| Laham JL et al, 1994, USA | 268 children aged 0–19, with apparent isolated head injuries defined by clinical and radiographic evidence in a single children’s hospital. | Retrospective cohort study | Performance of low risk criteria for excluding c-spine injury | No cervical spine injuries in the low risk group (n=135). 10 (7.5%) cervical injuries in the high risk group. (n=133) | The entry criteria of: significant head injury needing admission was made at the discretion of the PICU triage officer. |
| Low risk criteria for c-spine injury: capable of verbal communication and no neck pain | | | Sensitivity 100% | GCS was not consistently recorded in these children |
| | | | Specificity 52% | 215 children had cervical radiographs (80%) |
| Viccellio P, et al, 2001, USA | Multicenter evaluation of 3065 children (age <18) with suspected c-spine injury who underwent clinical evaluation before c-spine radiography. | Prospective cohort Study | Performance of low risk criteria for excluding c-spine injury | No child in the low risk group of 603 patients had a c-spine injury. | Number of children with cervical spine injury under nine was very low (only 4) |
| Low risk criteria (Nexus criteria) were defined as absence of: (1) midline cervical tenderness, (2) painful distracting injury, (3) altered alertness, (4) neurological deficit, and (5) intoxication | | | Nexus criteria identified all cases of cervical injury diagnosed by radiography | Total number of children with cervical injury was only 30 (0.98%), therefore, CI for sensitivity was wide (87.8% to 100.0%) |
| | | | Sensitivity 100% (CI 87.8% to 100%) | |
| | | | Specificity 19.8% | Caution is suggested for applying the Nexus criteria for children under 9 years. |
| American Association of Neurological Surgeons and the Congress of Neurological Surgeons, 2002, USA | Search of Medline (1966–2001) in the following subject headings: “spinal injuries” and “child” were reviewed with “cervical vertebrae”, “spinal injuries” and “child”. Altogether, 58 relevant articles were identified | Systematic review | Guidelines for the management of acute cervical spine and spinal cord injuries | In children experiencing trauma who are alert, conversant, have no neurological deficit, no midline cervical tenderness, no painful distracting injury and not intoxicated, cervical spine radiographs not recommended. | Search strategy is not reproducible. No mention of searching the grey literature or contacting experts for papers. |
| | | | This is a recommendation from grade 3 evidence papers except Nexus paper, which is grade 2 | |