Table 3
Author, date and countryPatient groupStudy type (level of evidence)OutcomesKey resultsStudy weaknesses
Laham JL et al, 1994, USA268 children aged 0–19, with apparent isolated head injuries defined by clinical and radiographic evidence in a single children’s hospital.Retrospective cohort studyPerformance of low risk criteria for excluding c-spine injuryNo 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 painSensitivity 100%GCS was not consistently recorded in these children
Specificity 52%215 children had cervical radiographs (80%)
Viccellio P, et al, 2001, USAMulticenter evaluation of 3065 children (age <18) with suspected c-spine injury who underwent clinical evaluation before c-spine radiography.Prospective cohort StudyPerformance of low risk criteria for excluding c-spine injuryNo 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) intoxicationNexus criteria identified all cases of cervical injury diagnosed by radiographyTotal 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, USASearch 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 identifiedSystematic reviewGuidelines for the management of acute cervical spine and spinal cord injuriesIn 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