Asymptomatic patients and unstable cervical spine injury

Hale DF, Fitzpatrick CM, Doski JJ, Stewart RM, Mueller DL. Absence of clinical
findings reliably excludes unstable cervical spine injuries in children 5 years
or younger. J Trauma Acute Care Surg. 2015 May;78(5):943-8.

Abstract

BACKGROUND:

Increased accessibility and rapidity of computed tomography (CT) have led to increased use and radiation exposure to pediatric trauma patients. The thyroid is radiosensitive and therefore at risk for developing malignancy from radiation exposure during cervical spine CT. This analysis aimed to determine which preelementary trauma patients warrant cervical spine CT by defining incidence and clinical characteristics of preelementary cervical spine injury.

METHODS:

This was a retrospective review of pre-elementary trauma patients from 1998 to 2010 with cervical spine injury admitted to a Level I trauma center. Patients were identified from the trauma registry using DRG International Classification of Diseases-9th Rev. codes and reviewed for demographics, mechanism of injury, clinical presentation, injury location, injury type, treatment, and outcome.

RESULTS:

A total of 2,972 preelementary trauma patients were identified. Twenty-two (0.74%) had confirmed cervical spine injuries. Eleven (50%) were boys, and the mean (SD) age was 3 (1.7) years. The most common mechanism of injury was motor vehicle collision (n = 16, 73%). The majority (59%) were in extremis, and 12 (55%) arrived intubated. The median Glasgow Coma Scale (GCS) score was 3 (interquartile range, 3-10); the median Injury Severity Score (ISS) was 33 (interquartile range, 17-56). Nineteen injuries (76%) were at the level of C4 level and higher. The mortality rate was 50%. All patients had clinical findings suggestive of or diagnostic for cervical spine injury; 18 (82%) had abnormal neurologic examination result, 2 (9%) had torticollis, and 2 (9%) had neck pain.

CONCLUSION:

The incidence of cervical spine injury in preelementary patients was consistent with previous reports. Missing a cervical spine injury in asymptomatic preelementary patients is extremely low. Reserving cervical spine CT to symptomatic preelementary patients would decrease unnecessary radiation exposure to the thyroid.

LEVEL OF EVIDENCE:

Therapeutic study, level IV.

From http://lifeinthefastlane.com/research-and-reviews-in-the-fastlane-092/ :
 

In this well done retrospective review of ~3,000 patients aged 5 years and younger who have imaging of their cervical spine, the authors give us some data and a common sense approach for the pre-elementary aged trauma patient’s c-spine evaluation. Essentially, in the words of the authors:“In those who were clinically evaluable (not in a coma), there were no asymptomatic patients who later were found to have unstable cervical spine injury”.So, if there is no neurologic deficit, and no pain or tenderness, there is no need to go crazy looking for an extremely rare, unlikely injury.

Courtesy of:  http://lifeinthefastlane.com/research-and-reviews-in-the-fastlane-092/