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Need for cervical spine imaging for alert children after trauma
  1. Andreas Kontos, Medical student,
  2. Savvas Omorphos, Medical student,
  3. Joel Desmond, RCS Research Fellow,
  4. K Mackway-Jones
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jones{at}man.ac.uk

    Abstract

    A short cut review was carried out to establish whether clinical examination can be used to exclude cervical spine injury in alert children. Altogether 298 papers were found using the reported search, of which three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by Andreas Kontos, Savvas Omorphos, Medical studentsChecked by Joel Desmond, RCS Research Fellow

    Clinical scenario

    An 11 year old boy is brought to the emergency department by paramedics after falling off his bicycle. They have immobilised his cervical spine with a hard collar. He has no visible external injury, is fully alert and cooperative and does not complain of any neck pain. You are aware of the “trend” for radiographic cervical spine imaging in virtually all blunt trauma patients, as unrecognised cervical spine injury can lead to disastrous neurological sequelae. However, you wonder whether imaging in this case is really necessary.

    Three part question

    In [alert children with suspected cervical trauma] is [clinical examination without cervical radiography] adequate to [exclude significant cervical injury]?

    Search strategy

    Medline 1966–12/02 using the OVID interface. [(exp spinal cord injuries) OR (cervical spine injur$.mp)] AND [(exp x-rays) OR (x-rays.mp) OR (radiograph$.mp)] AND [BestBETs Paediatric filter] LIMIT to human AND English.

    Search outcome

    Altogether 298 papers were identified of which two were relevant. In addition NICE are undergoing a systematic review of head and cervical spine injury, and checking their search results, we found one additional paper that has not yet been indexed by Medline. These three papers are shown in table 3.

    Table 3

    Comment(s)

    Although the issue of radiographic assessment of children with suspected cervical injury has been addressed in several studies, there is still insufficient evidence to support diagnostic standards, as the incidence of cervical injuries among paediatric samples is low. To date, the Nexus criteria (absence of: (1) midline cervical tenderness, (2) altered alertness, (3) intoxication, (4) neurological deficit, and (5) painful distracting injury) provide the most reliable instrument for assessing the need for cervical spine radiography in paediatric blunt trauma victims. However, in doubtful individual cases, decision should be at the clinician’s discretion, as these criteria may not be 100% sensitive, because of the wide confidence interval around these findings.

    CLINICAL BOTTOM LINE

    Cervical spine radiography is not necessary in paediatric blunt trauma victims over the age of 9 who are fully alert, conversant, show no signs of intoxication, have no neurological deficit, no midline cervical tenderness, and no painful distracting injury.

    Report by Andreas Kontos, Savvas Omorphos, Medical studentsChecked by Joel Desmond, RCS Research Fellow

    References

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