How Do I Clear the Pediatric Cervical Spine?

There is quite a bit of controversy surrounding clearing the cervical spine in children. The trauma and emergency medicine literature have few high quality studies to base recommendations on. However, a few very good studies have been carried out that did include children, and they are the basis for this suggested method for clearance.

There are a few key concepts that must be understood before approaching spine clearance in this patient group.

  1. Clinical clearance is key! The majority of children’s cervical spines can be cleared clinically
  2. Limit routine radiographic evaluation, especially by CT. The head and neck is packed with glandular tissue that is sensitive to radiation, especially in early childhood.
  3. If radiographs are required, be sure to have them read by a radiologist who routinely reads pediatric images. There are many nuances in ossification and bony positioning that may falsely lead to injury diagnoses.
  4. Memorize the NEXUS criteria. This study included enough children to allow treatment recommendations to be validated. They are:
    • Midline cervical tenderness
    • Focal neurologic deficit
    • Altered level of consciousness
    • Evidence of intoxication
    • Painful distracting injury

The first step is to determine whether the child is eligible to be clinically cleared. They must be able to verbalize and cooperate with your exam. They may not have a developmental delay, since this may interfere their ability to cooperate with your exam. Frequently, younger children are apprehensive around doctors, and I recommend that you have a parent perform appropriate parts of the exam under your verbal guidance.

Next, evaluate to see if any of the NEXUS critieria are met. The distracting injury criterion is the most difficult to assess. This is a judgment call, but if the child is aware of multiple potentially painful areas, then a distracting injury is probably not present.

If no NEXUS criteria are met, the spine is cleared and should be documented as such. If any are present, a lateral cervical spine xray should be ordered. If the child is >8 years old, a plain odontoid xray should also be obtained. If all are normal, the spine is cleared and should be documented. Children 8 or younger do not have an odontoid that visualizes well. In such cases, a CT from occiput to the base of C2 should be obtained, with appropriate shielding in place.

If, at any point, an abnormality is encountered, expert consultation must be sought in order to safely clear the cervical spine and remove any stabilization.

Factors Predicting Failure of Observation of Occult Pneumothorax

An occult pneumothorax is defined as one that is seen on CT scan, but not on plain chest x-ray. It is a common finding in blunt trauma that is evaluated using CT 2-12% of scans), but there is no consensus on management. It is recognized that some of these progress and require insertion of a chest tube, while many can be observed safely. The authors try to define what factors predict the need for chest tube management.

The authors reviewed their experience over a 3 year period, and identified 642 patients (10% of their registry entries) with a pneumothorax. 283 were occult, and 98 ultimately received a chest tube.

They found that age>35, ISS>24, more than 4 rib fractures, and need for positive pressure ventilation increased the risk for chest tube insertion. These seem to make sense, but there was one significant limitation in this study: there were no standard indications for a chest tube insertion among the surgeons involved with these patients. There was significant variability, so the actual need for tube insertion was probably less than reported.

An audience member related one anecdotal factor for chest tube as well: a heavy smoking history. This makes intuitive sense, but not everything that makes sense is borne out by research.

At Regions, we define an occult pneumothorax the same way these authors did. We routinely get a delayed chest xray 6 hours later. If there is still no visible pneumothorax, we stop looking. If it is visible, we will obtain periodic (q12-24 hrs) xrays until it stabilizes or grows to a size that demands tube or pigtail insertion.

Given the data conveyed in this paper, we will consider watching a bit longer than 6 hours in patients at higher risk.

Reference: Factors Predicting Failed Observation of Occult Pneumothorax in Blunt Trauma. Selander, Minshall, couillard, Leon. Medical University of South Carolina.

Presented at the 23rd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma

Can a Normal CT Scan Alone Clear the Cervical Spine in Obtunded Trauma Patients?

This is the first in a series of articles on interesting abstracts presented at the 23rd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma in Phoenix, Arizona.

C-spine clearance in obtunded trauma patients has been problematic for some time. The options have been:

  • CT plus MRI. This is probably only valid for the first 72 hours after injury, and entails some risk in placing a critically ill patient inside the MRI for 30 minutes or more.
  • CT plus flexion/extension images under fluoroscopy. These are generally only performed by a few brave souls.
  • Leave the collar on until a clinical exam can be performed. This frequently leads to significant skin breakdown problems.

The authors have been reviewing their experience with using CT scan alone. In this paper, they used this technique in patients who met the following criteria:

  • Obtunded
  • Blunt trauma
  • CT normal, as read by a neuroradiologist
  • Moving all extremities

They studied 197 patients, and found no injuries in all surviving patients (11% were lost to followup). One deceased patient had a stable ligamentous injury without spine fracture seen at autopsy. Using this technique resulted in a decrease in the average number of days to spine clearance from 7.5 to 3.3 days, a decrease in skin breakdown from 5% to 0.5%. A decreased length of stay from 23.4 to 13.8 days was also seen, but this could not be attributed to the collar.

Very intriguing! However, the fear of SCIWORA is high in all who clear c-spines. The rarity of this catastrophic problem means that no existing study has the statistical power to show that this type of clearance is safe.

Bottom line: We all need to decide “How many missed injuries is okay?” We will never be able to absolutely clear 100.000% of c-spines by xray alone, or even by adding a clinical exam. This study provides support for one technique, but eventually a catastrophic injury will occur. Who will decide what constitutes an acceptable complication and with what frequency they will occur?

Reference: A Normal CT Alone May Clear the Cervical Spine in Obtunded Blunt Trauma Patients with Gross Extremity Movement – A Prospective Evaluation of a Revised Protocol. Leukhardt, Como, Anderson, Wilczewski, Samia, Claridge. MetroHealth Medical Center, Cleveland, OH.

Trauma Twenty Years Ago: January 1990

It’s always interesting to review the trauma literature of days gone by to see where we’ve been and how it impacts where we are today in trauma care. Here are a few articles from the Jan 1990 Journal of Trauma (Volume 30 Number 1) worth commenting on:

Efficacy of Liver Wound Healing by Secondary Intent. Dulchavsky et al, page 44-48. This paper compared wound healing using tensile strength in pigs and dogs. The authors compared primary operative closure, closure with an omental buttress, and healing by secondary intention. They found that the strength of secondary healing equaled or exceeded that in both types of operative repair by 6 weeks post-injury. This paper and several similar ones laid the groundwork for our understanding of solid organ healing and lend weight to the somewhat arbitrary guidelines of resuming full physical activity after 6 weeks.

Intestinal Injuries Missed by Computed Tomography. Sherck et al, page 1-7. The authors retrospectively looked at 10 CT scans done over a 9 year period that were done in patients who eventually were found to have an intestinal injury. The injury became apparent in 2 hours to 3 days after the traumatic event. Even when the authors knew that a bowel injury was present, they could definitively diagnose the problem on the initial CT in only 2. The authors concluded that CT could not reliably detect these injuries. Little has changed since this paper was published, even though the scan technology has improved greatly (1 or 2 slice scanners in 1990, 16-64 slices now). We have gotten better at detecting bowel injury with better resolutions, but the diagnosis still remains a clinical one.

Techniques of Splenic Preservation Using Fibrin Glue. Shoemaker et al, page 97-101. The senior author first described the use of fibrin glue in splenic injury in 1983, and continued to investigate it over the next 7 years. This paper was the largest human series at the time. The authors found that it limited blood loss and transfusions, although there was no actual control group. They found that it increased splenic salvage rates to 86% in operative cases, and repeat CT did not show rebleeding or abscess formation. This study added a new technique to the trauma surgeon’s armamentarium in dealing with solid organ injury. Although later studies did find a modest increase in abscess formation, the technique remains a viable alternative when operatively managing solid organ injury. Overall, it is not used as much now because nonoperative management has become quite refined, with a success rate of about 93%.