medwireNews: Incorporating a cervical spine injury prediction rule into clinical care algorithms could “substantially” enhance the management of children with blunt trauma, and reduce unnecessary radiation exposure, investigators say.
The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule for cervical spine injury “showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging,” report Julie Leonard (The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, USA) and co-authors.
The team screened 22,430 children, aged 0–17 years (51.9% aged 0–8 years), who presented with known or suspected blunt trauma at specialized emergency departments of PECARN-affiliated hospitals across the USA between 2018 and 2021. Of these, 11,857 children were enrolled in a derivation cohort and 10,573 in a validation cohort.
The attending clinician completed the physical examination of these children and documented the cervical spine injury risk factors in an electronic questionnaire.
The researchers identified four factors associated with a high risk for cervical spine injury, namely altered mental status, based on a Glasgow Coma Scale (GCS) score of 3–8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness; abnormal airway, breathing, or circulation; and at least one focal neurological deficit, such as paresthesia, numbness, or weakness.
Among the 928 patients in the derivation cohort presenting with at least one of these factors, 12.7% were found to have cervical spine injuries, with the risk for such injuries increased a significant 8.9 times compared with children without any of the risk factors.
An additional five non-negligible risk factors for cervical spinal injury were identified through classification and regression tree analysis; neck pain, altered mental status – based on a GCS score of 9–14 or verbal or pain on the AVPU – substantial head or torso injury, and posterior midline neck tenderness.
Writing in The Lancet Child & Adolescent Health, Leonard and colleagues report that applying the combined nine factors to the validation cohort was 94.3% sensitive and 60.4% specific for cervical spinal injury and achieved a negative predictive value (NPV) of 99.9%.
They estimate that had the rule been applied to children, the use of imaging would have fallen from 17.2% of cases to 6.9%, and therefore “the number of children undergoing CT could have been reduced by more than 50% without missing clinically relevant injuries or increasing x-ray use.”
Nevertheless, the authors state that “[f]uture work should validate the prediction rule and care algorithm in more general settings such as community emergency departments.”
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