Child physical abuse and cervical spine injury: A prospective observational study of over 1,200 children in the...

The incidence and patterns of cervical spine injury (CSI) have not been well described in children who present after suspected child physical abuse (CPA). The purpose of this study was to describe the pattern of CSI in patients evaluated for suspected CPA in a large, prospectively collected dataset.

This is a secondary analysis of a prospectively collected, multicenter, pediatric CSI dataset which included 72 trauma centers across the United States. All children with suspected CPA were included, with concerns for CPA determined by each participating center. All children had cervical spine imaging within 24 h of injury.

Among 19,995 pediatric blunt trauma patients, 1251 children with suspected CPA were identified. Median age was 6 months (IQR 2-12), 42% female, 19% presented with a GCS less than 14, and 11% required intubation. Concomitant traumatic brain injury (TBI) was present in 61% of patients. Overall, 75 children (6%) were diagnosed with CSI. Ligamentous injury was most common (68%), followed by spinal cord injury (19%). No patient underwent operative cervical spine stabilization. Unstable ligamentous injury occurred in seven patients. Four were identified on CT, three were detected on MRI. One patient had a normal initial XR prior to MRI diagnosis with a presenting GCS of 10. On multivariable regression, GCS 3-13 (OR 3.29, 95% CI 1.61-6.47), and intubation (OR 3.07, 95% CI 1.57-6.27) were associated with CSI.

In this large prospective multicenter cohort, CSI occurred in 6% of children evaluated for suspected CPA and consisted primarily of ligamentous injuries. Low GCS and intubation were strongly associated with CSI. Unstable injuries were rare, CT identified all injuries in patients who underwent CT, and no missed unstable injuries were observed in neurologically intact children with normal screening radiographs. These findings suggest that CT may be a useful adjunct for CSI evaluation in obtunded patients with suspected CPA (GCS <14) and support a low threshold for advanced imaging in this population. In children with suspected physical abuse who undergo CT imaging, our findings support that a normal CT may be sufficient to allow removal of cervical immobilization regardless of mental status.