C-spine clearance
C-spine injuries occur in nearly 4% of all traumas, with 42% of these injuries being classified as “unstable.” Recent literature has highlighted the potential risk associated with prolonged C-spine immobilization (ulcers, airway difficulties, increased ICP, discomfort) and they have been shown to prolong ED stays. However, missing an unstable C-spine has some obvious downsides too. The overall goal of the evaluation of a trauma patient with a potential C-spine injury should be maintaining a very high sensitivity while avoiding the over-utilization of resources. The availability of pediatric specific data is somewhat limited, and the authors note that currently the evaluation of a child with a potential neck injury focuses on a very careful exam, selective radiography, and conservative thresholds for CT and MRI.
What did they do?
These authors performed a meta-analysis with a goal of evaluating performance of clinical decision rules, imaging options and clearance protocols in both adults and children. This was lofty, and it doesn’t quite live up to the hype. They note that “due to heterogeneity of studies” no quantitative meta-analysis could be done. Whomp.
What did they find?
Looking at 11 pediatric-specific studies over the last 10 years, they determine the following approach to be the best: clinical clearance and x-ray first when needed; use CT for high-risk cases and MRI for ligamentous injury or with ongoing neurological concern. They determine use of a standardized protocol can cut down on both CT and XR use and keep diagnostic safety intact. They mention PEDSPINE as a clinical decision rule with “limited sensitivity,” so in my opinion we should continue to use PECARN for this. One study they include introduced a “next-day exam + spine consult” protocol compared to their prior self-reported “CT heavy” approach. They note CT use fell from 90% to 28% though collar removal was delayed.
The Bottom Line:
Overall, I’d say this doesn’t add much but does support what we are already doing. Just because they have a C-collar on and say their neck hurts doesn’t mean they need a CT. Use a validated scoring tool like PECARN, make use of XR over CT when appropriate, and consider early clinical clearance if your exam (or repeat exam) allows.
What did they do?
These authors performed a meta-analysis with a goal of evaluating performance of clinical decision rules, imaging options and clearance protocols in both adults and children. This was lofty, and it doesn’t quite live up to the hype. They note that “due to heterogeneity of studies” no quantitative meta-analysis could be done. Whomp.
What did they find?
Looking at 11 pediatric-specific studies over the last 10 years, they determine the following approach to be the best: clinical clearance and x-ray first when needed; use CT for high-risk cases and MRI for ligamentous injury or with ongoing neurological concern. They determine use of a standardized protocol can cut down on both CT and XR use and keep diagnostic safety intact. They mention PEDSPINE as a clinical decision rule with “limited sensitivity,” so in my opinion we should continue to use PECARN for this. One study they include introduced a “next-day exam + spine consult” protocol compared to their prior self-reported “CT heavy” approach. They note CT use fell from 90% to 28% though collar removal was delayed.
The Bottom Line:
Overall, I’d say this doesn’t add much but does support what we are already doing. Just because they have a C-collar on and say their neck hurts doesn’t mean they need a CT. Use a validated scoring tool like PECARN, make use of XR over CT when appropriate, and consider early clinical clearance if your exam (or repeat exam) allows.
