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Cervical Spine Injury Risk Factors in Children with Blunt Trauma Julie C

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Cervical Spine Injury Risk Factors in Children with Blunt Trauma Julie C Cervical Spine Injury Risk Factors in Children With Blunt Trauma Julie C. Leonard, MD, MPH,a Lorin R. Browne, DO,b Fahd A. Ahmad, MD, MSCI,c Hamilton Schwartz, MD, MEd,d Michael Wallendorf, PhD,e Jeffrey R. Leonard, MD,f E. Brooke Lerner, PhD,b Nathan Kuppermann, MD, MPHg BACKGROUND: Adult prediction rules for cervical spine injury (CSI) exist; however, pediatric rules abstract do not. Our objectives were to determine test accuracies of retrospectively identified CSI risk factors in a prospective pediatric cohort and compare them to a de novo risk model. METHODS: We conducted a 4-center, prospective observational study of children 0 to 17 years old who experienced blunt trauma and underwent emergency medical services scene response, trauma evaluation, and/or cervical imaging. Emergency department providers recorded CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks, multivariable odds ratios, and test characteristics for the retrospective risk model and a de novo model. RESULTS: Of 4091 enrolled children, 74 (1.8%) had CSIs. Fourteen factors had bivariable associations with CSIs: diving, axial load, clotheslining, loss of consciousness, neck pain, inability to move neck, altered mental status, signs of basilar skull fracture, torso injury, thoracic injury, intubation, respiratory distress, decreased oxygen saturation, and neurologic deficits. The retrospective model (high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury) was 90.5% (95% confidence interval: 83.9%–97.2%) sensitive and 45.6% (44.0%–47.1%) specific for CSIs. The de novo model (diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress) was 92.0% (85.7%–98.1%) sensitive and 50.3% (48.7%–51.8%) specific. CONCLUSIONS: Our findings support previously identified pediatric CSI risk factors and prospective pediatric CSI prediction rule development. Departments of aPediatrics and fNeurosurgery, Nationwide Children’s Hospital and College of Medicine, The Ohio WHAT’S KNOWN ON THIS SUBJECT: Pediatric cervical State University, Columbus, Ohio; bDepartment of Pediatrics and Emergency Medicine, Medical College of spine injury (CSI) risk factors from a large, Wisconsin, Milwaukee, Wisconsin; cDepartments of Pediatrics and eBiostatistics, School of Medicine, Washington multicenter, retrospective case-control study warrant d University, St Louis, Missouri; Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and prospective evaluation: predisposing condition, diving, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and gDepartments of Emergency Medicine and Pediatrics, School of Medicine, University of California, Davis, Sacramento, California high-risk motor vehicle crash, neck pain, inability to move neck, altered mental status, neurologic deficits, Dr J.C. Leonard conceptualized and designed the study, designed the data collection instruments, and torso trauma. coordinated and supervised data collection, collaborated on data analyses, and drafted the manuscript; Drs Browne, Ahmad, Schwartz, J.R. Leonard, and Lerner designed the data collection WHAT THIS STUDY ADDS: In this 4-center prospective instruments and coordinated and supervised data collection; Dr Wallendorf designed the data observational study of 4091 children with blunt collection instruments, managed the data, and conducted the analyses; Dr Kuppermann trauma, 14 factors were associated with CSIs. Risk conceptualized and designed the study, designed the data collection instruments, collaborated on models with these variables accurately predicted CSIs data analyses, and drafted the manuscript; and all authors critically reviewed the manuscript for and support conducting a larger study to fully derive fi important intellectual content and approved the nal manuscript as submitted and agree to be a prediction rule. accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2018-3221 To cite: Leonard JC, Browne LR, Ahmad FA, et al. Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics. 2019;144(1):e20183221 Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 144, number 1, July 2019:e20183221 ARTICLE Pediatric cervical spine injuries The Pediatric Emergency Care presented to the emergency (CSIs) are associated with significant Applied Research Network department (ED) for blunt trauma morbidity and mortality.1 Cervical (PECARN) conducted a 17-center, and were transported from scene of plain radiographs and computed 5-year, retrospective case-control injury by emergency medical tomography (CT) use is prevalent study that identified risk factors services (EMS) in SMR, underwent – during trauma evaluation.2 4 CSIs, associated with CSIs in children trauma team evaluation, and/or however, are uncommon in children, with blunt trauma (altered mental had cervical spine imaging ordered and the great majority who undergo status, focal neurologic findings, in the ED. We excluded children radiographic screening are injury neck pain, torticollis [decreased whose injury mechanism was free.5 Indiscriminate use of neck mobility by report or exam], solely penetrating trauma, whose radiographic screening for pediatric substantial torso injury, conditions legal guardian had a substantial CSIs is controversial because of predisposing to CSI, diving, and language barrier, who were in concerns that radiation exposure high-risk motor vehicle crash state’scustody,orwhowere will increase lifetime risk of [MVC]).31,32 These factors were transferred from the study site – malignancy.6 14 98% sensitive for CSIs within the for definitive care. study cohort and, if used as Further controversy relates to a prediction rule, would reduce Methods and Measurements prehospital use of spinal motion cohort imaging by at least 25%. Data collection methods for this restriction (SMR) devices (cervical study were previously reported.33 collars and rigid longboards). Because of risks of SMR and neck In brief, trained research personnel Theoretically, these devices protect irradiation during evaluation of administered electronic branch- from spinal cord injury if unstable children after blunt trauma, there logic questionnaires to treating ED injuries are present but are is a need to derive and validate providers to gather observations associated with known risks. Most a CSI prediction rule that guides regarding CSI risk factors before germane during trauma evaluation clinical decision-making. Our knowledge of cervical spine imaging is that mere presence of these primary aim was to determine test results, if ordered or if obtained at devices leads to increased cervical accuracies of retrospectively a transferring hospital, before spine imaging.15 This may be due to identified PECARN CSI risk factors knowledge of their institutional increased pain complaints with SMR in a prospective cohort of children. radiologist’s interpretation. Risk or physicians deferring neck Our secondary aims were to derive factors included those previously examinations when devices are adenovomodelforpredicting demonstrated to be associated with present.15,16 CSIs in children after blunt trauma, CSIs, that had biological and/or to compare this with the PECARN Two large prospective observational anatomic plausibility, and with good model, and to evaluate potential studies, National Emergency interrater reliability.16,34–36 These effects on cervical spine imaging X-Radiography Utilization Study factors included mechanisms of rates if these models are used (NEXUS) and Canadian C-Spine Rule injury and injury biomechanics in decision support. for Radiography, derived adult CSI (high-risk MVC37:passenger prediction rules aimed at reducing compartment intrusion including cervical spine imaging.17–22 These METHODS roof .12 inches at occupant site or rules were validated in adults and .18 inches at any site, partial or Study Design and Setting used to safely limit prehospital SMR complete ejection from vehicle, and cervical imaging during trauma Between March 2014 and November death of a passenger in the same evaluation.23–26 Unfortunately, 2016, we conducted a prospective compartment, and/or vehicle these studies were not focused on observational study of consecutive telemetry consistent with high-risk children (NEXUS: 3065 children, 30 children evaluated at 4 tertiary care crashes; diving; axial load; or with CSIs; Canadian C-spine: no children’s hospitals. Participating clotheslining: biomechanical force children).5 Researchers have hospitals were academic caused by a rope, cable, or similar attempted to validate these rules in freestanding children’shospitals, item exerting traction on the neck children with small prospective American College of Surgeons while the body is in forward studies and retrospective analyses; Pediatric Level 1–verified, and motion), patient history variables however, results were mixed and PECARN members. (predisposing conditions, loss of sample sizes small.5,27–30 There are consciousness, neck pain, inability no CSI prediction rules specifically Selection of Participants to move neck, paresthesia, derived and validated in a pediatric Inclusion criteria consisted of numbness or weakness), and population. children younger than 18 years who physical examination findings Downloaded from www.aappublications.org/news
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