Determining clinical assessment sensitivity in evaluating the cervical spine of pediatric trauma patients

Abstract

The National Emergency X-Radiography Utilization Study (NEXUS) was a prospective, observational study on a decision instrument based on clinical criteria. The intention of the study was to help physicians identify patients who need radiograph evaluation of the cervical spine. Based on NEXUS study results, researchers recommended that the decision instrument may be safely used as a decision algorithm to evaluate for cervical spine injury in adult trauma patients. A similar decision instrument has not been developed for pediatric patients with possible cervical spine injury (CSI). Pediatric patients of blunt trauma have anatomical and developmental characteristics that make it difficult to assess their risk of CSI. Methodology: To determine if clinical assessment is sensitive enough to clear the pediatric cervical spine, a comprehensive literature review was performed. Four articles were identified that fit the inclusion criteria set by this evidence based literature review. Results: To assess the pediatric patient it should be determined if the patient is “low-risk” (at low risk of having obtained a CSI) or “highrisk” (at high risk of obtaining a CSI.) The patient’s clinical stability can be assessed by the presence or absence of each of the five low-risk criteria. The patient is considered low-risk if there is an absence of the following criteria: midline cervical tenderness, evidence of intoxication, altered level of alertness, focal neurologic deficit, and presence of distracting painful injury. Non-verbal children are high-risk because they are unable to verbalize pain. Patients that meet low-risk criteria may be cleared. Patients considered high-risk should undergo plain film radiography. Conclusion: Clinical assessment performed well in pediatric patients and reduced the number of patients undergoing radiography. Based on the lack of high quality evidence, a recommendation can not be made on applying clinical assessment to pediatric patients.