Developing a spinal clearance protocol for unconscious pediatric trauma patients

Triage tools for detecting cervical spine injury in paediatric trauma patients

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.

Development and first application testing of a new protocol for CT-based stability evaluation of the injured upper cervical spine

PURPOSE

For trauma surgeons, the evaluation of the stability of the upper cervical spine may be demanding. The aim of this study was to develop a protocol for decision-making on upper cervical spine stability in trauma patients based on established parameters obtained by CT imaging as well as testing the protocol by having it applied by trauma surgeons.

METHODS

A structured literature search on upper cervical spine stability was performed. The best evaluated instability criteria in CT imaging were determined. Based on these parameters a protocol for stability evaluation of the injured upper cervical spine was developed. A first application testing was performed. In addition to the assessment of instability, the time required for the assessment was analyzed.

RESULTS

A protocol for CT-based stability evaluation of the injured upper cervical spine based on the current literature was developed and displayed in a flow chart. Testing of the protocol found the stability of the cervical spine was correctly assessed in 55 of 56 evaluations (98.2%). In one test run, a stable upper cervical spine was judged to be unstable. Further analysis showed that this case was based on a measurement error. The assessment time of CT-images decreased significantly during repeat application of the protocol (p < 0.0001), from 336 ± 108 s (first case) to 180 ± 30 s (fourth case).

CONCLUSION

The protocol can be applied quickly and safely by non-specialized trauma surgeons. Thus, the protocol can support the decision-making process in CT-based evaluation of the stability of the injured upper cervical spine.

Cervical spine clearance in unconscious pediatric trauma patients: a level l trauma center experience

PURPOSE

To radiographically assess cervical spine clearance in unconscious pediatric trauma patients.

METHODS

A retrospective cohort study was conducted to review pediatric patients with suspected cervical spinal injuries between 2005 and 2018 at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. All pediatric patients aged 15 years and less, who sustained trauma (motor vehicle accident, pedestrian, fall, all-terrain vehicle accident, and sports injures) and were intubated at the scene or in the emergency department, were included.

RESULTS

A total of 62 patients were included. The average age for children was 8 ± 3.9 years. The average Glasgow coma scale (GCS) for children at initial trauma was 7.6 + 3.7. The average injury severity score (ISS) was 24.1 + 17.7. The most frequent abnormal finding identified on CT scan was cervical spine straightening (N = 8; 13.1%). A total of 13 children had abnormal MRI findings, with the most common injury being ligamentous in nature (N = 13; 46.42%). The sensitivity and specificity of CT scan in cervical spine clearance in unconscious children are 84.8% and 100%, respectively.

CONCLUSION

Utilizing CT scans in clearing the cervical spine is of paramount importance to promptly detect possible injuries. The role of MRI in cervical spine clearance still cannot be undervalued, especially when the clinical suspicion for injury is high.

Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts

The clinical presentation and diagnostic workup in pediatric cervical spine injuries (CSI) are different from adults owing to the unique anatomy and relative immaturity. The current article reviews the existing literature regarding the uniqueness of these injuries and discusses the current guidelines of radiological evaluation. A PubMed search was conducted using keywords "paediatric cervical spine injuries" or "paediatric cervical spine trauma." Six hundred and ninety two articles were available in total. Three hundred and forty three articles were considered for the review after eliminating unrelated and duplicate articles. Further screening was performed and 67 articles (original articles and review articles only) related to pediatric CSI were finally included. All articles were reviewed for details regarding epidemiology, injury patterns, anatomic considerations, clinical, and radiological evaluation protocols. CSIs are the most common level (60%-80%) for pediatric Spinal Injuries (SI). Children suffer from atlantoaxial injuries 2.5 times more often than adults. Children's unique anatomical features (large head size and highly flexible spine) predispose them to such a peculiar presentation. The role of National Emergency X-Ray Utilization Study, United State (NEXUS) and Canadian Cervical Spine Rule criteria in excluding pediatric cervical injury is questionable but cannot be ruled out completely. The minimum radiological examination includes 2- or 3-view cervical X-rays (anteroposterior, lateral ± open-mouth odontoid views). Additional radiological evaluations, including computerized tomography (CT) and magnetic resonance imaging (MRI) are obtained in situations of abnormal physical examination, abnormal X-rays, inability to obtain adequate X-rays, or to assess cord/soft-tissue status. The clinical criteria for cervical spine injury clearance can generally be applied to children older than 2 years of age. Nevertheless, adequate caution should be exercised before applying these rules in younger children. Initial radiographic investigation should be always adequate plain radiographs of cervical spine. CT and MRI scans should only be performed in an appropriate group of pediatric patients.

Triage tools for detecting cervical spine injury in pediatric trauma patients

BACKGROUND

Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population.

OBJECTIVES

To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma.

SEARCH METHODS

We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility.

SELECTION CRITERIA

We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy.

MAIN RESULTS

Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity.

AUTHORS' CONCLUSIONS

There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.

Utility of plain radiographs and MRI in cervical spine clearance in symptomatic non-obtunded pediatric patients without high-impact trauma

PURPOSE

The optimal imaging modality for evaluating cervical spine trauma and optimizing management in the pediatric population is controversial. In pediatric populations, there are no well-established guidelines for cervical spine trauma evaluation and treatment. Currently, there is virtually no literature regarding imaging and management of symptomatic pediatric patients who present with cervical spine trauma without high-impact mechanism. This study aims to establish an optimal imaging strategy for this subgroup of trauma patients.

METHODS

We performed a retrospective review of pediatric patients (aged below 18 years) who were admitted to Monash Medical Centre, Melbourne, Australia between July 2011 and June 2015, who did not suffer a high-impact trauma but were symptomatic for cervical spine injury following cervical trauma. Imaging and management strategies were reviewed and results compared.

RESULTS

Forty-seven pediatric patients were identified who met the inclusion criteria. Of these patients, 46 underwent cervical spine series (CSS) plain radiograph imaging. Thirty-four cases underwent magnetic resonance imaging (MRI) and 9 patients underwent CT. MRI was able to detect 4 cases of ligamentous injury, which were not seen in CSS imaging and was able to facilitate cervical spine clearance in a further two patients whose CSS radiographs were abnormal.

CONCLUSION

In this study, MRI has a greater sensitivity and specificity when compared to CSS radiography in a symptomatic pediatric low-impact trauma population. Our data call in to question the routine use of CSS radiographs in children.

Imaging investigations in Spine Trauma: The value of commonly used imaging modalities and emerging imaging modalities

Traumatic spine injuries can be devastating for patients affected and for health care professionals if preventable neurological deterioration occurs. This review discusses the imaging options for the diagnosis of spinal trauma. It lays out when imaging is appropriate and when it is not. It discusses strength and weakness of available imaging modalities. Advanced techniques for spinal injury imaging will be explored. The review concludes with a review of imaging protocols adjusted to clinical circumstances.

Spinal clearance in unconscious children following traumatic brain injury

Spinal clearance in unconscious children following traumatic brain injury is an area of controversy. The risk of significant injury in this high-risk group needs to be balanced against that of prolonged spinal immobilization and all its implications. No national or international guideline exists to aid clinicians faced with such a scenario. This article reviews traumatic spinal injury in children looking at prevalence, risk factors, anatomical considerations, and radiological investigation. Spinal immobilization is discussed along with the use of appropriate and targeted radiological investigations to aid clearance.

Pediatric craniovertebral junction trauma

The craniovertebral junction consists of the occiput, atlas, and axis, along with their strong ligamentous attachments. Because of its unique anatomical considerations, trauma to the craniovertebral junction requires specialized care. Children with potential injuries to the craniovertebral junction and cervical spinal cord demand specific considerations compared to adult patients. Prehospital immobilization techniques, diagnostic studies, and spinal injury patterns among young children can be different from those in adults. This review highlights the unique aspects in diagnosis and management of children with real or potential craniovertebral junction injuries.

An analysis of cervical spine magnetic resonance imaging findings after normal computed tomographic imaging findings in pediatric trauma patients: ten-year experience of a level I pediatric trauma center

BACKGROUND

A variety of radiologic screening protocols exist for evaluation of pediatric trauma patients with potential cervical spine (c-spine) injuries. The purpose of this study was to describe findings on c-spine magnetic resonance imaging (MRI) after previously normal c-spine computed tomographic (CT) scan findings at a Level 1 trauma center.

METHODS

A retrospective chart review of trauma patients evaluated at Rady Children's Hospital, San Diego, between January 2000 and February 2010 was conducted. Trauma patients who were younger than 18 years, placed in c-spine precautions, had a normal c-spine CT scan, who subsequently had a c-spine MRI were included. The sample was subdivided into patients who underwent CT scans between January 1, 2000 to July 31, 2005 (early group), and August 1, 2005 to February 28, 2010 (late group), to compare results between different CT scan resolutions.

RESULTS

A total of 173 patients met inclusion criteria. With 100% of patients demonstrating normal c-spine CT scan findings, 83% of c-spine MRI findings were also negative (p < 0.001). Thirty patients (17%) demonstrated significant abnormalities on MRI. Of the 30, 5 (2.9%) required operative c-spine stabilization. Eighty-five patients underwent CT scan in the early group, and 88 in the late group. All 5 patients with unstable injuries not discovered on CT scan were from the early group, compared with none in the late group (p = 0.027).

CONCLUSION

Our results suggest that high-resolution CT scan with sagittal and coronal reconstructions may be comparable with MRI for the detection of unstable c-spine injuries in pediatric trauma patients. Although minimizing CT scan radiation exposure remains essential, high-resolution c-spine CT scan may allow for earlier c-spine clearance with reduction of associated hard collar comorbidities in centers where MRI is not available or in situations where the patient's clinical stability precludes obtaining MRI.

LEVEL OF EVIDENCE

Diagnostic study, level III.

Clearing the cervical spine in children

Increasing evidence from adult trauma patients has allowed the formation of some international consensus on clearance protocols. The evidence for paediatric trauma remains more fragmented, making the creation of definitive protocols difficult. Spinal injury in children differs from that in adults by injury distribution and prevalence, as well as anatomical and radiological differences. This complicates the process of clearance of the cervical spine in children. The evidence for clearance can be considered in terms of three groups of patients – the alert and asymptomatic child, the conscious child with high-risk criteria and the unconscious or obtunded child. This systematic review summarises the available evidence to clarify the current best practice for each group of patients.

[Injury severity and pattern at the scene. What is the influence of the mechanism of injury?]

BACKGROUND

The mechanism of injury is the major cause for trauma team activation and emergency room resuscitation of trauma victims. To date, it remains unclear to what extent the injury mechanism influences injury pattern and severity.

METHODS

A comprehensive systematic literature search based on Medline was carried out.

RESULTS

Only a limited number of studies are available which investigated the influence of injury mechanisms on injury patterns and severity. There are no specific mechanisms for traumatic brain and spine injuries. Injuries to the chest and abdomen most frequently resulted from motor vehicle accidents involving passengers sitting on the side of the impact. Steering wheel deformity correlated with the injury severity. Pelvic fractures occurred most frequently due to motor vehicle accidents. The highest mortality resulted from pedestrians being struck by a vehicle and additional loss of life in the same vehicle compartment.

CONCLUSIONS

The systematic literature research showed inconsistent results regarding the influence of trauma mechanisms on the resulting injury. Therefore, a treatment algorithm for trauma patients should be independent of the mechanism which is represented in several training programs (e.g. ATLS and PHTLS). However, the mechanism of injury may increase the alertness of the trauma team with respect to injury distribution and severity.