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Tavender E, Eapen N, Wang J, Rausa VC, Babl FE, Phillips N. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev 2024; 3:CD011686. [PMID: 38517085 PMCID: PMC10958760 DOI: 10.1002/14651858.cd011686.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy. OBJECTIVES To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions. SELECTION CRITERIA We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach. MAIN RESULTS We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.
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Affiliation(s)
- Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
| | - Nitaa Eapen
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Junfeng Wang
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Vanessa C Rausa
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Australia
- Biomechanics and Spine Research Group, Centre for Children's Health Research, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, Australia
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Henderson VK, Brismée JM. Pediatric neck pain of a 10-year-old child with cervical spinal tumor evaluated and managed in direct access physical therapy: a case report. J Man Manip Ther 2024:1-8. [PMID: 38415682 DOI: 10.1080/10669817.2024.2319427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 02/10/2024] [Indexed: 02/29/2024] Open
Abstract
INTRODUCTION Differential diagnosis of pediatric neck pain requires age-appropriate communication and assessment tools. Recognizing these age-related nuances is critical, emphasizing the role of physical therapists in assessing and managing pediatric patients while ruling out severe pathologies. CASE DESCRIPTION A 10-year-old male presented to physical therapy with a five-week history of increasing neck pain. A thorough history and segmental cervical examination considering the patient's age and development, led to patient referral to the emergency department. This case underscores the significance of comprehensive evaluation in pediatric neck pain management. OUTCOMES The patient was diagnosed with Langerhans Cell Histiocytosis (LCH). LCH primarily affects children and is treated with chemotherapy. Chemotherapy reduced the tumor, revealing C2 vertebral body damage. The patient underwent C1-C3 fusion surgery, a standard procedure for atlanto-occipital region stabilization in children. The patient was advised to restrict motion for 6 months while monitoring for tumor growth. DISCUSSION-CONCLUSION Pediatric neck cancer presents diagnostic challenges due to varied symptoms, but research highlights specific indicators to assist with differential diagnosis. This case emphasizes the need to recognize the complexities of pediatric neck pain and perform a thorough age-appropriate evaluation.
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Affiliation(s)
| | - Jean-Michel Brismée
- Department of Rehabilitation Sciences, Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Muacevic A, Adler JR. Implementation of National Emergency X-Radiography Utilization Study (NEXUS) Criteria in Pediatrics: A Systematic Review. Cureus 2022; 14:e30065. [PMID: 36238421 PMCID: PMC9547612 DOI: 10.7759/cureus.30065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2022] [Indexed: 11/05/2022] Open
Abstract
Since its introduction in 1992, the National Emergency X-Radiography Utilization Study (NEXUS) criteria have been used in trauma to decide whether a patient requires radiographic imaging. The tool is important in reducing radiation exposure. However, applying the NEXUS criteria for cervical spine imaging in pediatric patients is poorly supported compared to their use in adults. The objective of this review was to examine the effectiveness of using the NEXUS criteria in the diagnostic management of pediatric cervical spine injuries (CSI). The following databases were searched for studies focused on applying the NEXUS criteria for CSI in pediatric patients: Cochrane, PubMed, Google Scholar, EMBASE, ELSEVIER, and ScienceDirect. Additional studies were found through reference lists of primary sources and previous systematic and meta-analyses. The search focused on randomized controlled trials (RCTs), cohort studies, retrospective studies, prospective studies, and other uncontrolled trials published from 2000 to 2022. There were seven included studies with a total of 4502 pediatric patients. Five of the included studies were retrospective studies, while the remaining were prospective and case studies. Our results show that the sensitivity ranged from 43% to 100%, while the specificity ranged from 12.93% to 96%. The sensitivity increased with age, with those under the age of two or under the age of eight reporting poorer outcomes than the older pediatric patients. One study also shows that the proportion of patients undergoing cervical spine CT increased from 18% to 61% in the initial period before the implementation of clearance guidelines. The implementation of guidelines led to a 23% decrease in CT scans clearable by NEXUS criteria after 12 months. One of the studies reported that NEXUS criteria were a cost-effective option when used along with X-rays and CT. Overall, the studies do not strongly support the application of the NEXUS criteria to image pediatric patients for CSI. In conclusion, there is weak support in the literature for applying the NEXUS criteria in determining the need for cervical spine imaging in pediatric trauma patients. The practice and research implications of the findings are also discussed.
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Nolte PC, Liao S, Kuch M, Grützner PA, Münzberg M, Kreinest M. Development of a New Emergency Medicine Spinal Immobilization Protocol for Pediatric Trauma Patients and First Applicability Test on Emergency Medicine Personnel. Pediatr Emerg Care 2022; 38:e75-e84. [PMID: 32604393 DOI: 10.1097/pec.0000000000002151] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to (i) develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) perform an applicability test on emergency medicine personnel. METHODS A structured search of the literature published between 1980 and 2019 was performed in MEDLINE using PubMed. Based on this literature search, a new Emergency Medicine Spinal Immobilization Protocol for pediatric trauma patients (E.M.S. IMMO Protocol Pediatric) was developed. Parameters found in the literature, such as trauma mechanism and clinical findings that accounted for a high probability of spinal injury, were included in the protocol. An applicability test was administered to German emergency medicine personnel using a questionnaire with case examples to assess correct decision making according to the protocol. RESULTS The E.M.S. IMMO Protocol Pediatric was developed based on evidence from published literature. In the applicability test involving 44 emergency medicine providers revealed that 82.9% of participants chose the correct type of immobilization based on the protocol. A total of 97.8% evaluated the E.M.S. IMMO Protocol Pediatric as helpful. CONCLUSIONS Based on the current literature, the E.M.S. IMMO Protocol Pediatric was developed in accordance with established procedures used in trauma care. The decision regarding immobilization is made on based on the cardiopulmonary status of the patient, and life-threatening injuries are treated with priority. If the patient presents in stable condition, the necessity for full immobilization is assessed based upon the mechanisms of injury, assessment of impairment, and clinical examination.
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Affiliation(s)
- Philip C Nolte
- From the Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | | | - Matthias Kuch
- Pediatric Emergency Department, Karlsruhe City Clinic, Karlsruhe
| | - Paul A Grützner
- From the Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | | | - Michael Kreinest
- From the Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
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Traynor MD, Zielinski MD, Moir CR, Ishitani MB, Klinkner DB, Bruce JL, Laing GL, Kong VY, Clarke DL. CT scans for pediatric injury in a middle-income country trauma center: Are we repeating past mistakes? J Pediatr Surg 2021; 56:2342-2347. [PMID: 33546900 DOI: 10.1016/j.jpedsurg.2021.01.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/18/2021] [Accepted: 01/23/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Sustained efforts in high-income countries have decreased the rate of unnecessary computed tomography (CT) among children, aiming to minimize radiation exposure. There are little data regarding CT use for pediatric trauma in low- and middle-income countries. We aimed to assess the pattern and utility of CT performed during evaluation of trauma patients presenting to a middle-income country (MIC) trauma center. METHODS We reviewed pediatric (age<18) trauma admissions at a single tertiary referral center in South Africa. Patient demographics, injury details, surgical intervention(s), and mortality were abstracted from the medical record. CT indications, results, and necessity were determined by review. RESULTS Of 1,630 children admitted to the trauma center, 826 (51%) had CT imaging. Children undergoing imaging were younger (median age 11 [IQR: 6, 16] vs 13 [IQR: 7, 17]) and had higher median ISS [9 [IQR: 4, 13] vs 4 [2, 9]) compared to those without imaging (both p<0.001). Overall, 1,224 scans were performed with normal findings in 609 (50%). A median of 1 scan was performed per patient (range: 1-5). The most common location was CT head (n = 695, 57%). Among patients with positive findings on CT head (n = 443), 31 (7%) underwent either intracranial pressure monitoring or surgery. CT of the cervical spine had positive findings in 12 (7%) with no patients undergoing spine surgery. Of 173 patients with abdominal CT imaging, 83 (48%) had abnormal findings and 18 (10%) required operative exploration. Thirteen (16%) patients with abnormal findings on abdominal CT had exploratory laparotomy. Of 111 children undergoing whole body CT, 8 (7%) underwent thoracic and/or abdominal operations. CONCLUSION Use of CT during evaluation of pediatric trauma is common in an MIC center. A high rate of normal findings and low rates of intervention following head, cervical spine, and abdominal CT suggest potential overuse of this resource. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | | | | | | | - John L Bruce
- Department of Surgery, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - Grant L Laing
- Department of Surgery, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - Victor Y Kong
- Department of Surgery, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa; Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Damian L Clarke
- Department of Surgery, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa; Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa.
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Schonenberg Llach M, Fishe JN, Yorkgitis BK. Implementation of a dual cervical spine and blunt cerebrovascular injury assessment pathway for pediatric trauma patients. Am J Emerg Med 2021; 47:74-79. [PMID: 33780736 DOI: 10.1016/j.ajem.2021.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/05/2021] [Accepted: 03/06/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Pediatric cervical spine (CSI) and blunt cerebrovascular injuries (BCVI) are challenging to evaluate as they are rare but carry high morbidity and mortality. CT scans are the traditional imaging modality to evaluate for CSI/BCVI, but involve radiation exposure and potential future increased risk of malignancy. Therefore, we present results from the implementation of a combined CSI/BCVI pediatric trauma clinical pathway to aid clinicians in their decision-making. METHODS We conducted a 2-year retrospective cohort study analyzing data pre and post implementation of the combined CSI/BCVI pathway. Data was obtained from a level 1 pediatric trauma center and included blunt trauma patients under the age of 14. We evaluated the use of cervical spine computed tomography (CT), CT angiography, and plain radiographs, as well as missed injuries and provider pathway adherence. RESULTS We included 358 patients: 209 pre-pathway and 149 post-pathway implementation. Patient mean age was 8.9 years and 61% were male (61% males). There were no significant differences in GCS, AIS, and ISS between pre and post pathway groups. Post pathway implementation saw reduced use of cervical spine CT, although this was not clinically significant (33% vs 31%, p = 0.74). However, cervical spine radiography use increased (9% vs 16%, p = 0.03), and there was also an increase in screening for BCVI injuries with higher use of CTA (5% vs 7%, p = 0.52). A total of 12 CSI and 3 BCVI were identified with no missed injuries. Provider adherence to the pathway was modest (54%). Conclusion Implementation of a combined CSI/BCVI clinical pathway for pediatric trauma patients increased screening radiography and did not miss any injuries. However, CT use did not significantly decrease and provider adherence was modest, supporting the need for further implementation analysis and larger studies to validate the pathway's sensitivity and specificity for CSI/BCVI.
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Affiliation(s)
- Maria Schonenberg Llach
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, USA.
| | - Jennifer N Fishe
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, USA.
| | - Brian K Yorkgitis
- Department of Surgery, University of Florida College of Medicine - Jacksonville, USA.
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7
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Overmann KM, Robinson BRH, Eckman MH. Cervical spine evaluation in pediatric trauma: A cost-effectiveness analysis. Am J Emerg Med 2019; 38:2347-2355. [PMID: 31870674 DOI: 10.1016/j.ajem.2019.11.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 11/26/2019] [Accepted: 11/30/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The emergent evaluation of children with suspected traumatic cervical spine injuries (CSI) remains a challenge. Pediatric clinical pathways have been developed to stratify the risk of CSI and guide computed tomography (CT) utilization. The cost-effectiveness of their application has not been evaluated. Our objective was to examine the cost-effectiveness of three common strategies for the evaluation of children with suspected CSI after blunt injury. METHODS We developed a decision analytic model comparing these strategies to estimate clinical outcomes and costs for a hypothetical population of 0-17 year old patients with blunt neck trauma. Strategies included: 1) clinical pathway to stratify risk using NEXUS criteria and determine need for diagnostic testing; 2) screening radiographs as a first diagnostic; and 3) immediate CT scanning for all patients. We measured effectiveness with quality-adjusted life years (QALYs), and costs with 2018 U.S. dollars. Costs and effectiveness were discounted at 3% per year. RESULTS The use of the clinical pathway results in a gain of 0.04 QALYs and a cost saving of $2800 compared with immediate CT scanning of all patients. Use of the clinical pathway was less costly and more effective than immediate CT scan as long as the sensitivity of the clinical prediction rule was greater than 87% and when the sensitivity of x-ray was greater than 84%. CONCLUSION A strategy using a clinical pathway to first stratify risk before further diagnostic testing was less costly and more effective than either performing CT scanning or screening cervical radiographs on all patients.
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Affiliation(s)
- Kevin M Overmann
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, USA; Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA.
| | - Bryce R H Robinson
- Department of Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, 325 Ninth Ave, Seattle, WA, USA.
| | - Mark H Eckman
- Department of Internal Medicine, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, USA.
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[Development and first application testing of a new protocol for preclinical spinal immobilization in children : Assessment of indications based on the E.M.S. IMMO Protocol Pediatric]. Unfallchirurg 2019; 123:289-301. [PMID: 31768566 DOI: 10.1007/s00113-019-00744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND To protect the spine from secondary damage, spinal immobilization is a standard procedure in prehospital trauma management. Immobilization protocols aim to support emergency medicine personnel in quick decision making but predominantly focus on the adult spine; however, trauma mechanisms and injury patterns in adults differ from those in children and applying adult prehospital immobilization protocols to pediatric patients may be insufficient. Adequate protocols for children with spinal injuries are currently unavailable. OBJECTIVE The aim of this study was (i) to develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) to perform a first analysis of the quality of results if the protocol is used by emergency personnel. MATERIAL AND METHODS Based on a structured literature search a new immobilization protocol was developed. Analysis of the quality of results was performed by a questionnaire containing four case scenarios in order to assess correct decision making. The decision about spinal immobilization was made without and with the utilization of the protocol. RESULTS The E.M.S. IMMO Protocol Pediatric was developed based on the literature. The analysis of the quality of results was performed involving 39 emergency medicine providers. It could be shown that if the E.M.S. IMMO Protocol Pediatric was used, the correct type of immobilization was chosen more frequently. A total of 38 out of 39 participants evaluated the protocol as helpful. CONCLUSION The E.M.S. IMMO Protocol Pediatric provides decision-making support whether pediatric spine immobilization is indicated with respect to the cardiopulmonary status of the patient. In a first analysis, the E.M.S. IMMO Protocol Pediatric improves decision making by emergency medical care providers.
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Single-lateral cervical radiograph in pediatric trauma is equivalent to multiple views. J Trauma Acute Care Surg 2019; 87:813-817. [PMID: 31162331 DOI: 10.1097/ta.0000000000002396] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cervical spine injuries (CSI) are rare within the pediatric population. Due to the significant consequences of missed CSI, children are often imaged excessively. In an attempt to decrease imaging of the cervical spine in children, we reviewed abnormal cervical radiographs (XR) to determine if the diagnosis of CSI could be made using a single-lateral cervical radiograph (LAT). Furthermore, we reviewed cervical computed tomography (CT) and magnetic resonance imaging (MRI) to ensure there were no missed CSI. METHODS Electronic medical records of trauma patients treated at a Level I Pediatric Trauma Center with abnormal XR findings followed by confirmatory CT or MRI between 2012 and 2017 were reviewed. All abnormal imaging on XR was compared with the LAT. In addition, all abnormal CTs and MRIs were reviewed to ensure there were no false negative XR. RESULTS A total of 3,735 XR were performed with 26 abnormal interpretations. All bony CSI were visualized on LAT. Confirmatory imaging found 13 (50%) were false positive and 13 (50%) were true positive. Secondary analysis of CT identified 12 injuries with prior XR; 8 of 12 LAT identifying the injury and 4 of 12 false positive on CT. Secondary analysis of MRI identified nine injuries with prior XR; 5 of 9 LAT identifying the injury. The four false-negative reads on MRI were ligamentous injuries. CONCLUSION Radiographs are commonly performed when evaluating CSI. In our population, initial assessment with a single LAT was equivalent to a multiple view XR. On secondary review, the only false-negative LAT reports were due to ligamentous injuries. This data suggests limiting exposure to LAT would accomplish the goal of reducing imaging without missing bony CSI and when ligamentous injury is suspected MRI should be the confirmatory study rather than CT. LEVEL OF EVIDENCE Diagnostic Test, level III.
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Herman MJ, Brown KO, Sponseller PD, Phillips JH, Petrucelli PM, Parikh DJ, Mody KS, Leonard JC, Moront M, Brockmeyer DL, Anderson RCE, Alder AC, Anderson JT, Bernstein RM, Booth TN, Braga BP, Cahill PJ, Joglar JM, Martus JE, Nesiama JAO, Pahys JM, Rathjen KE, Riccio AI, Schulz JF, Stans AA, Shah MI, Warner WC, Yaszay B. Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am 2019; 101:e1. [PMID: 30601421 DOI: 10.2106/jbjs.18.00217] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Martin J Herman
- Orthopedic Center for Children, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Kristin O Brown
- Orthopedic Center for Children, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Paul D Sponseller
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | | | - Philip M Petrucelli
- Department of Orthopedic Surgery (P.M.P.), Drexel University College of Medicine (D.J.P., and K.S.M.), Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Darshan J Parikh
- Department of Orthopedic Surgery (P.M.P.), Drexel University College of Medicine (D.J.P., and K.S.M.), Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Kush S Mody
- Department of Orthopedic Surgery (P.M.P.), Drexel University College of Medicine (D.J.P., and K.S.M.), Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, and Nationwide Children's Hospital, Columbus, Ohio
| | - Matthew Moront
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Douglas L Brockmeyer
- Department of Neurological Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Richard C E Anderson
- Department of Neurosurgery, Columbia University, Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, NY
| | - Adam C Alder
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - John T Anderson
- Department of Orthopedic Surgery, Children's Mercy and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Robert M Bernstein
- Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Timothy N Booth
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Bruno P Braga
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Patrick J Cahill
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeanne M Joglar
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Jeffrey E Martus
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jo-Ann O Nesiama
- Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Joshua M Pahys
- Shriners Hospitals for Children, Philadelphia, Pennsylvania
| | - Karl E Rathjen
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Anthony I Riccio
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Jacob F Schulz
- Department of Orthopedic Surgery, The Children's Hospital at Montefiore, Bronx, New York
| | - Anthony A Stans
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Manish I Shah
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - William C Warner
- Department of Orthopedic Surgery, University of Tennessee - Campbell Clinic and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Burt Yaszay
- Department of Orthopedics, Rady Children's Hospital and University of California-San Diego Medical Center, San Diego, California
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Lodwick DL, Cooper JN, Gonzalez DO, Lawrence AE, Lee C, Krishnamurthy R, Minneci PC, Deans KJ. Disparities in Radiation Burden from Trauma Evaluation at Pediatric Versus Nonpediatric Institutions. J Surg Res 2018; 232:475-483. [DOI: 10.1016/j.jss.2018.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/13/2018] [Accepted: 04/12/2018] [Indexed: 10/28/2022]
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Li C, Li L, Duan J, Zhang L, Liu Z. Surgical treatment for old subaxial cervical dislocation with bilateral locked facets in a 3-year-old girl: A case report. Medicine (Baltimore) 2018; 97:e0553. [PMID: 29718848 PMCID: PMC6393066 DOI: 10.1097/md.0000000000010553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE This study aimed to describe the case of a 3-year-old girl with old bilateral facet dislocation on cervical vertebrae 6 and 7, who had spinal cord transection, received surgical treatment, and achieved a relative satisfactory therapeutic effect. PATIENT CONCERNS A 3-year-old girl was urgently transferred to the hospital after a car accident. DIAGNOSES:: she was diagnosed with splenic rupture, intracranial hemorrhage, cervical dislocation, spinal transection, and Monteggia fracture of the left upper limb. INTERVENTIONS The girl underwent emergency splenectomy and was transferred to the intensive care unit of the hospital 15 days later. One-stage anterior-posterior approach surgery (anterior discectomy, posterior laminectomy, and pedicle screw fixation) was performed when the patient stabilized after 45-day symptomatic treatment. The operation was uneventful. OUTCOMES The reduction of lower cervical dislocation was satisfactory, with sufficient spinal cord decompression. The internal fixation position was good, and the spinal sequence was well restored. The girl was discharged 2 weeks later after the operation and followed up for 2 years. The major nerve function of both upper limbs was recovered, with no obvious retardation of the growth of immature spine. LESSONS A satisfactory therapeutic effect was achieved for a pediatric old subaxial cervical dislocation with bilateral locked facets using anterior discectomy, posterior laminectomy, and pedicle screw fixation. The posterior pedicle screw fixation provided a good three-dimensional stability of the spine, with reduced risk and complications caused by anterior internal fixation. The growth of immature spine was not obviously affected during the 2-year follow-up.
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The sensitivity and negative predictive value of a pediatric cervical spine clearance algorithm that minimizes computerized tomography. J Pediatr Surg 2017; 52:130-135. [PMID: 27908536 DOI: 10.1016/j.jpedsurg.2016.10.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 10/20/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND It is crucial to identify cervical spine injuries while minimizing ionizing radiation. This study analyzes the sensitivity and negative predictive value of a pediatric cervical spine clearance algorithm. METHODS We performed a retrospective review of all children <21years old who were admitted following blunt trauma and underwent cervical spine clearance utilizing our institution's cervical spine clearance algorithm over a 10-year period. Age, gender, International Classification of Diseases 9th Edition diagnosis codes, presence or absence of cervical collar on arrival, Injury Severity Score, and type of cervical spine imaging obtained were extracted from the trauma registry and electronic medical record. Descriptive statistics were used and the sensitivity and negative predictive value of the algorithm were calculated. RESULTS Approximately 125,000 children were evaluated in the Emergency Department and 11,331 were admitted. Of the admitted children, 1023 patients arrived in a cervical collar without advanced cervical spine imaging and were evaluated using the cervical spine clearance algorithm. Algorithm sensitivity was 94.4% and the negative predictive value was 99.9%. There was one missed injury, a spinous process tip fracture in a teenager maintained in a collar. CONCLUSIONS Our algorithm was associated with a low missed injury rate and low CT utilization rate, even in children <3years old. LEVEL OF EVIDENCE IV.
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Cui LW, Probst MA, Hoffman JR, Mower WR. Sensitivity of plain radiography for pediatric cervical spine injury. Emerg Radiol 2016; 23:443-8. [DOI: 10.1007/s10140-016-1417-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/15/2016] [Indexed: 11/29/2022]
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Baumann F, Ernstberger T, Neumann C, Nerlich M, Schroeder GD, Vaccaro AR, Loibl M. Pediatric Cervical Spine Injuries: A Rare But Challenging Entity. ACTA ACUST UNITED AC 2016; 28:E377-84. [PMID: 26165728 DOI: 10.1097/bsd.0000000000000307] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Injuries to the cervical spine in pediatric patients are uncommon. A missed injury can have devastating consequences in this age group. Because of the lack of routine in diagnosis and management of pediatric cervical spine injuries (PCSI), each of these cases represents a logistic and personal challenge. METHODS By means of clinical cases, we demonstrate key points in diagnostics and treatment of pediatric spine injuries. We highlight typical pediatric injury patterns and more adult-like injuries. RESULTS The most common cause of injury is blunt trauma. There is an age-related pattern of injuries in pediatric patients. Children under the age of 8 frequently sustain ligamentous injuries in the upper cervical spine. After the age of 8, the biomechanics of the cervical spine are similar to adults, and therefore, bony injuries of the subaxial cervical spine are most likely to occur. Clinical presentation of PCSI is heterogeneous. Younger children can neither interpret nor communicate neurological abnormalities, which make timely and accurate diagnosis difficult. Plain radiographs are often misinterpreted. We find different types of injuries at different locations, because of different biomechanical properties of the immature spine. We outline that initial management is crucial for long-term outcome. CONCLUSIONS Knowledge of biomechanical properties and radiographic presentation of the immature spine can improve the awareness for PCSI. Diagnosis and management of pediatric patients after neck trauma can be demanding. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Florian Baumann
- *Department of Trauma Surgery, Regensburg University Medical Center, Regensburg, Germany †The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Marin JR, Wang L, Winger DG, Mannix RC. Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits. J Pediatr 2015; 167:897-904.e3. [PMID: 26233603 PMCID: PMC4881390 DOI: 10.1016/j.jpeds.2015.06.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 05/21/2015] [Accepted: 06/25/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess variation in the use of computed tomography (CT) for pediatric injury-related emergency department (ED) visits. STUDY DESIGN This was a retrospective cohort study of visits to 14 network-affiliated EDs from November 2010 through February 2013. Visits were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Primary outcome was CT use. We used descriptive statistics and performed multivariable logistic regression to evaluate the association of patient and ED covariates on any and body region-specific CT use. RESULTS Of the 80 868 injury-related visits, 11.4% included CT, and 28.4% of those involved more than 1 CT. Across EDs, CT use ranged from 7.6% to 25.5% of visits and did not correlate with institutional Injury Severity Score (P = .33) or admission/transfer rates (P = .07). In multivariable analysis of nonpediatric EDs, trauma centers and nonacademic EDs were associated with CT use. Higher pediatric volume was associated with any CT use; however, there was an inverse relationship between volume and nonhead CT use. When the pediatric ED was included in multivariable modeling, the effect of level 1-3 trauma center designation remained, and the pediatric level 1 trauma center was less likely to use most body region-specific CTs. CONCLUSION There is wide variation in CT imaging for pediatric injury-related visits not attributable solely to case mix. Future work to optimize CT utilization should focus on additional factors contributing to imaging practices and interventions.
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Affiliation(s)
- Jennifer R Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Li Wang
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Rebekah C Mannix
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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