Developing a spinal clearance protocol for unconscious pediatric trauma patients.
Hutchings L., Atijosan O., Burgess C., Willett K.
BACKGROUND: Spinal injury in pediatric trauma is associated with significant morbidity and mortality, but no current consensus exists on the safest and most effective method of clearance in the high-risk pediatric trauma patient. METHODS: A retrospective analysis was performed on the records of 115 pediatric patients who had suffered major trauma and required admission to the pediatric intensive care unit of a United Kingdom level I trauma centre during a 7-year period from January 2000 to December 2006. The spinal imaging performed, and methods of clearance for each spinal region were obtained from analysis of written and electronic medical documentation. RESULTS: In the cohort of 115 patients, there was a male predominance (63%) with motor vehicle accidents as the major mechanism of injury (63.5%). Ten patients (8.7%) were identified with spinal injuries, all of whom had sustained closed head injuries. Two of these patients had spinal cord injuries; one subsequently died. Spinal injury resulted in longer intubation times and intensive care stays, but no difference in new injury severity score or outcome. Clearance methods ranged from clinical examination to imaging with radiographs, computed tomography (CT), and dynamic screening. Magnetic resonance imaging was used as a secondary modality in two cases only, and in neither case was it used for clearance. CT demonstrated 100% specificity and sensitivity with positive and negative predictive values of 1 for all spinal regions. There were no cases of Spinal Cord Injury WithOut Radiologic Abnormality and no evidence of missed injuries. CONCLUSIONS: There is a need for an evidence-based protocol for the clearance of the spine in the obtunded and high-risk pediatric trauma patient. High-resolution CT with sagittal and coronal reconstructions should be the basis for cervical spinal clearance, in combination with the interpretation of films by an expert radiologist. All spinal regions should be imaged, and clearance should be formally documented. The role of magnetic resonance imaging in routine clearance remains controversial. Multicenter prospective studies are needed to develop consensus for an evidenced-based protocol for clearance in this high-risk group.