Increased and unjustified CT usage in paediatric C-spine clearance in a level 2 trauma centre

Abstract

Purpose Cervical spine injury after blunt trauma in children is rare but can have severe consequences. Clear protocols for diagnostic workup are, therefore, needed, but currently not available. As a step in developing such a protocol, we determined the incidence of cervical spine injury and the degree of protocol adherence at our level 2 trauma centre. Methods We analysed data from all patients aged < 16 years suspected of cervical spine injury after blunt trauma who had presented to our hospital during two periods: January 2010 to June 2012, and January 2017 to June 2019. In the intervening period, the imaging protocol for diagnostic workup was updated. Outcomes were the incidence of cervical spine injury and protocol adherence in terms of the indication for imaging and the type of imaging. Results We included 170 children in the first study period and 83 in the second. One patient was diagnosed with cervical spine injury. Protocol adherence regarding the indication for imaging was > 80% in both periods. Adherence regarding the imaging type decreased over time, with 45.8% of the patients receiving a primary CT scan in the second study period versus 2.9% in the first. Conclusion Radiographic imaging is frequently performed when clearing the paediatric cervical spine, although cervical spine injury is rare. Particularly CT scan usage has wrongly been emerging over time. Stricter adherence to current protocols could limit overuse of radiographic imaging, but ultimately there is a need for an accurate rule predicting which children really are at risk of injury.

Variability of Pediatric Cervical Spine Clearance Protocols

“…Only one study demonstrated that updating their protocol increased primary CT scans (2.9%–45.8%), although CT after initial plain radiography decreased slightly (13.3%–6.7%) 25. As their protocol was only slightly updated between the 2 study periods, the authors attributed the large increase in primary CT to decreased adherence to the updated protocol, which could be due to many different factors.…”

“…Specifically, all protocols that included conscious patients (N=12) used XR as initial imaging; 10 of these studies always utilized XR first, whereas 2 indicated XR versus CT based on additional features, such as whether a CT head was already ordered15,16 or the patient’s age 26. Three protocols utilized different types of XR based on age, with the younger patients (below 5 years old in Arbuthnot and Mooney27 and below 8 years old in Ten Brinke et al25 and Luehmann et al28) undergoing anteroposterior (AP)/lateral films and the older patients receiving AP/lateral/odontoid films. The 2 protocols that pertained only to unconscious patients defaulted to CT as the initial imaging modality 20,21…”

“…Despite the variability, when we assessed algorithm characteristics, we found that 12 of the 16 protocols (75%) incorporated some or all NEXUS criteria, either as initial touchpoints or embedded into the algorithm. Four clinical decision-making tools utilized NEXUS criteria alone for initial clearance [22][23][24][25] ; however, 2 of these protocols limited the use of the tool to children over 3 years and 5 years, respectively. 23,24 Three additional protocols supplemented NEXUS with an additional novel clearance element.…”

Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years

“…Over the years, these adult-specific decision-making paradigms have been shown to significantly reduce the need for imaging in patients who meet certain exclusion criteria . These criteria, despite having an overall low number of very young patients in their study cohorts, have been extrapolated to the pediatric trauma population in an attempt to reduce radiation exposure, cost, and unnecessary use of imaging studies . Limitations of this approach, in addition to the unclear applicability of these criteria in the young pediatric population, includes the variability in clinician comfort in evaluating young children .…”

Disparities in computed tomography utilization for pediatric blunt trauma: a systematic review and meta-analysis comparing pediatric and non-pediatric trauma centers

“…The timely and accurate evaluation of pediatric blunt trauma is crucial for effective management and the prevention of potential complications [ 1 – 3 ]. Computed tomography (CT) imaging plays a pivotal role in the diagnostic process, providing detailed anatomical information and aiding in the identification of injuries [ 4 – 6 ].…”