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Clearing the Pediatric C-Spine – Risk Factors

July 4, 2019

Written by Clay Smith

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This paves the way for deriving a pediatric c-spine injury (PCSI) rule. In the meantime, children without the following variables – diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress – had low risk of PCSI.

Why does this matter?
The NEXUS c-spine rule was validated in children and adults, but just 2.5% were under age 8. Recently, an expert panel came up with an algorithm that’s very helpful for pediatric c-spine clearance. The PECARN group found 8 variables associated with PCSI using a case-control study. But these have not been prospectively assessed until now.

We need a pedi-NEXUS rule
This group looked at the 8 PECARN criteria previously found to be associated with PCSI and prospectively assessed them in this multicenter cohort of 4,091 children 0-17 years of age. PCSI was rare, with just 74 cases (1.8%). As a secondary aim, they also looked into other risks that might be associated with PCSI in order to derive a new rule that might perform even better. Using the 8 criteria from the previous PECARN study: high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury, they found a sensitivity of 90.5% (with a wide confidence interval), specificity 45.6%. They then applied a newly derived, slightly different rule with 7 variables: diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress. This performed better than the original 8-factor rule, with sensitivity 92% (again, wide CI), specificity 50%. Either rule would cut c-spine CT use in half. However, at this stage, strict application of the PECARN rule would have missed 7 cases of PCSI, and the newly derived rule would still miss 6. So, these need some refining. However, of the seven patients who would have been missed, all but one actually actually had PECARN risk factors on chart review and were misclassified.

Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics. 2019 Jun 20. pii: e20183221. doi: 10.1542/peds.2018-3221. [Epub ahead of print]

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