PTS 2014 PLENARY PAPER
Implementation of pediatric cervical spine clearance guidelines at a combined trauma center: Twelve-month impact Shannon F. Rosati, MD, Rami Maarouf, MD, Luke Wolfe, MS, Dan Parrish, MD, Michael Poppe, Robin Manners, Karen Brown, and Jeffrey H. Haynes, MD, Richmond, Virginia
Pediatric cervical spine clearance guidelines should reduce computed tomography (CT) usage in combined pediatric and adult trauma centers biased by adult CT clearance. METHODS: Cervical spine clearance under age 15 years was compared 12 months before (128 patients) and after (105 patients) guideline implementation, emphasizing National Emergency X-Radiography Utilization Study (NEXUS) criteria when appropriate. RESULTS: CT scans in patients clearable by NEXUS criteria decreased 23% (p = 0.01) and decreased by 16% in cases where radiography other than CT was indicated by guidelines (p = 0.01). CONCLUSION: Guideline implementation can have an immediate effect in decreasing pediatric cervical spine CT usage and should improve across time. (J Trauma Acute Care Surg. 2015;78: 1117Y1121. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Care management study, level IV. KEY WORDS: Cervical spine clearance. BACKGROUND:
BACKGROUND Cervical spine injury in children younger than 15 years is an unusual but a potentially extremely serious event, with an incidence of approximately 1% to 2%.1Y3 Despite the differences in incidence and severity between the adult and pediatric population, pediatric patients are usually subjected to the same traumatic workup of their cervical spine as adult trauma patients. Historically, the workup of the cervical spine involves obtaining a complete cervical spine computed tomography (CT) scan at many institutions, including ours. CT scanning is considered standard for adult clearance and, because most pediatric trauma nationally is managed outside of dedicated pediatric trauma centers, children, therefore, are often subjected to adult clearance methods. A cervical spine CT scan, besides being costly, also exposes children to large amounts of radiation, exposing them to potential future malignancies.4 There has therefore been interest in creating separate guidelines for the clearance of the pediatric cervical spine because they have been found to reduce significantly the exposure to radiation and such guidelines have been found to be effective without a CT scan of the cervical spine.5Y7 After implementing pediatric cervical spine clearance guidelines using National Emergency X-Radiography Utilization Study (NEXUS) criteria at our combined adult and pediatric Level I trauma center, we reviewed our results 12 months before Submitted: November 14, 2014, Revised: February 2, 2015, Accepted: March 6, 2015. From the Division of Pediatric Surgery (S.F.R., R.M., D.P., J.H.) and Department of Surgery (L.W.), School of Medicine (M.P., R.M., K.B.), and Children’s Trauma Center, Children’s Hospital of Richmond (J.H.H.), Virginia Commonwealth University Health System, Richmond, Virginia. This study was presented at the 1st annual meeting of the Pediatric Trauma Society, November 14Y15, 2014, in Chicago, Illinois. Address for reprints: Jeffrey H. Haynes, MD, Division of Pediatric Surgery, Children’s Hospital of Richmond at VCU, PO Box 980015, Richmond, VA 23298-0015. DOI: 10.1097/TA.0000000000000643
and 12 months after implementation. Our intent was to see if we could decrease the number of pediatric cervical spine CT scans performed.
PATIENTS AND METHODS We conducted an institutional review boardYapproved retrospective review of pediatric patients (aged G15 years) 12 months before and 12 months after the implementation of pediatric cervical spine clearance guidelines at our combined adult and pediatric Level I trauma center. Children evaluated were brought to our emergency department as either DELTA (first tier) or ECHO (second tier) trauma team alerts. Data collected included the patients’ age, Injury Severity Score (ISS), presence of NEXUS criteria (defined as presence of at least one of the following: midline cervical spine tenderness to palpation, altered consciousness, intoxication, distracting injury, or neurologic deficit). Guidelines were developed to emphasize the use of NEXUS criteria and to minimize radiation exposure (Fig. 1). NEXUS criteria were used at the discretion of the examining physician if the examination was determined to be reliable, despite age of the child. This was performed for children of all ages because the numbers of children younger than 3 years were not deemed to be a large enough cohort to analyze separately. The guidelines, which were developed for use by the individual clinician for each individual patient, begin with an evaluation of the child’s mental status using the Glasgow Coma Scale or the child’s ability to communicate at a developmentally appropriate normal level. Often, the Glasgow Coma Scale score was not listed in the patient records or, instead, there was a description of the child’s mental status in the initial trauma intake form; therefore, this variable was not included in the statistical analysis, although it certainly could be a confounding variable. If there are no NEXUS criteria present and the child has a normal range of motion of his or her cervical spine without any pain, the neck can be cleared clinically. Presence of any of the
J Trauma Acute Care Surg Volume 78, Number 6
1117
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 6
Rosati et al.
Figure 1. The pediatric cervical spine guidelines in use at our combined adult and pediatric Level I trauma institution.
aforementioned NEXUS criteria necessitates imaging, which begins with anteroposterior and lateral plain films of the cervical spine. A CT scan of the cervical spine is obtained only if there is a fracture or bony displacement on the initial plain films of the cervical spine. If pain is present with negative plain films, if the child has pain with range of motion, or if the child remains intubated or with neurologic deficit, magnetic resonance imaging (MRI) of the cervical spine is performed. If this MRI has positive findings of injury or if there are positive findings on a CT scan of the cervical spine, neurosurgery is consulted for further management. If the child’s cervical spine is nontender with no deficit or if an MRI is obtained and is normal, the Aspen collar can be removed and the cervical spine cleared with no additional consults or workup required.
Statistical analyses were performed using SAS 9.4. All tests were two-tailed and used a significance level of 0.05. Continuous variables were compared using the Wilcoxon rank test or the Kruskal-Wallis test and are represented as median and interquartile range (IQR). Rates were compared using Fisher’s exact test.
RESULTS A total of 233 children were evaluated during the 2-year period reviewed: 128 before guideline implementation and 105 afterward. There was no significant difference in ages between the two groups (median 6.0 years, IQR 7.0 vs. median 7.0, IQR 7.0 years; p = 0.8355) or ISS (median 4.0, IQR 9.0 vs. median
Figure 2. Comparison of the percentage of patients who received cervical spine CT scans with and without the presence of NEXUS criteria. A, Before guideline implementation. B, After guideline implementation. 1118
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 6
Rosati et al.
Figure 3. Comparison of the percentage of patients who received cervical spine CT scans with and without any other CT scan (head, chest, abdomen, or pelvis). A, Before guideline implementation. B, After guideline implementation.
4.0, IQR 8.0; p = 0.1851). Both before and after guideline implementation, children with higher ISSs were more likely to get cervical spine CT scans (Pre-Protocol CT No median 2.0 IQR 4.0 vs. CT Yes median 6.0 IQR 12.0; p = 0.0007 and PostProtocol CT No median 2.0 IQR 4.0 vs. CT Yes median 5.5 IQR 12.0; p = 0.0233). A total of 55 cervical spine CT scans were obtained in the year before the implementation of our guidelines. Eighteen percent of these patients (9 of 51) received a cervical spine CT with no NEXUS criteria present compared with 61% of patients (46 of 76) who had NEXUS criteria present. A total of 30 cervical spine CT scans were obtained in the year after the implementation of our guidelines. Fifteen percent of these patients (6 of 41) had no NEXUS criteria present, whereas 38% of patients (24 of 64) had the presence of NEXUS criteria. These data are shown in Figure 2. Fifty-five percent of patients (53 of 97) who had a cervical spine CT in the year before the guideline implementation also had another CT scan performed compared with 40% of patients (27 of 67) after protocol implementation (Fig. 3). We also examined the specific combination of cervical spine CT scans obtained with a head CT
(Fig. 4). Sixty percent of patients (51 of 86) who underwent a cervical spine CT also had a head CT performed in the year before guideline implementation compared with 44% of patients (29 of 69) after the guidelines were implemented. Overall results are shown in Figures 5 and 6. In a 12-month period, we were able to decrease the number of CT scans clearable by NEXUS criteria by 23% (p = 0.01) (Fig. 5). The total number of all radiographic studies performed on the cervical spine (plain films and MRI) also decreased by 13% (p = 0.02). Through the implementation of these guidelines, the number of CT scans of the cervical spine clearable by NEXUS criteria obtained in the setting of any other CT scan decreased by 15% (p = 0.08) and in the setting of head CT decreased by 16% (p = 0.09) (Fig. 6). In addition, no child has required follow-up imaging for a clinically apparent cervical spine injury during the 2-year period of our retrospective review.
DISCUSSION The epidemiologic features of pediatric spinal cord injury have shown that these injuries are uncommon and that the
Figure 4. Comparison of the percentage of patients who received cervical spine CT scans with and without a head CT scan only. A, Before guideline implementation. B, After guideline implementation. * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
1119
J Trauma Acute Care Surg Volume 78, Number 6
Rosati et al.
Figure 5. Comparison of the percentage of cervical spine CT scans and other imaging (cervical spine plain films or MRI) performed overall before and after implementation of the guidelines.
mechanism of injury is different depending on the age at the time of injury compared with the adult population.8 Cervical spine injuries in young children in particular, although rare, occur at an increased frequency compared with other spinal injuries, with 60% to 80% of all pediatric spine injuries occurring in the cervical region and when compared with adults.3,9Y15 These differences can be explained in part by the anatomy of a child’s cervical spine, which begins to resemble an adult’s cervical spine approximately 8 years of age; before this age, the cervical spine has incomplete ossification, a different vertebral configuration, and an increased ligamentous laxity.16Y19 These biomechanical and anatomic features of the immature pediatric cervical spine lead to differences in injury patterns when compared with adults.20 Given these differences, a CT scan of the cervical spine often will not demonstrate ligamentous injuries in children and, therefore, is the wrong imaging choice. MRI, if needed, could be of use to determine if these injuries are present. Clearance of the pediatric cervical spine can be challenging for a variety of reasons. Although the incidence of cervical spine injuries in children may be low, the results are potentially devastating. In addition, challenges may arise in evaluating the mental
status of a child younger than 3 years, in whom NEXUS criteria may or may not be valid. Principles in clearing the cervical spine of children should be similar to the adult trauma patient, with care taken to minimize radiation exposure. At our institution, which combines both adult and pediatric Level I trauma centers, adult trauma surgeons in tandem with pediatric emergency medicine physicians are the first to evaluate pediatric trauma patients. In a 12-month period, even with an initial learning curve included, we were able to create a statistically significant decrease in the number of CT scans of the cervical spine ordered in pediatric patients whose cervical spines were clearable by NEXUS criteria. We were also able to create a statistically significant decrease in the number of total radiographic studies obtained, as well as a decrease in the number of cervical spine CT scans obtained in the setting of other serious injury, worked up by head, chest, abdomen, or pelvis CT scans. With no missed cervical spine injuries in the 12 months before or 12 months after protocol implementation, we demonstrate here that guideline implementation can have an immediate impact on decreasing pediatric cervical spine CT scan usage, which should improve across time. The creation of separate guidelines for clearance of the cervical spine in the pediatric population could be used at other major combined trauma centers
Figure 6. Comparison of the percentage of cervical spine CT scans and other CT scans (all and head CT) performed overall before and after implementation of the guidelines. 1120
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 6
Rosati et al.
and may have applicability in nonpediatric trauma centers that evaluate injured children. AUTHORSHIP S.F.R., the primary author, wrote the manuscript, collected and analyzed the data, and designed the study. R.M. compiled all figures, analyzed the data, and edited and revised the manuscript. D.P. edited the manuscript, analyzed the data, and designed the study. L.W. is the statistician who compiled and performed all statistical analyses. M.P., R.M., and K.B. analyzed and collected the data and reviewed the literature. J.H. designed the study, analyzed the data, and critically revised the manuscript.
DISCLOSURE The authors declare no conflicts of interest.
REFERENCES 1. Reynolds R. Pediatric spinal injury. Curr Opin Pediatr. 2000;12:67Y71. 2. Avellino AM, Mann FA, Grady MS, Chapman JR, Ellenbogen RG, Alden TD, Mirza SK. The misdiagnosis of acute cervical spine injuries and fractures in infants and children: the 12-year experience of a Level I pediatric and adult trauma center. Childs Nerv Syst. 2005;21:122Y127. 3. Ruge JR, Sinson GP, McLone DG, Cerullo LJ. Pediatric spinal injury: the very young. J Neurosurg. 1988;68:25Y30. 4. Chen JX, Kachniarz B, Gilani S, Shin JJ. Risk of malignancy associated with head and neck CT in children: a systematic review. Otolaryngol Head Neck Surg. 2014;151:554Y566. 5. Sun R, Skeete D, Wetjen K, Lilienthal M, Liao J, Madsen M, Lancaster G, Shilyansky J, Choi K. A pediatric cervical spine clearance protocol to reduce radiation exposure in children. J Surg Res. 2013;183(1):341Y346. 6. Lee SL, Sena M, Greenholz SK, Fledderman M. A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results. J Pediatric Surg. 2003;38(3):358Y362.
7. Anderson RC, Kan P, Vanaman M, Rubsam J, Hansen KW, Scaife ER, Brockmeyer DL. Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age. J Neurosurg Pediatr. 2010; 5(3):292Y296. 8. Parent S, Mac-Thiong JM, Roy-Beaudry M, Sosa JF, Labelle H. Spinal cord injury in the pediatric population: a systematic review of the literature. J Neurotrauma. 2011;28:1515Y1524. 9. Kewalramani LS, Kraus JF, Sterling HM. Acute spinal-cord lesions in a paediatric population: epidemiological and clinical features. Paraplegia. 1980;18:206Y219. 10. Carty H, Shaw D, Brunelle F, et al. Imaging Children. Edinburgh, UK: Churchill Livingstone; 1994:1167Y1175. 11. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343:94Y99. 12. Jaffe DM, Binns H, Radkowski MA, Barthel MJ, Engelhard HH 3rd. Developing a clinical algorithm for early management of cervical spine injury in child trauma victims. Ann Emerg Med. 1987;16:270Y276. 13. Ehara S, El-Khoury GY, Sato Y. Cervical spine injury in children: radiologic manifestations. AJR Am J Roentgenol. 1988;151:1175Y1178. 14. Henrys P, Lyne ED, Lifton C, Salciccioli G. Clinical review of cervical spine injuries in children. Clin Orthop Relat Res. 1977;(129):172Y176. 15. Hill SA, Miller CA, Kosnik EJ, Hunt WE. Pediatric neck injuries. A clinical study. J Neurosurg. 1984;60:700Y706. 16. Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of pediatric cervical spine injuries. J Pediatr Surg. 2001;36:100Y105. 17. Finch GD, Barnes MJ. Major cervical spine injuries in children and adolescents. J Pediatr Orthop. 1998;18:811Y814. 18. Partrick DA, Bensard DD, Moore EE, Calkins CM, Karrer FM. Cervical spine trauma in the injured child: a tragic injury with potential for salvageable functional outcome. J Pediatr Surg. 2000;35:1571Y1575. 19. Slack SE, Clancy MJ. Clearing the cervical spine of paediatric trauma patients. Emerg Med J. 2004;21:189Y193. 20. Platzer P, Jaindl M, Thalhammer G, Dittrich S, Kutscha-Lissberg F, Vecsei V, Gaebler C. Cervical spine injuries in pediatric patients. J Trauma. 2007; 62:389Y396.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
1121
Implementation of pediatric cervical spine clearance guidelines at a combined trauma center: Twelve-month impact Shannon F. Rosati, MD, Rami Maarouf, MD, Luke Wolfe, MS, Dan Parrish, MD, Michael Poppe, Robin Manners, Karen Brown, and Jeffrey H. Haynes, MD, Richmond, Virginia
Pediatric cervical spine clearance guidelines should reduce computed tomography (CT) usage in combined pediatric and adult trauma centers biased by adult CT clearance. METHODS: Cervical spine clearance under age 15 years was compared 12 months before (128 patients) and after (105 patients) guideline implementation, emphasizing National Emergency X-Radiography Utilization Study (NEXUS) criteria when appropriate. RESULTS: CT scans in patients clearable by NEXUS criteria decreased 23% (p = 0.01) and decreased by 16% in cases where radiography other than CT was indicated by guidelines (p = 0.01). CONCLUSION: Guideline implementation can have an immediate effect in decreasing pediatric cervical spine CT usage and should improve across time. (J Trauma Acute Care Surg. 2015;78: 1117Y1121. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Care management study, level IV. KEY WORDS: Cervical spine clearance. BACKGROUND:
BACKGROUND Cervical spine injury in children younger than 15 years is an unusual but a potentially extremely serious event, with an incidence of approximately 1% to 2%.1Y3 Despite the differences in incidence and severity between the adult and pediatric population, pediatric patients are usually subjected to the same traumatic workup of their cervical spine as adult trauma patients. Historically, the workup of the cervical spine involves obtaining a complete cervical spine computed tomography (CT) scan at many institutions, including ours. CT scanning is considered standard for adult clearance and, because most pediatric trauma nationally is managed outside of dedicated pediatric trauma centers, children, therefore, are often subjected to adult clearance methods. A cervical spine CT scan, besides being costly, also exposes children to large amounts of radiation, exposing them to potential future malignancies.4 There has therefore been interest in creating separate guidelines for the clearance of the pediatric cervical spine because they have been found to reduce significantly the exposure to radiation and such guidelines have been found to be effective without a CT scan of the cervical spine.5Y7 After implementing pediatric cervical spine clearance guidelines using National Emergency X-Radiography Utilization Study (NEXUS) criteria at our combined adult and pediatric Level I trauma center, we reviewed our results 12 months before Submitted: November 14, 2014, Revised: February 2, 2015, Accepted: March 6, 2015. From the Division of Pediatric Surgery (S.F.R., R.M., D.P., J.H.) and Department of Surgery (L.W.), School of Medicine (M.P., R.M., K.B.), and Children’s Trauma Center, Children’s Hospital of Richmond (J.H.H.), Virginia Commonwealth University Health System, Richmond, Virginia. This study was presented at the 1st annual meeting of the Pediatric Trauma Society, November 14Y15, 2014, in Chicago, Illinois. Address for reprints: Jeffrey H. Haynes, MD, Division of Pediatric Surgery, Children’s Hospital of Richmond at VCU, PO Box 980015, Richmond, VA 23298-0015. DOI: 10.1097/TA.0000000000000643
and 12 months after implementation. Our intent was to see if we could decrease the number of pediatric cervical spine CT scans performed.
PATIENTS AND METHODS We conducted an institutional review boardYapproved retrospective review of pediatric patients (aged G15 years) 12 months before and 12 months after the implementation of pediatric cervical spine clearance guidelines at our combined adult and pediatric Level I trauma center. Children evaluated were brought to our emergency department as either DELTA (first tier) or ECHO (second tier) trauma team alerts. Data collected included the patients’ age, Injury Severity Score (ISS), presence of NEXUS criteria (defined as presence of at least one of the following: midline cervical spine tenderness to palpation, altered consciousness, intoxication, distracting injury, or neurologic deficit). Guidelines were developed to emphasize the use of NEXUS criteria and to minimize radiation exposure (Fig. 1). NEXUS criteria were used at the discretion of the examining physician if the examination was determined to be reliable, despite age of the child. This was performed for children of all ages because the numbers of children younger than 3 years were not deemed to be a large enough cohort to analyze separately. The guidelines, which were developed for use by the individual clinician for each individual patient, begin with an evaluation of the child’s mental status using the Glasgow Coma Scale or the child’s ability to communicate at a developmentally appropriate normal level. Often, the Glasgow Coma Scale score was not listed in the patient records or, instead, there was a description of the child’s mental status in the initial trauma intake form; therefore, this variable was not included in the statistical analysis, although it certainly could be a confounding variable. If there are no NEXUS criteria present and the child has a normal range of motion of his or her cervical spine without any pain, the neck can be cleared clinically. Presence of any of the
J Trauma Acute Care Surg Volume 78, Number 6
1117
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 6
Rosati et al.
Figure 1. The pediatric cervical spine guidelines in use at our combined adult and pediatric Level I trauma institution.
aforementioned NEXUS criteria necessitates imaging, which begins with anteroposterior and lateral plain films of the cervical spine. A CT scan of the cervical spine is obtained only if there is a fracture or bony displacement on the initial plain films of the cervical spine. If pain is present with negative plain films, if the child has pain with range of motion, or if the child remains intubated or with neurologic deficit, magnetic resonance imaging (MRI) of the cervical spine is performed. If this MRI has positive findings of injury or if there are positive findings on a CT scan of the cervical spine, neurosurgery is consulted for further management. If the child’s cervical spine is nontender with no deficit or if an MRI is obtained and is normal, the Aspen collar can be removed and the cervical spine cleared with no additional consults or workup required.
Statistical analyses were performed using SAS 9.4. All tests were two-tailed and used a significance level of 0.05. Continuous variables were compared using the Wilcoxon rank test or the Kruskal-Wallis test and are represented as median and interquartile range (IQR). Rates were compared using Fisher’s exact test.
RESULTS A total of 233 children were evaluated during the 2-year period reviewed: 128 before guideline implementation and 105 afterward. There was no significant difference in ages between the two groups (median 6.0 years, IQR 7.0 vs. median 7.0, IQR 7.0 years; p = 0.8355) or ISS (median 4.0, IQR 9.0 vs. median
Figure 2. Comparison of the percentage of patients who received cervical spine CT scans with and without the presence of NEXUS criteria. A, Before guideline implementation. B, After guideline implementation. 1118
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 6
Rosati et al.
Figure 3. Comparison of the percentage of patients who received cervical spine CT scans with and without any other CT scan (head, chest, abdomen, or pelvis). A, Before guideline implementation. B, After guideline implementation.
4.0, IQR 8.0; p = 0.1851). Both before and after guideline implementation, children with higher ISSs were more likely to get cervical spine CT scans (Pre-Protocol CT No median 2.0 IQR 4.0 vs. CT Yes median 6.0 IQR 12.0; p = 0.0007 and PostProtocol CT No median 2.0 IQR 4.0 vs. CT Yes median 5.5 IQR 12.0; p = 0.0233). A total of 55 cervical spine CT scans were obtained in the year before the implementation of our guidelines. Eighteen percent of these patients (9 of 51) received a cervical spine CT with no NEXUS criteria present compared with 61% of patients (46 of 76) who had NEXUS criteria present. A total of 30 cervical spine CT scans were obtained in the year after the implementation of our guidelines. Fifteen percent of these patients (6 of 41) had no NEXUS criteria present, whereas 38% of patients (24 of 64) had the presence of NEXUS criteria. These data are shown in Figure 2. Fifty-five percent of patients (53 of 97) who had a cervical spine CT in the year before the guideline implementation also had another CT scan performed compared with 40% of patients (27 of 67) after protocol implementation (Fig. 3). We also examined the specific combination of cervical spine CT scans obtained with a head CT
(Fig. 4). Sixty percent of patients (51 of 86) who underwent a cervical spine CT also had a head CT performed in the year before guideline implementation compared with 44% of patients (29 of 69) after the guidelines were implemented. Overall results are shown in Figures 5 and 6. In a 12-month period, we were able to decrease the number of CT scans clearable by NEXUS criteria by 23% (p = 0.01) (Fig. 5). The total number of all radiographic studies performed on the cervical spine (plain films and MRI) also decreased by 13% (p = 0.02). Through the implementation of these guidelines, the number of CT scans of the cervical spine clearable by NEXUS criteria obtained in the setting of any other CT scan decreased by 15% (p = 0.08) and in the setting of head CT decreased by 16% (p = 0.09) (Fig. 6). In addition, no child has required follow-up imaging for a clinically apparent cervical spine injury during the 2-year period of our retrospective review.
DISCUSSION The epidemiologic features of pediatric spinal cord injury have shown that these injuries are uncommon and that the
Figure 4. Comparison of the percentage of patients who received cervical spine CT scans with and without a head CT scan only. A, Before guideline implementation. B, After guideline implementation. * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
1119
J Trauma Acute Care Surg Volume 78, Number 6
Rosati et al.
Figure 5. Comparison of the percentage of cervical spine CT scans and other imaging (cervical spine plain films or MRI) performed overall before and after implementation of the guidelines.
mechanism of injury is different depending on the age at the time of injury compared with the adult population.8 Cervical spine injuries in young children in particular, although rare, occur at an increased frequency compared with other spinal injuries, with 60% to 80% of all pediatric spine injuries occurring in the cervical region and when compared with adults.3,9Y15 These differences can be explained in part by the anatomy of a child’s cervical spine, which begins to resemble an adult’s cervical spine approximately 8 years of age; before this age, the cervical spine has incomplete ossification, a different vertebral configuration, and an increased ligamentous laxity.16Y19 These biomechanical and anatomic features of the immature pediatric cervical spine lead to differences in injury patterns when compared with adults.20 Given these differences, a CT scan of the cervical spine often will not demonstrate ligamentous injuries in children and, therefore, is the wrong imaging choice. MRI, if needed, could be of use to determine if these injuries are present. Clearance of the pediatric cervical spine can be challenging for a variety of reasons. Although the incidence of cervical spine injuries in children may be low, the results are potentially devastating. In addition, challenges may arise in evaluating the mental
status of a child younger than 3 years, in whom NEXUS criteria may or may not be valid. Principles in clearing the cervical spine of children should be similar to the adult trauma patient, with care taken to minimize radiation exposure. At our institution, which combines both adult and pediatric Level I trauma centers, adult trauma surgeons in tandem with pediatric emergency medicine physicians are the first to evaluate pediatric trauma patients. In a 12-month period, even with an initial learning curve included, we were able to create a statistically significant decrease in the number of CT scans of the cervical spine ordered in pediatric patients whose cervical spines were clearable by NEXUS criteria. We were also able to create a statistically significant decrease in the number of total radiographic studies obtained, as well as a decrease in the number of cervical spine CT scans obtained in the setting of other serious injury, worked up by head, chest, abdomen, or pelvis CT scans. With no missed cervical spine injuries in the 12 months before or 12 months after protocol implementation, we demonstrate here that guideline implementation can have an immediate impact on decreasing pediatric cervical spine CT scan usage, which should improve across time. The creation of separate guidelines for clearance of the cervical spine in the pediatric population could be used at other major combined trauma centers
Figure 6. Comparison of the percentage of cervical spine CT scans and other CT scans (all and head CT) performed overall before and after implementation of the guidelines. 1120
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 6
Rosati et al.
and may have applicability in nonpediatric trauma centers that evaluate injured children. AUTHORSHIP S.F.R., the primary author, wrote the manuscript, collected and analyzed the data, and designed the study. R.M. compiled all figures, analyzed the data, and edited and revised the manuscript. D.P. edited the manuscript, analyzed the data, and designed the study. L.W. is the statistician who compiled and performed all statistical analyses. M.P., R.M., and K.B. analyzed and collected the data and reviewed the literature. J.H. designed the study, analyzed the data, and critically revised the manuscript.
DISCLOSURE The authors declare no conflicts of interest.
REFERENCES 1. Reynolds R. Pediatric spinal injury. Curr Opin Pediatr. 2000;12:67Y71. 2. Avellino AM, Mann FA, Grady MS, Chapman JR, Ellenbogen RG, Alden TD, Mirza SK. The misdiagnosis of acute cervical spine injuries and fractures in infants and children: the 12-year experience of a Level I pediatric and adult trauma center. Childs Nerv Syst. 2005;21:122Y127. 3. Ruge JR, Sinson GP, McLone DG, Cerullo LJ. Pediatric spinal injury: the very young. J Neurosurg. 1988;68:25Y30. 4. Chen JX, Kachniarz B, Gilani S, Shin JJ. Risk of malignancy associated with head and neck CT in children: a systematic review. Otolaryngol Head Neck Surg. 2014;151:554Y566. 5. Sun R, Skeete D, Wetjen K, Lilienthal M, Liao J, Madsen M, Lancaster G, Shilyansky J, Choi K. A pediatric cervical spine clearance protocol to reduce radiation exposure in children. J Surg Res. 2013;183(1):341Y346. 6. Lee SL, Sena M, Greenholz SK, Fledderman M. A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results. J Pediatric Surg. 2003;38(3):358Y362.
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