Factors Associated With Cervical Spine Injury in Children After Blunt Trauma

doi:10.1016/j.annemergmed.2010.08.038

Annals of Emergency Medicine

Volume 58, Issue 2, August 2011, Pages 145-155

Presented at the Pediatric Academic Societies annual meeting, May 2009, Baltimore, MD; and the Society of Academic Emergency Medicine annual meeting, May 2009, New Orleans, LA.

, , , , , , , , , , , , , , , , , , , …

https://doi.org/10.1016/j.annemergmed.2010.08.038 Get rights and content

Study objective

Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma.

Methods

We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the model's sensitivity and specificity.

Results

We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses.

Conclusion

We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.

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

References (30)

D. Chan et al.
The effect of spinal immobilization on healthy volunteers
Emerg Med Serv
(1994)
R.W. Schafermeyer et al.
Respiratory effects of spinal immobilization in children
Ann Emerg Med
(1991)
J.A. March et al.
Changes in physical examination caused by use of spinal immobilization
Prehosp Emerg Care
(2002)
J.R. Hoffman et al.
Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study
Ann Emerg Med
(1992)
D. Kerr et al.
Implementation of the Canadian C-Spine Rule reduces cervical spine x-ray rate for alert patients with potential neck injury
J Emerg Med
(2005)
G. Stroh et al.
Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries?an argument for selective immobilization
Ann Emerg Med
(2001)
D.M. Jaffe et al.
Developing a clinical algorithm for early management of cervical spine injury in child trauma victims
Ann Emerg Med
(1987)
P. Dayan et al.
The Pediatric Emergency Care Applied Research Network: progress and update
Clin Pediatr Emerg Med
(2006)
E.H. Gilbert et al.
Chart reviews in emergency medicine research: where are the methods?
Ann Emerg Med
(1996)
P. Viccellio et al.
A prospective multicenter study of cervical spine injury in children
Pediatrics
(2001)

W.H. Cordell et al.

Pain and tissue interface pressures during spine board immobilization

Ann Emerg Med

(1995)

H. Linares et al.

Association between pressure sores and immobilization in the immediate post-injury period

Orthopedics

(1987)

K.J. Heath

The effect on laryngoscopy of different cervical spine immobilization techniques

Anaesthesia

(1994)

J. Broder et al.

Increasing utilization of computed tomography in the pediatric emergency department, 2000-2006

Emerg Radiol

(2007)

R.R. Jimenez et al.

CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks?

Pediatr Radiol

(2008)

Cited by (128)

Patterns in Follow-Up Imaging Usage for Pediatric Patients with Whiplash-Associated Disorder
2023, World Neurosurgery
A clinical concern exists that pediatric patients with whiplash-associated disorder (WAD) might have missed structural injuries or, alternatively, subsequently develop structural injuries over time, despite initially negative imaging findings. The primary objective of this study is to assess follow-up imaging usage for pediatric patients presenting with WAD.
A retrospective review of 444 pediatric patients presenting to a level 1 pediatric trauma hospital from January 1, 2010 to December 31, 2019 was performed. Imaging was reviewed at the initial encounter and the 3- and 6-month follow-up appointments.
At the initial evaluation, children aged <6 years were more likely to receive radiographs (P = 0.007) and magnetic resonance imaging (P = 0.048) than were children aged 6–11 and 12–18 years. At the 3- and 6-month follow-up appointments, persistent neck pain was rare, representing <15% of patients at either time. Regardless of pain persistence, 80.2% of patients seen at the 3-month follow-up and 100% of patients at the 6-month follow-up underwent additional imaging studies. At the 3-month follow-up, children with persistent neck pain were more likely to undergo magnetic resonance imaging than were patients without persistent pain (P < 0.001). Also, patients with persistent neck pain were also more likely to not undergo any imaging evaluation (P = 0.002). Follow-up imaging studies did not reveal new structural injuries at either time point.
Follow-up imaging for pediatric patients with low-grade WAD did not identify new structural pathology—in patients with or without persistent neck pain.
Pediatric spinal injuries– current concepts
2023, Journal of Clinical Orthopaedics and Trauma
Spinal injuries in children contribute to the highest mortality and morbidity among all pediatric injuries. Fortunately, these injuries are a rare clinical entity but pose a difficulty in diagnosis due to challenges in neurological evaluation of a child and varied radiological presentation. Anatomical and biomechanical aspects of developing musculoskeletal system, relative plasticity of the pediatric spine make children vulnerable to spine injuries. Though motor vehicle collisions are common, children also suffer non-accidental trauma, falls and sports injuries. More chances of cervical spine involvement, higher susceptibility of spinal cord to tensile forces and associated multisystem injuries result in devastating consequences in children compared to adults. Injuries like SCIWORA, vertebral apophyseal injuries, birth-related spinal cord injuries are more specific injuries in pediatric age group. A vigilant clinical, neurological and radiological evaluation is mandatory in all children with suspected spinal injuries. Normal radiological features like ossification centers, pseudosubluxation and physiological vertebral wedging should be carefully noted as they could be misinterpreted as injuries. While CT scans help in better understanding of the fracture pattern, Magnetic Resonance Imaging in children is beneficial especially in detecting SCIWORA and other soft tissue injuries. Management principles of these pediatric spinal injuries are similar to adults. Literature evidences support conservative management in injuries like SCIWORA, unless there is an ongoing spinal cord compression. As in adults, the role of high dose methylprednisolone is still controversial in pediatric spinal cord injuries. Stable spinal injuries can be managed conservatively using orthosis or halo. Instrumentation by both anterior and posterior techniques has been described, but it is challenging due to smaller anatomy and poor implant purchase. In addition to pedicle screw instrumentation, wiring techniques are very beneficial especially in younger children.
Imaging of the Pediatric Cervical Spine
2023, Problem Solving in Pediatric Imaging
Pediatric spine trauma: A comprehensive review
2022, Clinical Imaging
Trauma to the pediatric spine can manifest as osseous, disco-ligamentous, and/or neurological injuries. Associated mortality is significantly higher than in adults. Injury patterns in children are distinct from those encountered in adults. Although spine radiographs are the first line of diagnosis, they may be challenging to interpret in children due to the difficulty of applying recognized radiographic landmarks to the partially ossified spine. Ligamentous laxity and developmental phenomena also lead to imaging pitfalls. Much of the recent literature on this subject focuses on region-specific injuries or individual entities, and may not be tailored specifically to the radiologist, thereby not stressing key aspects pertinent to the effective performance and successful interpretation of imaging exams. We aim to address this void. We provide a comprehensive review of pediatric spine trauma, outlining the clinical decision tools, imaging protocols including the current American College of Radiology (ACR) appropriateness guidelines, interpretive pitfalls and tips to navigate these pitfalls, and management implications of the spectrum of these injuries. Throughout the text, extensive tables, illustrations and imaging examples reinforce key concepts.
Imaging: Spine trauma
2022, Neural Repair and Regeneration after Spinal Cord Injury and Spine Trauma
With over 10,000 new cases and $14.5 billion of health-care-associated costs per year, spinal cord injuries continue to be one of the most disabling traumatic injuries to affect patients worldwide. One particular aspect of the workup of spinal trauma—radiographic imaging—has undergone considerable evolution over the past few years with the rise of new imaging modalities and refined imaging techniques. However, controversy continues to surround the indications for imaging and selection of the most clinically appropriate imaging modality in the traumatic setting. This chapter aims to outline the available imaging modalities, their utility in the posttraumatic setting, and potential limitations of each one. In addition, the chapter cites examples of common cervical injuries, as well as discussion of imaging approaches to thoracolumbar and vascular injuries.
Implementation of a dual cervical spine and blunt cerebrovascular injury assessment pathway for pediatric trauma patients
2021, American Journal of Emergency Medicine
Citation 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].
Background:
Pediatric cervical spine (CSI) and blunt cerebrovascular injuries (BCVI) are challenging to evaluate as they are rare but carry high morbidity and mortality. CT scans are the traditional imaging modality to evaluate for CSI/BCVI, but involve radiation exposure and potential future increased risk of malignancy. Therefore, we present results from the implementation of a combined CSI/BCVI pediatric trauma clinical pathway to aid clinicians in their decision-making.
Methods:
We conducted a 2-year retrospective cohort study analyzing data pre and post implementation of the combined CSI/BCVI pathway. Data was obtained from a level 1 pediatric trauma center and included blunt trauma patients under the age of 14. We evaluated the use of cervical spine computed tomography (CT), CT angiography, and plain radiographs, as well as missed injuries and provider pathway adherence.
Results:
We included 358 patients: 209 pre-pathway and 149 post-pathway implementation. Patient mean age was 8.9 years and 61% were male (61% males). There were no significant differences in GCS, AIS, and ISS between pre and post pathway groups. Post pathway implementation saw reduced use of cervical spine CT, although this was not clinically significant (33% vs 31%, p = 0.74). However, cervical spine radiography use increased (9% vs 16%, p = 0.03), and there was also an increase in screening for BCVI injuries with higher use of CTA (5% vs 7%, p = 0.52). A total of 12 CSI and 3 BCVI were identified with no missed injuries. Provider adherence to the pathway was modest (54%).
Conclusion
Implementation of a combined CSI/BCVI clinical pathway for pediatric trauma patients increased screening radiography and did not miss any injuries. However, CT use did not significantly decrease and provider adherence was modest, supporting the need for further implementation analysis and larger studies to validate the pathway's sensitivity and specificity for CSI/BCVI.

View all citing articles on Scopus

: Please see page 146 for the Editor's Capsule Summary of this article.

: Provide feedback on this article at the journal's Web site, www.annemergmed.com.

: A podcast for this article is available at www.annemergmed.com.

: 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.

^⁎: Participating centers and investigators are listed in the Appendix.

View full text

Pediatrics/original researchFactors Associated With Cervical Spine Injury in Children After Blunt Trauma

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Selection of Participants

Results

Limitations

Discussion

Emerg Med Serv

Ann Emerg Med

Prehosp Emerg Care

Ann Emerg Med

J Emerg Med

Ann Emerg Med

Ann Emerg Med

Clin Pediatr Emerg Med

Ann Emerg Med

A prospective multicenter study of cervical spine injury in children

Pediatrics

Pain and tissue interface pressures during spine board immobilization

Ann Emerg Med

Association between pressure sores and immobilization in the immediate post-injury period

Orthopedics

The effect on laryngoscopy of different cervical spine immobilization techniques

Anaesthesia

Increasing utilization of computed tomography in the pediatric emergency department, 2000-2006

Emerg Radiol

CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks?

Pediatr Radiol

Pediatrics/original research
Factors Associated With Cervical Spine Injury in Children After Blunt Trauma