#121: Straightening It All Out: Pediatric Cervical Spine Injuries and the PECARN Clinical Decision Rule

September 25, 2024 | By Sam Masur

Audio

Summary:

Join this fantastic conversation with Dr. Julie Leonard (Nationwide Children’s) and Dr. Dan Corwin (CHOP) about the management of pediatric cervical spine injuries. This duo teaches us about the new PECARN clinical decision rule for cervical spine injuries as well as key pearls on physical exam and imaging in pediatric patients with blunt trauma.

Pediatric Cervical Spine Injuries Pearls

1. Children are at highest risk for cervical spine injuries if they have substantial altered mental status (GCS 3-8 or unresponsive on AVPU scale), abnormal airway, breathing, or circulation and/or a focal neurological deficit and should have a CT neck
2. Altered mental status (GCS 9-14, verbal or pain on AVPU scale), self-reported neck pain or neck tenderness on exam, and substantial head or torso injury (requiring inpatient observation or surgical intervention) are also considered risk factors for cervical spine injury and should be evaluated with plain films of the neck
3. Clinicians should consider clinical clearance of the cervical spine in children without any of the above risk factors

Pediatric Cervical Spine Injuries and the PECARN Clinical Decision Rule Notes

Injury mechanism and predisposition to injury

• A severe mechanism of blunt trauma should prompt you to do a careful history and physical exam, not necessarily reflexively order cervical spine (c-spine) imaging
• High speed diving and motor vehicle collisions, with someone ejected from a car, a rollover, death in another passenger, or significant intrusion of the car are mechanisms that often cause c-spine injuries
• There are age related difference in c-spine injuries:
  •   Younger children have larger heads and a higher anatomical fulcrum, thus are more predisposed to upper cervical spine injuries
  •   Adolescents are often participating in activities such as sports and have axial load injuries that cause c-spine injuries
• Certain comorbid conditions should prompt you to have a heightened level of suspicion for cervical spine injuries and perform a detailed exam in the setting of blunt trauma, but they do not automatically require imaging, including children with Down syndrome, osteogenesis imperfecta, or achondroplasia

Physical exam

• Have a systematic approach to the physical exam for every patient with trauma that you see
• Start with your primary survey – ABCs (airway, breathing, and circulation) and DE (disability & exposure)
• Assessing the ABCs
  • Airway: is it patent, is the older patient talking, is the younger patient crying?
  • Breathing: do we have equal and bilateral breath sounds?
  • Circulation: Do we have strong peripheral pulses, a normal heart rate, and a normal blood pressure?
  •  Key point: If you have an injury that’s severe enough to compromise your ABCs, you should be concerned that there may also be a cervical spine injury  
• Disability / Glasgow coma scale (GCS)
  •  Assess for weakness, sensory changes, paresthesia
  •  Mentation: a head first axial load impact can result in brain injury, and there is a lot of comorbidity between brain injuries and spine injuries
  • Noting abnormalities in mental status or injuries on exam to the head, neck, chest, and abdomen are important for predicting cervical spine injury
• Ask the patient where they are feeling pain
  • Young children rarely report neck pain, but are excellent at pointing to where their pain is
  • One of the strongest predictors for c-spine injury in toddlers was self-reported neck pain
• It is important to take the collar off and fully inspect the neck
  •  Palpate the posterior neck and along the midline spinous processes to see if there’s any tenderness
  •  Ensure the child can turn the neck fully and without pain
    •  Expert opinion: ensure that the rest of your exam is reassuring, the patient has a normal mental status without any neurological findings, and there is no reported neck pain or point tenderness prior to assessing range of motion of the neck
• You can clear the cervical spine of a very young child!
  • Pay close attention to mental status and focal neurological deficits
  • Young children may cover or shake a limb if they’re having paresthesias  

Cervical collar placement

• Many providers including EMS providers, nurses, and physicians can decide to place a cervical collar
• The standard of care for EMS was to assume a trauma had a cervical spine injury until imaging was performed, so cervical collars were the standard of care
• No intervention is benign
  • Cervical collars increase pain scores
  • May bias providers and leads them to do more imaging or interventions
  • Providers may not fully examine the neck or remove the collar

The NEW PECARN C-Spine Rule

• 18 pediatric emergency departments
• The FIRST neck imaging rule specific for children, with ~22,000 children ages 0-17 years old included
• A rule that was designed to be clinically sensible and not include variables that are open to interpretation (such as “a distracting injury” – which can means different things to different providers)
• PECARN Rule:
  •  High-risk (12% risk of c-spine injury): Consider CT
    •  GCS 3-8 or unresponsive on AVPU scale
    • Abnormal airway, breathing, or circulation (based on clinician observation that ABCs are abnormal and need to be intervened on)
    • Focal neurological deficit
  • Non-negligible risk factors (3% risk of c-spine injury):  Consider plain x-ray
    • Altered mental status (GCS 9-14, verbal or pain on AVPU scale)
    • Self-reported neck pain or neck tenderness on exam
    • Substantial head or torso injury (requiring inpatient observation or surgical intervention) 
  • No risk factors: (0.2% risk of c-spine injury):  Consider clinical clearance
• If the PECARN c-spine imaging rules were applied, there would have been a two-thirds reduction in CT use (17.2% to 6.9%).
  • There is practice variation in who obtains a CT neck; children who were seen at general emergency departments before being transferred to a children’s hospital had more CT scans performed
  • Most children are seen at general emergency departments, so this is an area where broad dissemination of the new PECARN c-spine imaging and implementation of the rules may help to reduce radiation in children  
• This rule is great, but always remember your clinical judgment can trump a decision rule!
• Of the 22,430 patients in the study:
  • 1,549 children in the high risk group (12% with c-spine injury)
  • 7,676 children in the middle risk group (3% with c-spine injury)
  • 13,205 children with NO  risk factors present
    •  0.2% (29 patients) had a cervical spinal injury
      • On review of medical records, 20 of the 29 actually had one of the risk factors present
      • 9 children had no risk factors and had a cervical spine injury; however, none needed any surgical intervention

Imaging Pearls

• Obtain 3 views of the cervical spine (anterior posterior, lateral, and odontoid views)
  •  90% of injuries will be seen on AP and lateral views
  • If you are having difficulty obtaining an good open mouth/odontoid view, check to see if a head CT was obtained in your patient. You can often discuss with radiology because they may be able to evaluate the cranial cervical junction on head CT instead
  • You do not save a patient radiation by obtaining a CT head and CT neck at the same time

The Child with Persistent Neck Pain

• There is a lot of practice variation on what to do with a patient with persistent neck pain and normal imaging; currently there is no clear evidence on what to do
• Be sure to treat pain and re-assess your patient; pain is dynamic and can change over time
• Some patients may be discharged home in a soft collar with close outpatient follow up; some patients may be admitted for MRI
  •  A soft collar is strictly for patient comfort and not for treatment

Resources

• Emergency Medical Services for Children Innovation and Improvement Center (EMSC EIIC)
• PECARN Twitter: @PECARNteam

Goal

Listeners will understand risk factors for cervical spine injury and understand how to apply a clinical decision rule in blunt trauma to improve emergent care of injured children and reduce radiation exposure. 

Learning Objectives

After listening to this episode listeners will…  

1. Recall what mechanisms and comorbid conditions place a patient at risk for c-spine injury
2. Utilize a systematic approach to the physician exam in patients with blunt trauma who may be at risk for c-spine injury 
3. Apply the PECARN c-spine injury clinical decision rule to assess a patient’s risk for c-spine injury 
4. Describe the types of imaging obtained in evaluating for c-spine injury

Disclosures

Dr. Leonard and Dr. Corwin report no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Kelly JM, Leonard J, Corwin D, Masur S, Chiu C “#121: Straightening It All Out: Pediatric Cervical Spine Injuries and the PECARN Clinical Decision Rule”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ September 25, 2024.