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Clearing the Pediatric C-Spine

February 11, 2019

Written by Clay Smith

Spoon Feed
This expert panel came up with a comprehensive algorithm to clear the c-spine in children with trauma.

Why does this matter?
It can be very challenging to clear the c-spine in children. PECARN did an important case-control that helped shape this algorithm. The goal is to identify all injuries yet clear children quickly out of the collar and minimize radiation exposure. Here is what these experts came up with.

Clearing kids’ c-spines
This was a group of experts, mostly pediatric orthopedic surgeons, who developed this based on 80% agreement of the committee members. Also represented were specialists in pediatric emergency, neurosurgery, trauma, and radiology. The key graphic from the article looked pretty pixelated. I remade it here exactly as they had it in the paper but with better graphic quality. Here is the algorithm. I have made a few comments at the end.

Adapted from cited article Image adapted from cited article

Here are some of my thoughts.

  • Children with a broken neck who are alert (GCS 14-15) will hold their head oddly and won’t want to move their neck. You can clear them clinically if they hold their head normally, move their neck normally, are not tender on palpation, and are moving their arms and legs normally. This group agrees.
  • Plain x-ray (favoring just a lateral view) was the first-line imaging recommended in alert patients with an abnormal exam in this algorithm. This is debatable, which was acknowledged in the paper. At least a 2-view is standard, and many advocate for CT first-line given its higher sensitivity.
  • A study from 2017 at Vanderbilt found one-third of injuries would have been missed with x-ray alone. The sensitivity of x-ray was 51% for all injuries and just 62% for clinically significant injuries (as defined by NEXUS). That’s a little concerning.
  • This group did not recommend imaging based on mechanism of injury alone, apart from other clinical findings or concerns. The threshold for imaging should be low with axial load (i.e. diving), clothes-line, or high-risk MVC as the mechanism.
  • Children with abusive head trauma need c-spine MRI per this group.
  • The lower the GCS, the more they need a CT c-spine.
  • If children have severe injury to the chest, abdomen, or pelvis, the authors do not recommend clinical clearance.
  • There is debate over whether MRI is really necessary after a negative high-quality CT. The utility of flexion/extension films in that part of the algorithm is also debatable.
  • Keep in mind, much of this is based on expert opinion. Many of the recommendations are based on low-quality evidence. So, don’t take this as gospel.

Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am. 2019 Jan 2;101(1):e1. doi: 10.2106/JBJS.18.00217.

Reviewed by Thomas Davis

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