnosed by radiography Sensitivity 100% (CI 87.8% - 100%) Specificity 19.8%	Number of children with cervical spine injury under nine was very low (only 4) Total number of children with cervical injury was only 30 (0.98%), therefore, CI for sensitivity was wide (87.8-100.0%) Caution is suggested for applying the Nexus criteria for children under 9 years
American Association of Neurological Surgeons and the Congress of Neurological Surgeons, 2002, USA	Search of Medline (1966-2001) in the following subject headings: “spinal injuries” and “child” were reviewed with “cervical vertebrae”, “spinal injuries” and “child”. Altogether, 58 relevant articles were identified	Systematic review	Guidelines for the management of acute cervical spine and spinal cord injuries	In children experiencing trauma who are alert, conversant, have no neurological deficit, no midline cervical tenderness, no painful distracting injury and not intoxicated, cervical spine radiographs not recommended. This is a recommendation from grade 3 evidence papers except Nexus paper which is grade 2	Search strategy is not reproducible No mention of searching the grey literature or contacting experts for papers

Comment(s)

Although the issue of radiographic assessment of children with suspected cervical injury has been addressed in several studies, there is still insufficient evidence to support diagnostic standards, as the incidence of cervical injuries amongst paediatric samples is low. To date, the Nexus criteria (absence of: 1)midline cervical tenderness, 2) altered alertness, 3) intoxication, 4) neurological deficit and 5) painful distracting injury) provide the most reliable instrument for assessing the need for cervical spine radiography in paediatric blunt trauma victims. However, in doubtful individual cases, decision should be at the clinician’s discretion, as these criteria may not be 100% sensitive, due to the wide confidence interval around these findings.

Clinical Bottom Line

Cervical spine radiography is not necessary in paediatric blunt trauma victims over the age of nine who are fully alert, conversant, show no signs of intoxication, have no neurological deficit, no midline cervical tenderness and no painful distracting injury.

References

1. Laham JL, Cotcamp DH, Gibbons PA, et al. Isolated head injuries versus multiple trauma in pediatric patients: Do the same indications for cervical spine evaluation apply? Pediatric Neurosurgery 1994;21:221-226.
2. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics 2001;108(2):E20.
3. American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery 2002;50(Suppl 3):S85-S99.