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Traumatic pediatric cervical spine injury-a proposed clearance algorithm incorporating a 24-h time delay
Victoria E Fischer1,2, Vaidehi M Mahadev3,4, Jacob A Bethel4,5
1Department of Neurosurgery, University of Texas Health at San Antonio, San Antonio, TX, USA. fischerv@uthscsa.edu.
Insights
A delayed 24-hour reapplication of combined NEXUS Criteria and Canadian C-spine Rules may improve screening for pediatric cervical spine injuries (pCSI). This approach could reduce unnecessary imaging while ensuring accurate diagnosis in pediatric trauma patients.
Area of Science:
- Pediatric Emergency Medicine
- Trauma Surgery
- Radiology
Background:
- Pediatric cervical spine injury (pCSI) is rare, with unique physiological differences from adults.
- Current management lacks standardized pediatric protocols, leading to inconsistent application of adult-validated clinical decision rules (CDRs).
- Previous studies show mixed results when applying NEXUS Criteria (NX) and Canadian C-spine Rules (CCR) to children.
Purpose of the Study:
- To evaluate the efficacy of a combined NX + CCR approach for pCSI screening.
- To test the hypothesis that a delayed 24-hour reapplication of CDRs enhances screening accuracy.
- To identify potential improvements in diagnostic yield and reduction in imaging overuse.
Main Methods:
- Retrospective review of a prospectively collected database (15 months) at a Level-1 trauma center.
- Inclusion based on age and mechanism of injury.
- Retroactive application of NX and CCR criteria at initial presentation (T0) and 24 hours later (T1).
Main Results:
- 306 patients met inclusion criteria; 97.4% underwent CT scans.
- More patients met combined NX + CCR criteria at T1 (24h) versus T0 (initial presentation) (p=0.008).
- No pCSI cases were missed with the delayed application, suggesting potential for reduced imaging overuse (15 patients, 8.6%).
Conclusions:
- Incorporating a 24-hour delay for a second CDR reapplication may enhance pCSI screening efficacy.
- A novel algorithm combining delayed CDR reapplication with literature-based recommendations could standardize pCSI evaluation.
- This approach may offer a more accurate and efficient method for managing pCSI in acute trauma.
Purpose:
Pediatric cervical spine injury (pCSI) is rare. Physiological differences necessitate alternate management from adults. Yet, no standardized pediatric protocols exist. Previous investigations applying adult-validated clinical decision rules (CDRs)-NEXUS Criteria (NX) and Canadian C-spine Rules (CCR)-to children are mixed. We hypothesized a combined NX + CCR approach applied at a delayed 24-h time point would enhance screening efficacy in select patients.
Methods:
We conducted a retrospective review of a prospectively-collected database over 15 months at a pediatric-capable Level-1 trauma center. Age and mechanism determined initial inclusion. NX and CCR criteria were collected and retroactively applied on arrival (T0) and 24 h later (T1). Statistical analyses were performed in SPSS.
Results:
A total of 306 patients met inclusion. Current practices compel computed tomography (CT) overuse for craniocervical evaluations: 298 (97.4%) underwent ≥ 1 CT. Of cervical spines imaged (n = 175), 161 (92.0%) underwent CT while 74 (42.3%) underwent magnetic resonance imaging with 14 (18.9%) completed after 72 h. Of collars placed on arrival (n = 181), 136 (75.1%) were cleared before discharge with 86 (63.2%) CTs denoting preferred clearance modality; CT utilization was unchanged when stratified by age < 5 years (p = 0.819). Notably, we found more patients met NX + CCR criteria at T1 versus T0 (p = 0.008) without missed pCSI resulting in imaging overutilization in 15 (8.6%) patients.
Conclusion:
We showed incorporating a 24-h time delay before a second CDR reapplication may enhance screening efficacy in pCSI. Our new algorithm combines these findings with other literature-based recommendations and may represent a standardizable option for evaluating pCSI in the acute trauma setting.
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