SGEM#441: Searching Searching for the best Clinical Decision Rule to Detect Pediatric C-Spine Injury

Reference: Tavender E, et al. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev. 2024 Date: May 29, 2024 Guest Skeptic: Dr. Caleb Ward is a pediatric emergency medicine attending and Associate Professor of Pediatrics and Emergency Medicine at Children’s National Hospital and The George Washington School of Medicine and Health Sciences in Washington, DC. His research focuses on the pre-hospital care of children by EMS. He is the principal investigator for EMSC State Partnership in Washington, DC and is also involved in various multi-center EMS studies with the Pediatric Emergency Care Applied Research Network (PECARN). Dr. Caleb Ward Case: A 4-year-old boy is brought to the emergency department (ED) by Emergency Medical Services (EMS) after falling from a tall tree. The fall was witnessed by his family. They tell you that he is going through a Spiderman phase and tries to climb everything. They saw him slip off the tree and landed in the grass below. He did not have any loss of consciousness. EMS placed him in a C-collar and brought him to you. On examination, you only notice a few scrapes, but he is cradling his left arm and complaining that it hurts. There looks to be an obvious deformity of his forearm. The family members ask you, “he seems uncomfortable in the neck collar, can we remove it? Do you think he injured his neck?” Background: Pediatric cervical spine injuries (CSI), though rare, can have devastating consequences if missed. Imaging studies include X-rays, CT scans, and MRIs. Typically, we see the use of X-ray or CT more often in the acute setting. The downside of these methods is exposing children to radiation. Clinical Decision Rules (CDRs) have been developed to help guide decision-making and minimize unnecessary tests and imaging while detecting significant injuries. Because there is no standardized process for identifying children with CSI after blunt trauma, practice varies based on clinician, institution, location, and available resources. We have covered some of these CDRs in pediatrics on the SGEM before: Ankle and Knee Injuries (SGEM#3, SGEM#5) Trauma (SGEM#127) Appendicitis (SGEM#155) Head Trauma (SGEM #412, SGEM #225) Febrile Infants (SGEM#171, SGEM #296) While there are CDRs for cervical spine injury in adults like the Canadian C-spine Rule and NEXUS criteria for C-spine imaging, we do not have a dedicated, accurate CDR for pediatric patients. Clinical Question: Which triage tools or Clinical Decision Rules (CDRs) are most effective for detecting cervical spine injuries in pediatric trauma patients?  Reference: Tavender E, et al. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev. 2024. Population: Children (aged 0 to <18 years) who underwent blunt trauma evaluation in emergency departments. (ED) Excluded: Patients with previous cervical spine surgery or congenital cervical spine anomalies Intervention: Application of various CDRs or sets of clinical criteria to evaluate the presence of cervical spine injuries following blunt trauma. Comparison: The CDRs were compared with each other and with reference standards like X-ray, CT, MRI, or clinical clearance/follow-up in low-risk children. Outcome: The primary outcome of interest was the diagnostic accuracy of the CDRs, specifically their sensitivity and specificity in detecting cervical spine injuries. Trial: Systematic review Authors’ Conclusions: “There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed,