Introduction
Most of our treatment strategy in young children is based on our clinical judgement. The evidence on clearing cervical spines, in those older than 18 years, is clear, validated, accepted and is duty of care. The evidence for clearing the cervical spine is not as clear. It is even more obscure for less than 8 year olds, being difficult to find much evidence at all. We tend to use good judgement more than anything else, for the very young. Good judgement is based on experience and experience is the result of bad judgement. However due to rare nature of this injury, our judgement is not based on experience, but more on good sense.
What do we already know?
- Cervical spine injuries in less than 8 year olds are rare.
- It is because of the low prevalence of the disease, that no decision rules exist.
- Tumour risk from imaging is high.
- Anatomy affects the pattern of injury
(a) <8 year olds have high cervical injuries and
(b) >8 year olds have low cervical injuries.
In adults we have the Nexus Criteria and the Canadian C-spine rules, however there is no specific rule for children and the literature is mostly retrospective.
The Canadian C spine Rule, did not include patients less than 18 years old, so it cannot be used.
The Nexus study included 3065 patients less than 18 years old. There were 26 cervical injuries in this group. Only 905 patients were less than 8 years old. In this later group, there were only 4 injuries, all high cervical. The numbers are small and although we can use nexus in the older age group ie., > 8 years old, we cannot use it for the younger group.
A further challenge occurs in the < 8 yo group; the very young are non-verbal; they can’t tell you if they have pain.
Most of the studies for younger children are retrospective. Leonard et al (1) found certain risk factors that are associated with cervical injury. The presence of one or more of these factors had a sensitivity of 98% and specificity of 26% for cervical injury. The factors were:
- Altered mental status
- Focal neurological deficit(s)Complaint of neck pain
- Torticollis
- Substantial torso injury
- Diving
- High risk motor vehicle crash
- Predisposing conditions such as Downs Syndrome, Rheumatoid arthritis, Rickets, osteogenesis imperfecta, Klippel-Feil Disease, Ehler-Danlos Syndrome, Achondroplasia, Marfan Syndrome and Renal osteodystrophy
Hale et al(2) looked at children less than 5 years old, in a retrospective registry study. 2972 patients were included, of which 22(0.74%) had cervical injuries. All had clinical findings suggestive of cervical injury:
- Abnormal Neurology (82%)
- Torticollis(9%)
- Neck Pain(9%)
My Approach
Any child that presents with:
- Major trauma
- Intubated
- de-gloving
- Femoral fractures as part of trauma
- Depressed conscious state
- Neurology- beware transient Symptoms
- Neck pain complaint
- Diving injury
Will get imaging- CT or MRI
In children older than 8 years of age
I will apply the Nexus Rule (3)
In children younger than 8 years old
I will apply judgement, + Nexus + X-ray.
In children that can answer questions, I’l feel down the midline of the neck and make them turn the head and simply engage and distract and play, until, I am happy that there is no pain. If there is some minor pain and no real mechanism, I give some simple analgesia such as Paracetamol and review.
In the non-verbal group I will watch. I’ll feel the c spine, to ensure I can’t elicit pain. I will then watch them play and ensure they are able to turn the head unaided and with no pain.
References
1Leonard JC, Kuppermann N, Olsen C, Babcock-Cimpello L, Brown K, Mahajan P, et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med. 2011; 58(2): 145-55
2Hale, DF, Fitxpatrick C.M, Doski J.J, Ronald M,Mueller D.L. Absence of clinical findings reliably excludes unstable cervical spine injurie in children 5 years or younger. Journal of Trauma and Acute Care Surgery May 2015, Vol 78, Issue 5, pp., 943-948
3 Goergen S, Ditchfield M, Babl F, Oakley E, Rahman T, Johnson S. Paediatric Cervical Spine Trauma. Education Modules for Appropriate Imaging Referrals: Royal Australian and New Zealand College of Radiologists; 2015.
I agree there are not any very robust evidence-based decision rules for children, especially younger ones.
However I’m not sure I agree with everything you wrote Peter.
For instance we, at one of your local children’s hospitals, would not do a CT or MRI on EVERY child with a femoral fracture, presence of any transient neurological symptom or just a complaint of neck pain. We have a more selective process.
You say “Tumour risk from imaging is high” in children. What do you consider high? Estimated lifetime cancer mortality risk from a single CT C-Spine would be around 0.01-0.1% depending on the age of the child.
If we kept to your criteria we would CT many hundreds more children a year judging by the number of painful necks with transient distal paraethesiae we get each week especially in the rugby seasons. We also would need a few more MRI scanners to avoid the increased risk of a resultant tumour. Following our current C-spine trauma and imaging protocols together with the low incidence, we have an excellent record of picking up significant cervical injuries.
Hi Adrian
Thanks for the email. You’ve missed a bit of what I was trying to say, or I probably haven’t written it clearly enough. So let’s take this opportunity to make it clearer.
The purpose of the blog is to demonstrate 4 things:
1. The evidence is sparse and what there is, is not great
2. Any protocols for very young children are based more on consensus and common sense, than anything else. When you speak of a ‘selective process’, it is a mixture of sparse evidence and consensus agreement.
3. To remind us that children don’t just bounce, they do break and even though this is a rare condition, many of us have seen it.
4. To make us aware of the evidence that is available and to curb the ‘open shirted, hairy chested‘ approach we see, where cervical spines are cleared, without being aware of what might be missed.
My figure for tumour risk is similar to yours; 1 in 2000, so we don’t take CT scans lightly.
The first group in the blog is meant to depict a sicker group of patients with major trauma and neck pain etc. Of course, an isolated femoral fracture doesn’t need cervical spine imaging, as long as it is isolated and there is no neck pain and it’s not distracting. But be sure that it is isolated! The point here, is that there are are a group of sick patients that will need a scan.
Those patients with minor trauma, that have minor neck pain, can be cleared clinically, or get some simple analgesia and be re-examined. I think that’s clear.
Those patients with neurological symptoms are a concern, especially when you have neck pain and neurology. There is some evidence here, over several years. In one study of children with SCIWORA (JNSurg., 1986:57(1):114), 52% had delayed onset of paralysis. Most of these children had transient neurology, including paresthesia, numbness or ‘subjective’ paralysis. All had a poor outcome. So we need to be careful here as there is evidence of this type of injury, that is compelling.
In terms of number of MRIs needed; I understand what you say. Unless you work in a tertiary referral centre, most of us are resource poor, and most practice a rational investigation strategy. The problem with any rule in young children, will be that to get to a high sensitivity, it will be associated with a low specificity. This means a lot more children need investigating. That’s why the chances of a ‘rule’ being developed in the very young is low. But please don’t fall into this trap; don’t worry about how many MRIs it takes, do what’s right for the patient, difficult as it may sometimes be.
Adrian, It sounds like you might have enough numbers for a good series. You should look at your figures and consider publishing. Although you don’t have a gold standard, followup may be enough. It will be helpful work to get out there.
Thanks for the feedback. It helps me make it better. I hope that’s a little clearer. I will add a little more to the blog.