Evaluation Reveals Insights into Pediatric Trauma Cervical Spine Clearance for Obtunded Patient 

Evaluation of the cervical spine (c-spine) in pediatric patients must be thorough and accommodate a wide range of development and ability to cooperate with a neurologic exam.

Although pediatric c-spine injuries are rare events, they can lead to potentially life-altering consequences.^1-3 The incidence, characteristics, and severity of c-spine injuries in children differ from adults, but often the traumatic workup of the c-spine follows that of adult trauma patients.⁴  

Separate pediatric-specific c-spine clearance pathways have been found to be effective and reduce radiation exposure.^5-8 Diagnostic algorithms become even more important in this patient population considering that pediatric patients with significant head or c-spine injury often may be obtunded or unable to participate and produce a reliable neurological exam. 

Earlier work at our institution showed that implementation of a pediatric c-spine clearance pathway (CSCP) was feasible, helped reduce radiation exposure, increased clinical clearance of c-spines, and improved resource allocation.^8,9 Our pathway led to fewer c-spine radiographs, reduced spine specialty consults, and an increase in the number of patients who were cleared clinically.⁸ The algorithm also specifically offers clinicians guidance for patients who had neurologic deficits or were obtunded, calling for advanced imaging in those cases.

Reviewing the Clinical Pathway to Enhance Quality Improvement

During development of our institution’s pediatric CSCP, input from pediatric orthopaedic spine surgery and neurosurgery coupled with an evidence-based review, lead to including a computed tomography (CT) scan with magnetic resonance imaging (MRI) of the c-spine for patients with a neurologic deficit or who remained obtunded for longer than 72 hours, regardless of the CT results (see Figure 1). Our institution included this requirement in light of the controversy regarding plain radiograph, CT, and MRI in the obtunded pediatric patient.^10-12

Prior work by Brockmeyer and colleagues evaluated 24 comatose, intubated children using four different imaging modalities: plain radiographs, flexion-extension radiographs under fluoroscopy, CT, and MRI. Results showed that MRI had a high false-positive rate, and therefore this study advised against the use of MRI in the comatose, obtunded pediatric patient.¹⁰ The study’s authors recommend the use of either plain radiographs or CT for initial c-spine injury and flexion-extension radiographs for the evaluation of ligamentous instability with normal CT results.

However, work with larger patient populations has demonstrated the benefit of MRI to detect injuries not visible on plain radiographs. In 2002, Flynn and colleagues described the protocol implemented at their institution. This protocol required an MRI be obtained for various indications, including the obtunded or altered patient. A total of 237 children were included in their study, 74 of which underwent MRI of the c-spine, while 64 of these patients had negative plain radiographs. Despite this, 15 of the 64 patients (23.4%) had additional injuries that would not have been detected or treated without MRI investigation.¹¹ More recently, in 2015 Qualls and colleagues evaluated 1,196 children with head injuries. C-spine CT and MR imaging were obtained for children with a Glasgow Coma Scale (GCS) score of ≤8. A total of 63 children underwent both imaging modalities, and MRI identified injuries in seven out of 63 (11%) children that were not detected on CT alone.¹²

In response to these conflicting opinions regarding various imaging studies in the evaluation of pediatric c-spine injuries, a consensus position and algorithm from a large multidisciplinary panel of fellowship- trained pediatric c-spine experts was developed.¹³

In their algorithm, Herman and colleagues required MRI of the c-spine for patients with negative CT if a patient’s GCS score was less than 8 and not expected to improve within 72 hours of admission.¹³ They acknowledge the potential for increased radiation exposure in CT imaging and the potential for false-positive findings in MRI, and yet strongly recommended the use of both modalities, especially in a patient with a GCS score less than 8. The authors cite decreased access to MRI, the need for sedation, and costs associated with MRI as reasons for using CT as the initial imaging modality in the obtunded patient.

As the evidence supporting these imaging mechanisms varies, we decided that it was critical to review this portion of our pathway for further quality improvement. Thus, this study aims to review our experience over the last 13 years with c-spine evaluation in pediatric blunt trauma patients who present with neurologic deficits or are obtunded.

The c-spine clearance pathway was implemented in August 2016, with medical executive board approval. The original data were published May 1, 2019.⁹ Since that time, the c-spine clearance pathway has continued to be a part of every level of pediatric trauma activation.   

In order to determine the need for CT and MRI evaluation of an obtunded patient, we conducted a retrospective review from January 2010 through December 2022 of pediatric trauma patients who underwent imaging of their c-spine. This project was initiated to evaluate the use of MR and CT imaging in an obtunded patient. Patients included in the retrospective review were younger than 18 years, presented as a leveled trauma activation site between the time period noted earlier, had a GCS score of less than 10, and had some form of CT of their c-spine.

 A total of 95 patients were included in the review. Median age of presentation was 12.3 years (range 1.4-18.0); 64% of patients were male, and median GCS score was 5 (IQR 3.0-10.0). Descriptive analysis and mechanisms of injury are summarized in Table 1 time from initial imaging to MRI, if ordered, also were recorded (see Table 2).

Patients included in the study had a median time from presentation to CT of 48 minutes or 0.8 hours. Patients for whom MRI was ordered had a median time from presentation at our institution to MRI of 62.6 hours. There were no MRI-associated complications (Table 2).

A total of 23 patients underwent an MRI after they had a CT scan of the c-spine. Of the patients who underwent MRI, eight (36.3%) had an injury identified using this imaging modality (Table 2). Of the eight injured patients identified by MRI, only three (37.5%) of the injuries were captured fully on CT (Figure 2). Of note, MRI diagnosed four injuries for patients with a normal CT scan and one injury for a patient with an equivocal CT scan. Furthermore, three patients with an abnormal CT scan had an MRI that further detailed their injuries.  

Of the 20 patients who underwent MRI despite a normal or equivocal CT, five (26.3%) had a newly diagnosed injury after undergoing MRI. These injuries included: a syrinx in the cervical cord, anterior ligamentous injury, rotary subluxation, spinal cord contusion, C6-C7 disc bulge and desiccation, C6 fracture, and a C5-6 ligamentum flavum injury (see Table 3). One patient with normal CT imaging required surgical management of their c-spine injury with fixation via Halo for a C1-C2 ligamentous injury with subluxation and a C2 cord contusion. The remainder required prolonged C-collar immobilization.

Results Support MRI for CSCP Obtunded Patients

Our review revealed five newly diagnosed injuries in obtunded patients that would have otherwise been undetected and potentially undertreated. One such injury, not seen on CT, required surgical treatment with fixation. Without MRI, this patient could have been severely undertreated. MRI was obtained for these patients without significant delay in care and without MRI-related complications. This review supports the use of both CT and MRI for c-spine evaluation in neurologically compromised patients after blunt trauma and will be kept in our pathway.

Our rate-of-injury identification is consistent with previously published literature. Qualls and colleagues reviewed 1,196 children with head injuries. They identified seven children with negative CT imaging and positive MRI findings.¹² Garagas and colleagues similarly evaluated pediatric trauma patients. In their cohort of 173 patients, 30 (17%) had significant abnormalities on MRI without corresponding findings on CT. Of these 30 patients, five required surgical stabilization.¹⁴

This combined with our own experience suggests that requiring MRI imaging for an obtunded patient with a negative CT of the c-spine may lead to the identification of clinically significant injuries without delay in care and without imaging-related complications. Consistent with comprehensive consensus statements¹² our results support the continued use of MRI in our CSCP for patients who remain obtunded.

Consistent use and review of a clinical decision pathway is needed to ensure best care. Our prior experience demonstrated that including the decision-making pathway in our electronic health record documentation led to improved adherence with the CSCP. By monitoring adherence and deviations, we can further evaluate how well we provide this evaluation to our patients. We encourage regular monitoring to show effectiveness and benefit.

We also suggest a review of parts of the pathway that may need revision or review based on current literature, as we have done here. This approach can help ensure that the pathway changes as the evidence and available modalities for work-up evolve. In addition, feedback and review during monthly trauma quality improvement meetings to help address issues or concerns related to the pathway are encouraged.

Dr. Begum Akay is a board-certified and fellowship-trained pediatric general and thoracic surgeon in the Department of Pediatric Surgery at Corewell Health Children’s at William Beaumont University Hospital Royal Oak, MI. She is the institution’s surgeon champion for the National Surgical Quality Improvement Program-Pediatric.

Dr. Jacob Applegarth is a general surgery resident at Corewell Health East, William Beaumont University Hospital in Royal Oak, MI. He recently completed an ACS-Accredited Education Institutes Fellowship Program focused on simulation-based surgical education and training.

References

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