A 14 year old male presents to your Emergency Department by private car with neck pain following a failed back-flip whilst playing on the family trampoline at home.
You are approached by the Triage Nurse to ‘try and clear his neck’ so he can avoid a spinal collar and the unnecessary use of a bed. So you head over to see the patient…
He reports attempting a back-flip, however paused halfway through the rotation causing him to fall and land directly on his head. His neck extended significantly during this impact. There was no loss of consciousness and he has not had any specific neurological symptoms (altered sensation, weakness etc).
He reports immediate left sided neck pain and poor range of motion, but was able to mobilise immediately afterwards.
He is normally fit and well
No significant PMHx
No regular medications
No known allergies
Immunisations up-to-date.
Back to the question – are you able to clear his neck clinically?
The two commonly used clinical decision rules for clearance of the cervical spine are the Canadian C-spine Rules (CCR) and NEXUS. But are they helpful in the paediatric population?
Canadian C-Spine Rules:
from canadiem.org
The CCRs excluded patients less than 16 years of age. They cannot therefore be applied to our patient in this case.
NEXUS:
from ebmedicine.net
The NEXUS study enrolled over 34,000 patients (aged less than 1 year to 101) and identified all but 8 of the 818 patients who had cervical spine injury (sensitivity 99.0%).
There were 3065 children in the study with only 30 cases of spinal cord injury. Only 905 children age <8 years were enrolled of which only four had injuries.
NEXUS performed well in this paediatric subgroup;
Sn 100%, Sp 19.9%
NPV 100%, PPV 1.2%
No ‘low-risk’ patients with subsequent spinal injury
Potential to reduce cervical spine imaging by ~20%.
With this in mind, you examine the patient who essentially has an unremarkable primary survey.
Patent & protected airway.
Chest clear without chest wall tenderness, crepitus or subcutaneous emphysema
Normal haemodynamics. Warm and well perfused
Normal neurological exam (GCS 15, normal tone/power/reflexes, pupils equal & reactive).
No bruising or contusion.
On examination of the neck, there is no midline tenderness, physical step or deformity. He does however have significant left sided neck tenderness on palpation and is unable to rotate his neck due to pain.
Based on the degree of tenderness & inability to rotate the neck laterally you order a plain cervical spine X-ray series…
from Chris Partyka
from Chris Partyka
from Chris Partyka
There is an obvious disruption of the anterior and posterior vertebral line at C3/4 with ~5mm of anterior displacement. A facet joint appears subluxed anteriorly.
Based on these findings you elect to proceed with a CT scan of the cervical spine.
Now, how are we going to tackle this clinical question next time around …
Paediatric c-spine clearance.
Alert, asymptomatic and normal examination.
Apply NEXUS!
…and for those less than 5 years of age
The absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger.
Normal neurological exam
Normal mentation
No neck pain
No torticollis
…then take the collar off & observe.
Painless range-of-motion, normal behaviour & neck movement = cleared spine.
Slack, S. E. (2004). Clearing the cervical spine of paediatric trauma patients.Emergency Medicine Journal,21(2), 189–193.http://doi.org/10.1136/emj.2003.012310
Hannon, M., Mannix, R., Dorney, K., Mooney, D., & Hennelly, K. (2015). Pediatric cervical spine injury evaluation after blunt trauma: a clinical decision analysis.Annals of Emergency Medicine,65(3), 239–247.http://doi.org/10.1016/j.annemergmed.2014.09.002
Hale, D. F., Fitzpatrick, C. M., Doski, J. J., Stewart, R. M., & Mueller, D. L. (2015). Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. The Journal of Trauma and Acute Care Surgery, 78(5), 943–948. http://doi.org/10.1097/TA.0000000000000603
Viccellio P, Simon H, Pressman BD. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001; 108(2):E20. [pubmed]
Dr Chris Partyka is an advanced trainee in Emergency Medicine working at Liverpool Hospital, NSW. Chris is one of the rare ED docs with an Australian accent! He has a keen interest in medical education, ultrasound & coffee. He also authors thebluntdissection blog & tries to out-smart his paediatric patient's with a sound knowledge of cartoons.
Author: Chris PartykaDr Chris Partyka is an advanced trainee in Emergency Medicine working at Liverpool Hospital, NSW. Chris is one of the rare ED docs with an Australian accent! He has a keen interest in medical education, ultrasound & coffee. He also authors thebluntdissection blog & tries to out-smart his paediatric patient's with a sound knowledge of cartoons.
Paediatric c-spine injuries
Tags: cervical spine, chris partyka
A 14 year old male presents to your Emergency Department by private car with neck pain following a failed back-flip whilst playing on the family trampoline at home.
You are approached by the Triage Nurse to ‘try and clear his neck’ so he can avoid a spinal collar and the unnecessary use of a bed. So you head over to see the patient…
Back to the question – are you able to clear his neck clinically?
The two commonly used clinical decision rules for clearance of the cervical spine are the Canadian C-spine Rules (CCR) and NEXUS. But are they helpful in the paediatric population?
Canadian C-Spine Rules:
from canadiem.org
The CCRs excluded patients less than 16 years of age. They cannot therefore be applied to our patient in this case.
NEXUS:
from ebmedicine.net
The NEXUS study enrolled over 34,000 patients (aged less than 1 year to 101) and identified all but 8 of the 818 patients who had cervical spine injury (sensitivity 99.0%).
There were 3065 children in the study with only 30 cases of spinal cord injury. Only 905 children age <8 years were enrolled of which only four had injuries.
NEXUS performed well in this paediatric subgroup;
With this in mind, you examine the patient who essentially has an unremarkable primary survey.
Based on the degree of tenderness & inability to rotate the neck laterally you order a plain cervical spine X-ray series…
There is an obvious disruption of the anterior and posterior vertebral line at C3/4 with ~5mm of anterior displacement. A facet joint appears subluxed anteriorly.
Based on these findings you elect to proceed with a CT scan of the cervical spine.
Now, how are we going to tackle this clinical question next time around …
Paediatric c-spine clearance.
Alert, asymptomatic and normal examination.
Apply NEXUS!
…and for those less than 5 years of age
The absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger.
…then take the collar off & observe.
Painless range-of-motion, normal behaviour & neck movement = cleared spine.
Cervical spine signs & symptoms.
Screening x-ray
Impaired consciousness.
A CT scan or MRI is most likely indicated.
References
Slack, S. E. (2004). Clearing the cervical spine of paediatric trauma patients. Emergency Medicine Journal, 21(2), 189–193. http://doi.org/10.1136/emj.2003.012310
Hannon, M., Mannix, R., Dorney, K., Mooney, D., & Hennelly, K. (2015). Pediatric cervical spine injury evaluation after blunt trauma: a clinical decision analysis. Annals of Emergency Medicine, 65(3), 239–247. http://doi.org/10.1016/j.annemergmed.2014.09.002
Hale, D. F., Fitzpatrick, C. M., Doski, J. J., Stewart, R. M., & Mueller, D. L. (2015). Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. The Journal of Trauma and Acute Care Surgery, 78(5), 943–948. http://doi.org/10.1097/TA.0000000000000603
Viccellio P, Simon H, Pressman BD. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001; 108(2):E20. [pubmed]
#FOAM
Pediatric C-spine Clearance – via ERCAST
Pediatric Cervical Trauma Overview – via OrthoBullets
Clearing The Pediatric C-spine – via PEM ED
Pseudosubluxation of the C spine – via Wheeless’ Textbook of Orthopaedics
About Chris Partyka
Dr Chris Partyka is an advanced trainee in Emergency Medicine working at Liverpool Hospital, NSW. Chris is one of the rare ED docs with an Australian accent! He has a keen interest in medical education, ultrasound & coffee. He also authors thebluntdissection blog & tries to out-smart his paediatric patient's with a sound knowledge of cartoons.