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Comparison of Cervical Spine Injury Clinical Prediction Rules for Children After Blunt Trauma
Lois K Lee1, Fahd A Ahmad2, Lorin R Browne3
1Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts.
Insights
The Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury (CSI) rule demonstrated superior sensitivity and negative predictive value in identifying pediatric patients with CSI after blunt trauma, leading to reduced computed tomography (CT) imaging rates.
Area of Science:
- Pediatric Emergency Medicine
- Trauma Surgery
- Radiology
Background:
- Pediatric cervical spine injury (CSI) is rare but can cause severe disability or death.
- Accurate risk stratification is crucial for determining the need for cervical spine imaging in children after blunt trauma.
- Existing clinical prediction rules require comparison to optimize diagnostic strategies.
Purpose of the Study:
- To compare the diagnostic accuracy and projected imaging rates of three clinical prediction rules for pediatric CSI.
- Specifically, to evaluate the Pediatric Emergency Care Applied Research Network (PECARN) CSI rule, the National Emergency X-Radiography Utilization Study (NEXUS) rule, and the Canadian Cervical Spine (c-spine) rule (CCR).
Main Methods:
- A comparative effectiveness study analyzing data from a prospective observational study.
- Included children up to age 17 presenting after blunt trauma across 18 emergency departments.
- Compared test characteristics (sensitivity, specificity, PPV, NPV) and estimated projected CT imaging rates for each rule.
Main Results:
- The study enrolled 22,430 children, with 1.9% having CSI.
- The PECARN CSI rule showed the highest sensitivity (93.3%) and negative predictive value (99.8%).
- Strict application of the PECARN rule projected the lowest CT imaging rate (6.9%) compared to NEXUS (10.8%) and CCR (13.2%).
Conclusions:
- The PECARN CSI rule is the most effective for identifying children at risk of CSI after blunt trauma.
- It offers superior sensitivity and negative predictive value while minimizing unnecessary CT imaging.
- This finding supports the PECARN rule as the preferred choice for risk stratification in this population.
Importance:
Pediatric cervical spine injury (CSI) is a rare occurrence; however, CSI can result in significant disability and death. It is essential to determine the optimal CSI clinical prediction rule to risk stratify children with potential CSI after blunt trauma who require cervical spine imaging.
Objective:
To compare the test characteristics and projected imaging rates between 3 prospectively derived CSI clinical prediction rules: the Pediatric Emergency Care Applied Research Network CSI prediction rule (PECARN CSI rule), the National Emergency X-Radiography Utilization Study (NEXUS), and the Canadian Cervical Spine (c-spine) rule (CCR).
Design, Setting, And Participants:
This comparative effectiveness study was a planned secondary analysis of a prospective observational study enrolling from December 2018 to October 2021 in 18 PECARN emergency departments. Eligible participants were children up through age 17 years presenting after blunt trauma. Data were analyzed between March 2024 and January 2025.
Exposures:
Enrollment in the primary study to develop and validate the PECARN CSI prediction rule.
Main Outcome Measures:
Test characteristics with 95% CIs (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV]) and area under the curve (AUC) for the receiver operator curves (ROC) for the detection of CSI using each of the 3 rules. We also estimated the projected c-spine imaging rate (radiography or computed tomography [CT]) based on criteria for each of the 3 rules.
Results:
There were 22 430 eligible children enrolled (median [IQR] age 8 [2.0-13.0] years; 13 068 male [58.3%]) and 433 (1.9%) had CSI. C-spine imaging was performed 12 768 children (56.9%): 8912 (39.7%) had radiography and 3856 (17.2%) were imaged with CT. The sensitivity of the 3 rules was: PECARN CSI rule, 93.3% (95% CI, 90.9%-95.7%); NEXUS, 85.7% (95% CI, 82.4%-89.0%); and CCR, 90.8% (95% CI, 88.0%-93.5%). The NPV of the 3 rules was: PECARN, 99.8% (95% CI, 99.7%-99.9%); NEXUS, 99.6% (95% CI, 99.5%-99.7%); and CCR, 99.7% (95% CI, 99.6%-99.8%). Strictly applying each rule resulted in projected CT imaging of 1549 children (6.9%) for PECARN, 2419 (10.8%) for NEXUS, and 2968 (13.2%) for CCR.
Conclusions And Relevance:
In this comparative effectiveness study of CSI prediction rules in children, the PECARN CSI rule had the highest sensitivity and NPV for identifying children at risk for CSI after blunt trauma, with the lowest projected CT imaging rate.
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