It is usually reasonable to exercise an abundance of caution with trauma patients suspected of having cervical spine injuries. However, an abundance of caution sometimes means an abundance of radiation – and the costs and harms associated with such testing can be immense, regardless of technical difficulty in a young pediatric population.
This is a retrospective evaluation of 2,972 trauma patients aged less than 5 years, reviewing specifically the overall incidence of diagnosed cervical spine injury. In this 12 year cohort, a grand total of 22 had confirmed CSI. Most importantly, however, nearly all cases of CSI were associated with other serious injuries – a cohort with a median ISS of 33. Twelve of 22 arrived intubated, 13 were in extremis, and overall mortality was 50%. All evaluable patients had either neurologic deficits, severe neck pain, or were unable to range their neck.
These authors do not further describe their cohort for evaluation with regard to developing a predictive instrument for cervical spine injury, but these data do support a very reasonable conclusion regarding the rarity of pediatric injuries – and the near impossibility of isolated cervical spine injuries. I tend to agree with the authors’ stated management strategy for such patients:
“Pediatric patients with abnormal neurologic examination result, decreased mental status, neck pain, or torticollis are evaluated with cervical spine CT; however if the child is asymptomatic defined by a normal neurologic examination result, appropriate mental status, with absence of neck pain or torticollis, our first step is to remove the cervical collar. We examine the patient for cervical tenderness if they are able to communicate and observe the child for normal range of motion of the neck. In preverbal patients, we simply observe neck range of motion with the collar removed. If the child seems to move his or her neck without discomfort and full range of motion, then we do not pursue any further radiologic evaluation.”
“Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger”