Targeted Imaging Is the Best Approach for Pediatric Cervical Spine Evaluation

Authors: Hannon M et al., Ann Emerg Med 2014 Oct 15;

Children with NEXUS risk factors for cervical spine injury should undergo plain radiographic imaging, and computed tomography should be reserved for those with positive radiographic findings.

Investigators determined the optimal strategy for evaluating cervical spine injuries in children with blunt trauma, taking into account risks for cervical spine injury and radiation-induced malignancy. They used data from the National Emergency X-radiography Utilization Study (NEXUS) and the Pediatric Emergency Care Applied Research Network (PECARN) to construct decision analysis trees; the models assumed a baseline risk of cervical spine injury of 0.98% for all patients and 1.22% for NEXUS-positive patients, and an average probability of malignancy of 40/10,000 cervical computed tomography (CT) scans.

In a hypothetical pediatric population (age <19 years) presenting with blunt trauma, the preferred management strategy was clinical clearance for NEXUS-negative patients and plain radiography for NEXUS-positive patients, followed by CT scans for patients with positive plain radiographs. The preferred strategy changed to CT for all patients if the probability of cervical spine injuries was 25% or higher.

Comment
The lower risk for cervical spine injury and the higher risk for radiation-induced malignancy in children than adults mandate a pediatric-specific approach. Children without NEXUS risk factors can be clinically cleared, while those with NEXUS risk factors should undergo plain radiography, with CT reserved for those with findings on plain radiographs. Due to increased risk of injury in children with neurologic findings, plain radiography should be bypassed and they should undergo immediate CT.