An analysis of potential cervical spine clearance in children with computed tomography alone

Abstract

Introduction: Clearance of the pediatric cervical spine (CS) after trauma remains a challenge. While missing an injury is unacceptable, prolonged immobilization is also detrimental. We aimed to determine the sensitivity and negative predictive value of computed tomography (CT) for the identification of clinically significant cervical spine injuries (CSIs) in pediatric blunt trauma patients across a large health system. We hypothesized that CT would be highly sensitive for detecting CSIs across a diverse network of hospitals.

Methods: A retrospective cohort study of pediatric patients younger than 18 years with trauma diagnosis codes who underwent CS imaging within 24 hours of presentation to an emergency department was conducted across a mixed adult and pediatric 23-hospital system from January 2012 through December 2023. A clinically significant CSI was defined as an injury requiring CS surgery or halo placement within 7 days of presentation. Patients who underwent CT and had a clinically significant CSI were compared with those without.

Results: A total of 14,232 pediatric trauma patients were evaluated with CS CTs. An additional 10,900 with minor trauma were screened with x-ray and no CT. Of patients who underwent CT, 109 (0.8%) had CSIs. On univariate analysis, CSI patients were more likely to be obtunded shown by an increase in intubation (19% vs. 5%, p < 0.001), and a Glasgow Coma Scale score of <14 (22% vs. 6%, p = 0.049). Four patients with CSIs had normal CTs per initial radiographic report. Post hoc analysis by an expert spine panel identified abnormalities on all CTs. The sensitivity of CT for diagnosing CSI was 96%, and the negative predictive value was 100%. This was consistent across all age groups.

Conclusion: Computed tomography has a high sensitivity for detecting clinically significant CSIs in pediatric trauma patients across all ages and a wide variety of hospitals. Consideration must be given to clearing the pediatric CS based on a negative CT in the absence of symptoms.

Level of evidence: Therapeutic/Care Management; Level IV.

Keywords: Pediatric; c-collar; cervical clearance; cervical spine imaging; cervical spine injury.