Reducing Pediatric CTs Just Got Easier

Figure: Pediatric CTs, PECARN, cervical spine, C-spine, injuries, SCIWORA, spinal cord injury without radiographic abnormality, motor vehicle collisions, falls, diving, sports, clotheslining force, trauma, child abuse, neurologic exam, NEXUS, Canadian C-Spine rule, radiation, cancerFigureWarmer months means that trauma season is officially here, and missed cervical spine (C-spine) injuries are a fear of every emergency physician. Thankfully, they are rare, making up about one percent of all blunt trauma injuries. (J Pediatr Surg. 2011;46[9]:1771.) The cervical spine is the most common location for a pediatric spinal injury, however, so we are correct to focus our apprehension on this region. They are also devastating injuries if missed. A new risk stratification tool was published this spring on pediatric C-spine trauma, and we need to consider that and the boogeyman that is SCIWORA (spinal cord injury without radiographic abnormality). Pediatric C-spine injuries are caused by the same activities that plague adults: motor vehicle collisions, falls, diving, sports, clotheslining force, or, rarely, trauma from child abuse. (J Pediatr Surg. 1990;25[1]:85.) Injuries in children are typically higher on the cervical spine, with a majority between the skull and C4. (Pediatrics. 2014;133[5]:e1179; https://tinyurl.com/4xx8an9m.) Children have larger heads than bodies, which means a higher fulcrum, leading to high cervical spinal injury. Atlanto-axial injuries are also more common. (J Emerg Med. 1989;7[2]:133.) It is proper to follow Advanced Trauma Life Support when a pediatric trauma patient arrives at your hospital so you don't get lost in the weeds. Caring for these patients brings added stress due to the patient's age and the concern of loved ones. Managing staff discomfort is critical if your shop does not regularly care for children. You will go through your standard primary assessment (i.e., ABCDE), keeping in mind that about 50 percent of children with C-spine trauma have some neurologic deficits, so don't just settle on a GCS. (J Pediatr Ortho. 1998;18[6]:811; https://tinyurl.com/yck2yf6t.) Do a diligent neurologic exam. High-risk factors for C-spine trauma in children include diving injury, fall from more than 10 feet, trauma from child abuse, or MVC with fatality, rollover, ejection, or lack of proper restraint or car seat. (Indian J Orthop. 2018;52[5]:489; https://tinyurl.com/57ze9s2p.) We are faced with a situation of a rare diagnosis, devastating if missed, and a patient population difficult to examine and interview. These patients also have a different anatomy compared with adults. The NEXUS and Canadian C-Spine Rule also have not been validated in patients under age 16. The urgency of avoiding radiation exposure is important in children; even a single C-spine CT scan in childhood increases the lifetime risk of thyroid cancer by 78 percent. (BMJ. 2013;346:f2360; https://tinyurl.com/57tzf2bn.) High Risk for Injury Thankfully, the latest PECARN prediction rule for cervical spine injury can help. The researchers enrolled 22,340 children ages 0-17 presenting with blunt trauma across 18 PECARN-affiliated EDs in the United States. (Lancet Child Adolesc Health. 2024;8[7]:482.) The investigators derived and validated their own clinical prediction rule based on data from these children and then validated it afterward in their study population (half were in the derivation, half in the validation cohort). The risk of C-spine injury in the prospective validation cohort was 0.2 percent. The study found that using this decision rule would have reduced CT imaging by more than 50 percent! The rule has a sensitivity of 94.3% and a negative predictive value of 99.9%. This validated prediction rule is especially important in patients under age 8, where the ability to perform a proper history and exam can be limited. The study found that high-risk factors for C-spine injury included a GCS of 3-8 or being unresponsive, any focal neurologic deficits, and abnormal airway, breathing, or circulation (e.g., abnormal vitals, requiring intubation, pulse deficit). These patients were found to have a 12.1 percent risk of C-spine injury and require CT. Intermediate risk factors include altered mental status (not age-appropriate behavior), self-reported neck pain or tenderness on exam, and substantial head or torso injury. Importantly, “substantial” was defined as injuries warranting inpatient observation or surgery. Their risk of injury was 2.8 percent. The study suggests these patients should have C-spine radiographs. Patients who do not fit either group were considered low risk and do not require further imaging. Their risk of cervical spine injury was 0.2 percent. Their collar can be cleared and loved ones reassured. Talk to the family about the risks and benefits of C-spine imaging if the child has no risk factors but you are still concerned about the mechanism. One frightening condition that lives in our nightmares is SCIWORA. Children have quite the elastic spinal column due to unfused ossification centers from active growth and ligamentous laxity. These do not fuse until about ages 5 to 7. (J Emerg Med. 1989;7[2]:133.) This means a distracting injury can move as much as 5 cm without structural injury. Yet the spinal cord itself is not that forgiving, and this is what causes SCIWORA: essentially no fracture but a spinal cord injury. SCIWORA is rare, and an MRI is needed to diagnose it. Consider MRI in patients who have altered mental status or focal neurologic deficits but negative CT imaging. The latest PECARN prediction rule adds a valuable asset in determining risk stratification for pediatric C-spine trauma. Utilize this rule in patients under 16 to assist in imaging decision-making. Use the NEXUS or Canadian C-spine rules in children 16 and older and consider CT imaging if unable to clear the C-spine. Consider cervical MRI in any patient with negative CT imaging but who has focal deficits or persistent symptoms. DR. BRIGGS is an assistant professor of emergency medicine at the University of Tennessee Medical Center in Knoxville. He is the founder, a podcast host, and the editor-in-chief of EM Board Bombs (https://www.emboardbombs.com), a multiplatform educational tool designed to provide board prep and focus on what EPs need to know for the practice of emergency medicine. Listen to his podcast with Iltifat Husain, MD, at http://tinyurl.com/EMBoardBombsatEMN, and follow him on X @blakebriggsmd. Read his past columns at http://tinyurl.com/EMN-Briggs. 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