• imaging
• trauma
• spine and pelvis
• paediatric emergency med
• paediatric injury

‘Tis a lesson you should heed

Try, try again.

If at first you don’t succeed,

Try, try again.

— Thomas H Palmer Teacher’s Manual

Paediatric cervical spine injuries are rare events, particularly in young children. An individual emergency provider may see less than a handful in her entire career, even as she is continuously presented with patients considered at risk for injury. In the same career, each provider will likely expose thousands of children to significant doses of radiation with an indeterminate but finite risk of inducing a downstream malignancy. Thus, with the increasing awareness of the cumulative risks associated with radiation exposure, the decision as to which patient should be radiographically studied and at what threshold often becomes an uncomfortable one.

Useful clinical decision rules (CDRs) for identifying cervical spine injuries have been derived, validated and are broadly embraced for adult patients: the National Emergency X-Radiography Utilization Study (NEXUS) from the US and the Canadian C-Spine Rules (CCR).1 2 No comparable, validated paediatric decision-making tools have been created and medical providers have been largely left to extrapolate the findings of adult studies to their paediatric patients whose injuries and risks differ mechanistically and physiologically from their future selves. In an effort to provide better guidance to emergency providers, the investigators of the NEXUS trial analysed a paediatric subset with a very limited sample size (n=3065 with 30 cervical spine injuries), while the Pediatric Emergency Care Applied Research Network (PECARN) attempted to tackle the problem differently through a case-controlled methodology.3 4 Both of these paediatric efforts suffer significant limitations compared with the afore-mentioned large prospective observational studies.

In a side-by-side comparison of these three decision tools, …