Pediatric C-spine Clearance

There are several general principles to keep in mind regarding clearance of the pediatric C-spine:

-C-spine injuries are uncommon in children, and when they occur are more likely lower C-spine (C5-7)

-Children are often not able to communicate reliably where they are having pain or what their pain feels like

-In general, we try to limit radiation exposure in children, so CT scans are not the immediate test of choice

-There are many normal variations in pediatric C-spine that can make plan x-rays difficult to interpret, such as absence or difference in the normal cervical lordosis, epiphyseal variations, incomplete ossification, and pseudosubluxation.

Pseudosubluxation, resolves with placement of shoulder roll:

The goals of a protocol for C-spine clearance include:

-Reduce the time to clearing the C-spine

-Reduce unnecessary imaging and consults

-Minimize missed injuries

-Provide consistent patient care; a protocol should be easy enough to use that all physicians (no matter if they are rotators or seasoned residents) can give the same care to all patients.

Here's what the Stroger pediatric C-spine protocol looks like:

It looks pretty complicated, but is actually quite easy to use. Start with appendix A (top) and follow the flow chart based on the results and the patient’s exam.

It is useful to be familiar with the data behind this algorithm. The entire pediatric C-spine clearance protocol at Stroger comes from a study performed at Primary Children’s Medical Center in Salt Lake City, UT.

 

 The goals of this study were to reduce Neurosurgery consults to pediatric C-spine clearance, while maximizing the goals mentioned previously regarding C-spine clearance (minimizing missed injuries, minimizing time to clearance, etc). The research team used a multidisciplinary board made up of members from General Surgery, Neurosurgery, Emergency Medicine, and Critical Care Medicine to develop an algorithm for pediatric C-spine clearance. Data was collected from the three year time period leading up to the implementation of the new algorithm, as well as for three years after the algorithm was put into use in the ED.

Results:

	2001-2003, N (%)	2004-2006, N (%)
# of trauma cases	936	937
Children < 3 years old	293 (33)	290 (30)
CT performed	81 (9)	224 (24)
MRI performed	26 (3)	69 (7)
Ligament injury only	21 (2.2)	12 (1.3)
Fracture	8 (0.9)	10 (1.1)
Dislocation	4 (0.4)	4 (0.4)
Operative stabilization	5 (0.5)	4 (0.4)
Late injuries found	0 (0)	0 (0)
C-spine cleared by NON-NSurg	46 (5)	585 (62.4)
C-spine cleared by NSurg	890 (95)	352 (37.6)
Patient sent home in collar	0 (0)	85 (9)

The results of this study essentially revealed that the implementation of the algorithm:

-Reduced the number of Neurosurgery consults

-Increased the number of C-spines that were cleared by NON-neurosurgical physicians

-and probably most importantly, did not lead to an increase in missed injuries.

What this study did not show was any reduction in radiation or imaging ordering practices by the Emergency physicians, but that wasn’t one of the goals of the study.

Some weaknesses of this study from Primary Children’s Medical Center are:

-Every child got a PA/lateral neck x-ray (more on this below…)

-There were many CTs and MRIs ordered from referring hospitals so it is hard to tell which images would have been ordered if all the patients had presented initially to PCMC

-The algorithm does not provide any indication for what the neurosurgical consultant should order or do to clear the C-spine once that consult has been placed.

Is it possible that the future of pediatric C-spine clearance that includes a protocol which does not require PA/lateral C-spine x-rays for all pediatric patients in a C-collar…? Consider this study:

…which found that the NEXUS (National Emergency X-radiography Utilization Study) criteria correctly identifies pediatric patients at low risk for C-spine injury and who therefore don't need an x-ray at all. Specifically, the NEXUS criteria have a 100% negative predictive value (95% CI [99-100%]) for identifying low-risk patients. Fully 20% of the patients in this study could have been cleared clinically without x-rays.

Recall that the NEXUS criteria are:

1.    No midline C-spine tenderness

2.    Not intoxicated

3.    Normal level of alertness

4.    Normal neurologic exam

5.    No distracting injury

You are familiar with these criteria because they are the first step of Stroger’s adult C-spine clearance protocol. By incorporating these criteria as the first step in the evaluation of pediatric trauma patients, there could be a substantial decrease in the number of x-rays ordered in this patient population. At this point in time the NEXUS criteria are a part of Stroger’s pediatric C-spine clearance protocol, but are only used after the PA/lateral C-spine films have been obtained and read as normal. After further studies are performed at major pediatric trauma centers, we may see a shift in C-spine clearance algorithms to reflect this promising data.

In summary, Stroger has an excellent evidence-based protocol for pediatric C-spine clearance. This C-spine clearance protocol (as well as the other pediatric protocols for head, chest, and abdomen clearance) is found readily in the trauma ED in hard copy as well as on the Stroger Intranet site. The pediatric protocols are evidence-based, easy to use, and maximize patient care and resource utilization.

from Dr. Emily Roben