Triage tools for detecting cervical spine injury in pediatric trauma patients

Slaar, Annelie; Fockens, M. Matthijs; Wang, Junfeng; Maas, Mario; Wilson, David J.; Goslings, J. Carel; Schep, N.W.L.; Rijn, Rick R. van

doi:10.1002/14651858.cd011686.pub2

Cited by 25 publications

(17 citation statements)

References 131 publications

(6 reference statements)

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“…In agreement with other authors and according to a Cochrane review, [ 13 ] we recommend obtaining cervical X-ray images in lateral projection, rather than open-mouth odontoid X-rays images, in children less than 8 to 10 years of age. [ 5 , 14 – 16 ] Frequently, the upper C-spine is not visualized clearly in the AP projection, and open-mouth X-ray images are difficult to obtain in young children.…”

Section: Discussionsupporting

confidence: 75%

Conservative treatment and outcome of upper cervical spine fractures in young children

Tomaszewski¹,

Sesia

Studer

et al. 2021

Medicine

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Cervical spine (C-spine) fractures in young children are very rare, and little information on treatment modalities and functional, radiographic, and patient-reported outcome exists. In this 2-center, retrospective case series, we assessed subjective and functional mid-term outcomes in children aged ≤5 years whose C-spine fractures were treated nonoperatively. Between 2000 and 2018, 6 children (median age at injury: 23.5 months; range: 16–31 months) with C1 or C2 injuries were treated with Minerva cast/brace or soft collar brace at 1 of the 2 study centers. Two patients suffered C1 fractures, and 4 patients had lysis of the odontoid synchondrosis. Overall, 3 children had sustained polytrauma. One child died due to the consequences of massive head injury. For the primary outcome parameter, we recorded subjective symptoms such as pain and functional restrictions due to the sequelae of C-spine injuries at follow-up. Based on medical records, we also assessed the causes of injury, diagnostic procedures, treatments and complications, and time to fracture consolidation. Median follow-up of the 5 surviving children was 51 months (range: 36–160 months). At the latest follow-up, 4 of 5 children did not complain of any pain. One child who sustained an open head injury in combination with a subluxation of the odontoid and undisplaced fracture of the massa lateralis reported occasional headache. All patients experienced complete fracture healing and normal range of motion of the cervical spine. Median duration of cast/brace treatment was 8.5 weeks. Fracture healing was confirmed by computed tomography in all patients. All C-spine injuries were managed with either Minerva cast/Halo brace or soft collar brace without complications. In our retrospective case series, nonoperative treatment of atlas fractures and dislocations or subluxations of the odontoid in young children using Minerva casts or prefabricated Halo braces resulted in good subjective and functional outcomes at mid-term. We observed no complications of conservative treatment of C1 and C2 injuries in young children.

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Section: Discussionsupporting

confidence: 75%

Conservative treatment and outcome of upper cervical spine fractures in young children

Tomaszewski¹,

Sesia

Studer

et al. 2021

Medicine

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“…3 Another retrospective case-control study 21 found that neither CCR nor NEXUS performed well enough to be used as designed in children younger than 10 years. A recent Cochrane review 16 identified similar concerns with both rules, finding insufficient evidence for use of CCR in paediatric cohorts, advising caution with NEXUS use in paediatric patients given sensitivity concerns and finding no evidence for use in children under 8 years. Future large multicentre studies are needed to assess individual CDR performance and projected effects on imaging rates across different paediatric age groups, with particular consideration given to younger cohorts.…”

Section: Discussionmentioning

confidence: 99%

“…12 13 ED clinicians are thus faced with the decision of which children should receive imaging and for whom it can be safely avoided. [14][15][16] To address these concerns, attempts have been made to risk stratify patients with blunt trauma, identifying those at higher risk of CSI, and thus in need of imaging, through the use of clinical decision rules (CDRs). The most well known of these are the US derived National Emergency X-Radiography Utilization Study Low Risk Criteria (NEXUS) 17 18 and the Canadian C-Spine rule (CCR).…”

Section: Introductionmentioning

confidence: 99%

Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort

et al. 2021

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BackgroundClinical decision rules (CDRs) are commonly used to guide imaging decisions in cervical spine injury (CSI) assessment despite limited evidence for their use in paediatric populations. We set out to determine CSI incidence, imaging rates and the frequency of previously identified CSI risk factors, and thus assess the projected impact on imaging rates if CDRs were strictly applied as a rule in our population.MethodsA single-centre prospective observational study on all aged under 16 years presenting for assessment of possible CSI to a tertiary paediatric emergency department over a year, commencing September 2015. CDR variables from the National Emergency X-Radiography Utilization Study (NEXUS) rule, Canadian C-Spine rule (CCR) and proposed Paediatric Emergency Care Applied Research Network (PECARN) rule were collected prospectively and applied post hoc.Results1010 children were enrolled; 973 had not received prior imaging. Of these, 40.7% received cervical spine imaging; 32.4% X-rays, 13.4% CT scan and 3% MRI. All three CDRs identified the five children (0.5%) with CSI who had not received prior imaging. If CDRs were strictly applied as a rule for imaging, projected imaging rates in our setting would be as follows: NEXUS-44% (95% CI 41% to 47.4%), CCR-at least 48.4% (95% CI 45.3% to 51.7%) and PECARN-68% (95% CI 65.1% to 71.1%).ConclusionCSIs were rare (0.5% of our cohort), however, 40% of children received imaging. CDRs have been designed to guide imaging decisions; if strictly applied as a rule for imaging, the CDRs assessed in this study would increase imaging rates. Projected rates differ considerably depending on the CDR applied. These findings highlight the need for a validated paediatric-specific cervical spine imaging CDR.

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“…Analysis of these tools in children, however, is sparse. A 2017 meta-analysis concluded that the NEXUS criteria are at best a guide to clinical assessment, and not a strict protocol, while evidence for the accuracy of the CCR to detect CSI in the paediatric population is lacking [14]. Nevertheless, current international guidelines recommend combining both predicting rules [11,15,16].…”

Section: Introductionmentioning

confidence: 99%

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

Brinke

Slinger

Slaar³

et al. 2020

Eur J Trauma Emerg Surg

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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.

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Triage tools for detecting cervical spine injury in pediatric trauma patients

Cited by 25 publications

References 131 publications

Conservative treatment and outcome of upper cervical spine fractures in young children

Conservative treatment and outcome of upper cervical spine fractures in young children

Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort

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

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