Pediatrics/original researchFactors Associated With Cervical Spine Injury in Children After Blunt Trauma
Introduction
Cervical spine injury occurs in fewer than 1% of children presenting for trauma evaluation.1 Interventions aimed at protecting the cervical spine during out-of-hospital transport and subsequent radiographic assessment of the cervical spine during evaluation in the emergency department (ED) are common and known to be associated with adverse effects, including pain, pressure wounds, encumbered airway management and respiratory function, and exposure to ionizing radiation.2, 3, 4, 5, 6, 7, 8, 9, 10 More than 99% of children evaluated after trauma do not have cervical spine injury and therefore may be unnecessarily exposed to these harms.
Risk stratification strategies that have been developed in adults allow clinicians to limit these potentially harmful interventions to those at non-negligible risk of cervical spine injury. The best known of these rules, the National Emergency X-Radiography Utilization Study (NEXUS) criteria11, 12 and the Canadian C-spine Rule for alert and stable trauma patients13 are more than 99% sensitive for cervical spine injury in adults. When applied prospectively, these strategies were shown to significantly reduce the use of spinal immobilization and radiographic clearance without missing significant cervical spine injuries.14, 15, 16, 17, 18, 19
Efforts to develop similar risk stratification strategies in children with blunt trauma have been limited by small sample sizes, particularly among young children.1, 20, 21 Generalization of adult-derived cervical spine injury decision rules to children may be hazardous because children have age-dependent differences in cervical spine anatomy and injury patterns, as well as different mechanisms of injury and abilities to report symptoms. There is a pressing need to develop cervical spine injury risk stratification strategies for use in injured children. The purpose of our study was to identify risk factors associated with cervical spine injury in children after blunt trauma.
Section snippets
Selection of Participants
We conducted a retrospective case-control study in which we evaluated the medical records of children presenting to 17 medical centers (study sites) in the Pediatric Emergency Care Applied Research Network (PECARN) between 2000 and 2004.22, 23 We obtained institutional review board approval from all participating sites. Children were eligible if they were evaluated at a study site with cervical spine radiography after blunt trauma before 16 years of age.
Children who had cervical spine injury
Results
We identified 2,395 children as potential cases (Figure). Of these, 540 (23%) met inclusion criteria and were enrolled. Potential controls included 42,376 children, of whom 1,060 met inclusion criteria and were enrolled as random controls; 1,012, as mechanism of injury controls; and 702, as EMS controls. There was very little overlap between the control groups, with only 3 control patients being used in more than 1 control group. Descriptive characteristics of the cases and control groups are
Limitations
Most of the limitations of this study are inherent to retrospective chart reviews and include the potential for ascertainment and sampling bias and missing data. The chart abstraction in our study was rigorously conducted, however, and we used several measures to limit these biases. These measures included uniform training of all study personnel, explicit instructions for data abstraction for each variable, interrater reliability measurements, and careful study monitoring. We also used multiple
Discussion
In this large, multicenter case-control analysis, we identified 8 factors associated with cervical spine injury in children who experienced blunt trauma (altered mental status, focal neurologic deficits, complaint of neck pain, torticollis, substantial injury to the torso, predisposing condition, high-risk motor vehicle crash, and diving). These historical and physical examination findings are highly predictive of cervical spine injury in children after trauma and differ somewhat from
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2022, Clinical ImagingImaging: Spine trauma
2022, Neural Repair and Regeneration after Spinal Cord Injury and Spine TraumaImplementation of a dual cervical spine and blunt cerebrovascular injury assessment pathway for pediatric trauma patients
2021, American Journal of Emergency MedicineCitation Excerpt :Further complicating the diagnosis of BCVI is that its neurologic sequelae may be delayed by hours or even days [10-13]. Currently there are several validated clinical decision tools to screen adult trauma patients for CSI and help guide CT use [14-16]. However, those tools have produced mixed results when tested in a pediatric population, likely owing to the lower incidence of pediatric CSI and anatomic differences that result in different injury patterns [5,17].
Please see page 146 for the Editor's Capsule Summary of this article.
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Supervising editors: Kelly D. Young, MD, MS; Steven M. Green, MD
Author contributions: JCL and DMJ conceived the study and obtained grant funding. JCL, NK, and DMJ designed the study. JCL, NK, LB-C, KB, PM, KA, JA, DB, AD, JDH, EK, KL, LEN, EP, GR, DMJ, SDR, AJR, CS, and GT acquired data and provided supervision for the study. JCL and JRL verified all cervical spine injuries. JCL, NK, CO, and DMJ conducted the data analysis and interpreted the data. JCL drafted the article, and all authors critically revised it. JCL takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This work was supported by a grant from the Health Resources and Services Administration/Maternal and Child Health Bureau (HRSA/MCHB), Emergency Medical Services of Children (EMSC) Program (H34 MC04372). The Pediatric Emergency Care Applied Research Network (PECARN) is supported by cooperative agreements U03MC00001, U03MC00003, U03MC00006, U03MC00007, and U03MC00008 from the EMSC program of the MCHB, HRSA, US Department of Health and Human Services.
Publication date: Available online October 29, 2010.