Pediatric emergency medicine trisk 3581 3581
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patient does not have a high-risk mechanism of injury (motor vehicle accident, fall
>10 ft, dive, or sports injury), is awake and alert, can have an interactive
conversation (not inebriated, no altered level of consciousness, verbal at baseline),
does not complain of cervical spine pain, has no tenderness on palpation
(especially in the posterior midline), has normal neck mobility, has a completely
normal neurologic examination without a history of abnormal neurologic
symptoms or signs at any time after the injury, and has no other painful injuries
(which may distract the patient and mask neck pain), the patient may not need
radiographic evaluation of the cervical spine. The National Emergency XRadiography Utilization Study (NEXUS) suggests the following criteria for the
assessment of risk of spinal injury: (i) midline cervical tenderness, (ii)
intoxication, (iii) alertness, (iv) focal neurologic deficit, and (v) distracting
(painful) injury (i.e., long bone fracture, visceral injury, large laceration,
degloving or crush injury, large burns, and injuries producing impairment in
appreciation of other injuries). If these are negative, then the patient is believed to
be at low risk for a spinal injury and may be able to forgo radiographic evaluation.
In adults, NEXUS low-risk criteria have been reported to be 99.6% sensitive in
the detection of clinically important cervical spine injury and have a high NPV for
low-risk patients. When NEXUS criteria were applied to children <18 years, the
2017 Cochrane review reported that sensitivities are 57% to 100% with low
specificity, 20% to 54% in the context of a very low incidence of pediatric spinal
cord injury (0.98%), an underrepresentation of children <9 years, and an absence
of children with injuries under 2 years of age. A subsequent validation study
demonstrated a sensitivity of 88% in children under 8 years of age. Therefore,
caution should be exercised when utilizing these criteria in the evaluation of
traumatized children since they may not have the same validity in young children
as they do in older children and adults. A large multicenter study specifically
addressed clinical clearance of the cervical spine in children <3 years. They found
that a GCS <14, a GCS for eye opening of 1, motor vehicle crash, and age >2
years were independent predictors of a cervical spine injury with an associated
NPV of 99.93% and a sensitivity of 92.9% if any one was present. These have not
yet been validated but address a population whose cervical spine can be uniquely
challenging to clinically evaluate.
A recent study from the Pediatric Emergency Care Applied Research Network
(PECARN) group identified eight clinical variables for children under the age of
16 years old that when any one of them was present, there was a high sensitivity
for identifying potential cervical spine injury. These variables are similar to other
studies that have highlighted risk factors for CSI: altered mental status, neurologic
