CLEARING CHILDRENS’ CERVICAL SPINES IS A PAIN IN THE NECK!
So, it’s been a couple of years since the blog has discussed cervical spine clearance in children. It’s a notoriously difficult task because the Nexus criteria* and the Canadian C-Spine Rule* (both developed for adults but often applied to children by clinicians) can be nearly impossible to assess in a screaming and frightened child. Additionally, these criteria are not particularly well-studied or validated in children. In fact, there are currently no nationally recognized guidelines for cervical spine clearance in children, making for a variable practice among clinicians and centers, and a lot of confused head scratching for new residents!
* No room to review these criteria here – google them if you need a refresher!
Let’s start with what we know about cervical spine injury in children:
– Motor vehicle collisions are the most common cause
– C-spine injuries in children are relatively rare (incidence of around 1% in children evaluated after blunt trauma)
– Children under 8 years of age are more susceptible due to:
o Relatively large head to body ratio
o Horizontally inclined vertebral facets which predispose to sliding
o Weaker musculature
o Ligamentous laxity
o The youngest children (less than 3) are at higher risk for higher fractures (C1-C3)
o By 8-10 years of age the bony anatomy is relatively similar to that of adults
Next, let’s talk about the questions that usually come up:
– Wait, you can’t clear him, he has a distracting injury!
o But is that really a distracting injury?
o It doesn’t matter, the NEXUS criteria don’t apply to children!
o Then why are we using them???
– He’s screaming and kicking his arms and legs – what are the odds he has a c-spine injury?
– Should we do an X-ray or a CT?
Let’s review the literature to see what criteria we should be using:
A Prospective Multicenter Study of Cervical Spine Injury in Children
Pediatrics 2001
In the only prospective study to my knowledge, Viccello et al applied the NEXUS criteria to 3065 children under 18 who presented with blunt trauma, only 88 of whom were under 2. The decision to image was up to the provider, independent of NEXUS. A total of 30 (0.98%) had cervical spine injury. All of these patients were under 9, none were under 2, and the majority of the injuries were lower (C5-C7) cervical spine.
The NEXUS criteria correctly identified ALL injuries – with the most common criteria met being distracting injury and tenderness. No injuries were found in patients who did not meet at least 1 of the criteria – had the NEXUS criteria been used as a decision rule, no injuries would have been missed but 20% less radiographs would have been performed.
They concluded that they believe their data supports the use of NEXUS criteria in children, but caution against using it in young patients under the age of 2 due to the very small number of patients in that age group who participated in the study.
Utility of Plain Radiographs in Detecting Traumatic Injuries of the Cervical Spine in Children
Pediatric Emergency Care 2012
In a retrospective cohort study of 206 patients with blunt trauma-related cervical spine injuries, Nigrovic et al found that plain cervical spine radiographs with two or more views correctly identified cervical spine injury in most patients, citing a sensitivity of 90% (95% CI 85%-94%).
Factors Associated with Cervical Spine Injury in Children After Blunt Trauma
Annals of Emergency Medicine 2011
Leonard et al published a retrospective case control study reviewing the charts of thousands of pediatric patients with cervical spine injury and identified 8 factors associated with cervical spine injury in children who experienced blunt trauma: altered mental status, focal neurologic deficits, complaint of neck pain, torticollis, substantial injury to the torso, predisposing condition, high-risk motor vehicle crash, and diving.
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 2000
Pieretti-Vanmarcke et al published a multicenter retrospective review of more than 12,000 pediatric blunt trauma patients under 3 years of age and identified a very low rate of cervical spine injury (only 83 patients), as well as 4 clinical predictors: GCS <14, MVC, GCS eye score 1, and age
Effect of age on cervical spine injury in pediatric population: a National Trauma Data Bank review
Journal of Pediatric Surgery 2011
Mohseni et al reviewed 240,647 pediatric blunt trauma patients. They identified 3,035 (1.3%) patients with a cervical spine injury. The incidence increased from infancy to adolescents (0.4% in infants and preschool children, 0.8% in pre-adolescents, 2.6% in adolescents). The spine level was more likely to be upper (C1-4) in preschool and young children, more likely to be lower (C5-7) in pre-adolescents and adolescents.
FINALLY, here is some food for thought – a protocol for cervical spine clearance from the pediatric trauma society – note that they go straight to CT!
http://pediatrictraumasociety.org/multimedia/files/clinical-resources/C-Spine-1.pdf
TAKE HOME POINTS
– Cervical spine injury is rare in children, especially very young children
– Infants and toddlers are more likely to have upper cervical spine injury
– The NEXUS criteria can probably be used safely in school aged children
– It is ok to make your decision based on a variety of clinical criteria based on the available evidence – just know what criteria you are using and why!
REFERENCES
1) Mohseni S, Talving P, Branco BC, et al. Effect of age on cervi¬cal spine injury in pediatric population: a National Trauma Data Bank review. J Pediatr Surg. 2011;46(9):1771-1776.
2) Leonard JC, Kuppermann N, Olsen C, et al. Factors associat¬ed with cervical spine injury in children after blunt trauma. Ann Emerg Med. 2011;58(2):145-155.
3) Nigrovic LE, Rogers AJ, Adelgais KM, et al. Utility of plain radiographs in detecting traumatic injuries of the cervical spine in children. Pediatr Emerg Care. 2012;28(5):426-432.
4) Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of
cervical spine injury in children. Pedi¬atrics. 2001;108(2):E20.
5) Pieretti-Vanmarke et al. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multicenter study of the american association for the surgery of trauma. J Trauma: 67(3). September 2009.
6) www.pediatrictraumasociety.org
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1 Comment
jkhadpe · August 25, 2014 at 5:39 pm
Really helpful review! Good to know these injuries are very rare but disappointing that there have not been larger studies on this topic. Seems like the Pediatric Trauma Society algorithm is a reasonable approach (probably a little on the conservative side). I like that you emphasized that we often try to extend clinical decision rules to situations where they don’t apply or at least have not been studied enough to reliably use. It’s important whenever you want to use a CDR to know the inclusion and exclusion criteria for the rule so you can apply it to the appropriate patient population.