New PECARN C-Spine Rule

August 26, 2024

Written by Joshua Belfer

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A new PECARN clinical decision rule for cervical spine imaging in children after blunt trauma identifies children at low risk for C-spine injury utilizing nine risk factors.

We all love a clinical decision algorithm
A prospective observational cohort study of children 0-17 years old presenting with known or suspected blunt trauma aimed to derive and validate a clinical decision rule to guide radiographic screening for cervical spine injury. The study enrolled over 22,000 children who met one of the following criteria:

• Evaluated by a trauma team;
• Transported from the scene of injury to the participating hospital by EMS;
• Underwent C-spine imaging at the included or transferring hospitals.

A 3-tiered decision rule was created:

Four “high risk” factors were identified: GCS score of 3-8; unresponsive on AVPU scale; abnormal airway, breathing, or circulation; and focal neurological deficits, including paresthesia, numbness, or weakness. Of those children with any of these risk factors, 12.1% had a cervical spine injury; the algorithm recommends CT imaging. Five other risk factors were identified: altered mental status; self-reported neck pain; substantial torso injury; substantial head injury; and posterior midline neck tenderness. Of children with any of these risk factors, 2.8% had a C-spine injury; the algorithm recommends X-ray imaging. If none of these nine risk factors were present, 0.2% had a C-spine injury, and the algorithm recommends clinical clearance of the C-spine without imaging.

In the validation cohort, the prediction rule had a 94.3% sensitivity, 60.4% specificity, and 99.9% negative predictive value. Of note, application of the clinical algorithm in the study population would have reduced imaging rates, decreasing CT imaging rates by more than half.

How will this change my practice?
Similar to the PECARN Head Injury study, this clinical prediction rule aims to classify patients into risk categories that can guide the need for ionizing radiation studies. The rule performs quite well, and utilizes risk factors that, in most patients, will be easy to elicit. I think this is another great PECARN study that will significantly impact ED management.

Reflecting on this rule, there are several groups of patients that deserve further consideration. A subset of patients not included in this study are those who self-refer to the ED. While those patients typically have less concerning mechanisms, improper utilization of this rule may lead to overimaging, particularly X-ray for those presenting with neck pain. You will notice that the rule applies to all ages, as compared to the head injury rule that separately considers younger children. While mechanism is not included in the rule, I wonder if, in young children who cannot necessarily report neck pain and in whom neck tenderness can be difficult to elicit, mechanism may be considered by clinicians in determining the need for imaging. In those cases, I can envision increased imaging in otherwise low risk patients. Finally, as written about prior, there is debate regarding the risk of missing injury when XR alone is utilized.

Editor’s note: With >10,000 children in the validation cohort, this evidence is promising. External validation is the next important step. However, I plan to begin using this rule in practice – with some possible modifications. The sensitivity of x-ray for clinically significant c-spine injury was 62% in a prior retrospective study. So, I am uncertain about x-ray in the middle tier patient group (the yellow color). Also, it’s hard for me to imagine caring for a child with a GCS of 9, pneumothorax, or other significant torso injury and not getting a c-spine CT. I think in a child with only pain or tenderness, I will consider plain x-ray. That said, I am still wrestling with how to implement this knowledge in my day-to-day practice. I would love to hear the thoughts of others. Please comment. ~Clay Smith

Source
PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. 2024 Jul;8(7):482-490. doi: 10.1016/S2352-4642(24)00104-4. Epub 2024 Jun 4. PMID: 38843852; PMCID: PMC11261431.