Increased and unjustified CT usage in paediatric C-spine clearance in a level 2 trauma centre

Abstract Purpose Cervical spine injury after blunt trauma in children is rare but can have severe consequences. Clear protocols for diagnostic workup are, therefore, needed, but currently not available. As a step in developing such a protocol, we determined the incidence of cervical spine injury and the degree of protocol adherence at our level 2 trauma centre. Methods We analysed data from all patients aged < 16 years suspected of cervical spine injury after blunt trauma who had presented to our hospital during two periods: January 2010 to June 2012, and January 2017 to June 2019. In the intervening period, the imaging protocol for diagnostic workup was updated. Outcomes were the incidence of cervical spine injury and protocol adherence in terms of the indication for imaging and the type of imaging. Results We included 170 children in the first study period and 83 in the second. One patient was diagnosed with cervical spine injury. Protocol adherence regarding the indication for imaging was > 80% in both periods. Adherence regarding the imaging type decreased over time, with 45.8% of the patients receiving a primary CT scan in the second study period versus 2.9% in the first. Conclusion Radiographic imaging is frequently performed when clearing the paediatric cervical spine, although cervical spine injury is rare. Particularly CT scan usage has wrongly been emerging over time. Stricter adherence to current protocols could limit overuse of radiographic imaging, but ultimately there is a need for an accurate rule predicting which children really are at risk of injury.

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Cervical spine clearance after blunt trauma: current state of the art

EFORT Open Reviews ◽

10.1302/2058-5241.5.190047 ◽

2020 ◽

Vol 5 (4) ◽

pp. 253-259

Author(s):

Michaël Moeri ◽

Dominique A. Rothenfluh ◽

Christoph J. Laux ◽

Dennis E. Dominguez

Keyword(s):

Cervical Spine ◽

Clinical Practice ◽

Ct Scan ◽

Blunt Trauma ◽

Experimental Studies ◽

High Sensitivity ◽

Trauma Centre ◽

Spine Injury ◽

Spine Injuries ◽

Pubmed Search

No definite consensus exists for the clearance of the cervical spine (C-spine) after blunt trauma, despite many validated algorithms, recommendations and guidelines. We intend to answer the most relevant questions with which physicians are confronted when clearing C-spines after blunt trauma in emergency departments (EDs). To exclude significant C-spine injuries we designed an algorithm to be compatible with clinical practice, to simplify patient management and avoid unrewarding evaluation. We conducted an exploratory PubMed search including articles published from January 2000 to October 2018. Keywords used were “cervical spine”, “injury”, “clearance”, “Canadian C-spine Rule”, “CCR” and “national emergency x-radiography utilization study”. Clinical and experimental studies were included in a detailed review. We based our literature review on 33 articles. While answering fundamental triage questions from daily clinical practice, the current literature is discussed in detail. We designed an algorithm for the C-spine clearance suitable for any trauma centre with a high-quality multiplanar reconstruction computerized tomography (CT) scan continuously available. The high sensitivity of the Canadian C-spine Rule (CCR) prevents missing C-spine injuries while limiting the amount of unnecessary radiologic examinations. Plain radiographs were fully abandoned for C-spine clearance. A negative CT scan is sufficient to clear the majority of C-spine injuries and allows for collar removal. In case of motor symptoms or radio-clinical discrepancy, the advice of a specialized spine surgeon must be requested. Magnetic resonance imaging must not be routinely used. Neck pain despite negative imaging is not a reason to delay removal of stiff cervical collars. Cite this article: EFORT Open Rev 2020;5:253-259. DOI: 10.1302/2058-5241.5.190047

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64-Slice CT compared to MRI to clear cervical spine injury in high-risk GCS < 14 blunt trauma patients admitted to the ICU

Trauma ◽

10.1177/1460408617698512 ◽

2017 ◽

Vol 20 (1) ◽

pp. 38-45

Author(s):

Jessica McCallum ◽

Patrick McLaughlin ◽

Morad Hameed ◽

Hussein D Kanji

Keyword(s):

Cervical Spine ◽

High Risk ◽

Ct Scan ◽

Blunt Trauma ◽

Cervical Spine Injury ◽

Spine Injury ◽

Trauma Patients ◽

Positive Finding ◽

Clinically Significant ◽

Significant Injury

Objective Clearance of cervical spine injury including ligamentous injury is of paramount importance as results of missed injury may have serious consequences. In obtunded patients, cervical spine clearance is challenging. This study sought to determine whether a negative 64-slice CT scan alone is sufficient to clear cervical spine injury. Patients and methods All consecutive blunt trauma patients admitted to a regional (level 1) trauma center from 1 April 2008 to 31 March 2012 were screened for inclusion in this study. High-risk, GCS < 14, blunt trauma patients were included if they were admitted to the intensive care unit, had a negative 64-slice CT, and MRI of diagnostic quality. GCS was measured at the time of CT scan. Patients with a positive finding on CT scan were excluded. All images were re-interpreted by a trauma radiologist blinded to clinical outcome. Details of missed injuries and clinical impact were reported. The primary outcome was missed clinically significant injury, defined as any injury requiring an additional intervention including continued immobilization or surgery. Results There were 5891 blunt trauma patients admitted to the ICU, 44 of whom met inclusion criteria. Patients had a median injury severity score of 35 and MRI three (2–9) days after CT. Eight of 44 (18%) patients had a positive finding on MRI and five of the findings were clinically insignificant. Three patients (7%) with focal neurologic findings on clinical exam had missed injuries requiring immobilization with a collar. Two of these patients had spine disease, which may have increased their injury risk. Conclusions In high-risk obtunded blunt trauma patients admitted to the ICU, a negative 64-slice CT scan alone is insufficient to clear clinically significant cervical spine injury, with a missed clinically significant injury rate of 7%. When considered with symmetric motor function, a negative 64-slice CT scan may be sufficient. A prospective study is required to confirm these findings.

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