Cervical Spine Clearance - APSA Practice Gaps 2019

In a 2-year-old, their most likely injury is going to be ligamentous

About 50% of injuries in children under eight are bony and about 50% are ligamentous or spinal cord injury without radiological abnormality

If you can clinically clear the patient, that would be the best way to do it

In older children, mechanism of injury should not play a role in cervical spine clearance decisions

In younger patients, particularly those with suspected non-intentional trauma (child abuse), there is a higher risk of cervical injury

The CDC has transitioned to calling non-accidental trauma 'child abuse' in the past year

The APSA position statement on child abuse was released last month in the Journal of Pediatric Surgery

Children where you're concerned about child abuse need a skeletal survey as part of their evaluation, and as part of that skeletal survey, you need at least a single view of the cervical spine

At one institution, neurosurgeons have a protocol where any child three and under gets cleared by the neurosurgeons

46% of institutions don't have a protocol for cervical spine clearance in children

Cervical spine injury occurs in 1 to 2% of all pediatric traumas

In older children, 70 to 80% of cervical spine injuries are bony injuries

In children less than or equal to eight years old, about 50% will have isolated fractures and 50% will have ligamentous injury, dislocations or spinal cord injury without radiologic abnormality

60 to 80% of vertebral injuries in kids will be in their cervical spine compared to 34 to 40% of vertebral injuries in adults

The AAST study looked at over 12,000 kids who'd undergone blunt trauma and found 87 cervical spine injuries (0.6%)

Four independent predictors of cervical spine injury in children under three were identified: GCS less than 14, GCS eye of one, involvement in motor vehicle crash, and age greater than or equal to two years

Patients with cervical spine injury score of zero to one points had a negative predictive value for cervical spine injury of over 99% and did not need imaging

Five patients in the AAST study had a cervical spine injury score less than two but actually had injury; these patients had concurrent significant traumatic injuries including facial fracture, skull fracture, long bone fractures, loss of consciousness, and neck pain or splinting

Patients with neck pain and splinting need imaging and would automatically fall out of the no imaging category

For skeletal survey in suspected child abuse, a lateral view is used as the single cervical spine view

If using imaging to clear cervical spine (not just for skeletal survey), you need two views at least: an AP and lateral

CT is not commonly done in kids for cervical spine injury because most injuries are not bony but ligamentous, so MRI is preferred if cross-sectional imaging is needed

In unreliable patients, you can leave them in a collar, wait till they calm down or pain is under control, then reexamine and may be able to clinically clear them at that point

Patients with abnormal neurologic exam cannot be clinically cleared and need an MRI