Missouri — Targeted Issue

Author(s)/Presenter(s)

Babcock, L., C. S. Olsen, D. M. Jaffe, J. C. Leonard, G. PECARN Cervical Spine Study Group

Abstract/Description

Objective: The aim of this study was to ascertain potential factors associated with cervical spine injuries in children injured during sports and recreational activities.

Methods: This is a secondary analysis of a multicenter retrospective case-control study involving children younger than 16 years who presented to emergency departments after blunt trauma and underwent cervical spine radiography. Cases had cervical spine injury from sports or recreational activities (n = 179). Comparison groups sustained (1) cervical spine injury from other mechanisms (n = 361) or (2) other injuries from sports and recreational activities but were free of cervical spine injury (n = 180).

Results: For children with sport and recreational activity-related cervical spine injuries, common injury patterns were subaxial (49%) and fractures (56%). These children were at increased odds of spinal cord injury without radiographic abnormalities compared with children with cervical spine injuries from other mechanisms (25% vs 6%). Children with sport and recreational activity-related trauma had increased odds of cervical spine injury if they had focal neurologic findings (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.5-9.4), had complaints of neck pain (OR, 3.1; 95% CI, 1.9-5.0), were injured diving (OR, 43.5; 95% CI, 5.9-321.3), or sustained axial loading impacts (OR, 2.2; 95% CI, 1.3-3.5). Football (22%), diving (20%), and bicycle crashes (11%) were the leading activities associated with cervical spine injury.

Conclusions: In children injured during sports and recreational activities, focal neurologic findings, neck pain, axial loading impacts, and the possibility of spinal cord injury without radiographic abnormality should guide the diagnostic evaluation for potential cervical spine injuries. Certain activities have a considerable frequency of cervical spine injury, which may benefit from activity-specific preventive measures.

Author(s)/Presenter(s)

Powell, E. C., J. R. Leonard, C. S. Olsen, D. M. Jaffe, J. Anders and J. C. Leonard

Abstract/Description

Objectives: Pediatric cervical injuries are uncommon. This study was to describe injury circumstances, clinical findings, and management among children diagnosed with atlantoaxial rotatory subluxation (AARS) to aid in its recognition and management.

Methods: Subanalysis of a large case-control study January 2000 to December 2004 in seventeen hospitals in the Pediatric Emergency Care Applied Research Network. Cases were children younger than 16-years-old with AARS after blunt trauma (n=55); controls were a.) children with other cervical spine injuries (other CSI) (n=485) and b.) those with normal imaging of the cervical spine (non-CSI) (n=1060).

Results: Children with AARS were younger: (mean (SD) age 7.7 (3.8) vs. 10.7 (4.6), Wilcoxon p<0.01). Falls accounted for 36% of injuries; there were no diving mechanisms (vs. other CSI, falls 19%, Fisher’s exact p<0.01; diving 7%, p=0.04). Children with AARS sought medical care more than 24 hours after the injury event (21% vs. 1% for non-CSI controls, p<.01). Clinical findings associated with AARS included neck pain (67%) and torticollis (57%) vs. other CSI, pain (47%) torticollis (5%) p≤.01 for each, and vs. non-CSI controls, pain (33%) and torticollis (6%), p<.01 for each. Management of AARS included no intervention (n=6, 11%), soft or rigid collar only (n=24, 44%), traction (n=14, 25%), halo (n=9, 16%), and internal fixation (n=2, 4%) and varied across institutions (p=0.02).

Conclusions: Children with AARS often have a delayed presentation with neck pain and torticollis; falls are a common injury mechanism. Treatment varied across institutions. Further work is needed to identify optimal management.

Author(s)/Presenter(s)

sen, C. S., N. Kuppermann, D. M. Jaffe, K. Brown, L. Babcock, P. V. Mahajan, J. C. Leonard, PECARN Cervical Spine Injury Study Group

Abstract/Description

Objectives: The objective was to describe the interobserver agreement between trained chart reviewers and physician reviewers in a multicenter retrospective chart review study of children with cervical spine injuries (CSIs).

Methods: Medical records of children younger than 16 years old with cervical spine radiography from 17 Pediatric Emergency Care Applied Research Network (PECARN) hospitals from years 2000 through 2004 were abstracted by trained reviewers for a study aimed to identify predictors of CSIs in children. Independent physician-reviewers abstracted patient history and clinical findings from a random sample of study patient medical records at each hospital. Interobserver agreement was assessed using percent agreement and the weighted kappa (κ) statistic, with lower 95% confidence intervals.

Results: Moderate or better agreement (κ > 0.4) was achieved for most candidate CSI predictors, including altered mental status (κ = 0.87); focal neurologic findings (κ = 0.74); posterior midline neck tenderness (κ = 0.74); any neck tenderness (κ = 0.89); torticollis (κ = 0.79); complaint of neck pain (κ = 0.83); history of loss of consciousness (κ = 0.89); nonambulatory status (κ = 0.74); and substantial injuries to the head (κ = 0.50), torso/trunk (κ = 0.48), and extremities (κ = 0.59). High-risk mechanisms showed near-perfect agreement (diving, κ = 1.0; struck by car, κ = 0.93; other motorized vehicle crash, κ = 0.93; fall, κ = 0.92; high-risk motor vehicle collision, κ = 0.89; hanging, κ = 0.80). Fair agreement was found for clotheslining mechanisms (κ = 0.36) and substantial face injuries (κ = 0.40).

Conclusions: Most retrospectively assessed variables thought to be predictive of CSIs in blunt trauma-injured children had at least moderate interobserver agreement, suggesting that these data are sufficiently valid for use in identifying potential predictors of CSI.

Author(s)/Presenter(s)

Leonard, J. C., D. M. Jaffe, C. S. Olsen and N. Kuppermann

Abstract/Description

Objectives: The Pediatric Emergency Care Applied Research Network (PECARN) investigators previously identified risk factors associated with cervical spine injuries (CSIs) in children. Anatomic maturation and age-related variation in mechanisms of injury suggested the need to explore factors separately for younger versus older children. The purpose of this substudy was to investigate CSI risk factors in age subgroups within the PECARN study cohort.

Methods: This was an age-stratified case-control analysis of children younger than 16 years presenting to 17 PECARN hospitals following blunt trauma between January 1, 2000 and December 31, 2004. Data were abstracted for children with CSIs and randomly selected CSI-free children. Age-stratified multivariable logistic regression was performed to identify factors associated with CSI within three age groups: younger than 2, 2 to 7, and 8 to 15 years. Sensitivity and specificity for CSI were estimated for both the age-specific and original (altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, predisposing conditions, diving, and high-risk motor vehicle crash [MVC]) models.

Results: Among 540 children with CSIs, 27 were younger than 2 years, 140 were 2 to 7 years, and 373 were 8 to 15 years. Focal neurologic deficits and high-risk MVC were associated with CSIs in all age-specific models. Other age-specific factors included the following: younger than 2 years, none; 2 to 7 years, altered mental status, neck pain, torticollis; and 8 to 15 years, altered mental status, neck pain, diving. Age-specific models had comparable sensitivity to the original model among the older groups, but had lower sensitivity and higher specificity among the youngest children.

Conclusions: While this analysis supports the original PECARN model for CSI, there were subtle age variations in factors associated with CSIs in children that warrant future investigation.

Author(s)/Presenter(s)

Anders, J. F., K. Adelgais, J. D. Hoyle, C. Olsen, D. M. Jaffe, J. C. Leonard, PECARN

Abstract/Description

Background: Pediatric cervical spine injury is rare. As a result, evidence-based guidance for prehospital triage of children with suspected cervical spine injuries is limited. The effects of transport time and secondary transfer for specialty care have not previously been examined in the subset of children with cervical spine injuries.

Objectives: The primary objective was to determine if prehospital destination choice affects outcomes for children with cervical spine injuries. The secondary objectives were to describe prehospital and local hospital interventions for children ultimately transferred to pediatric trauma centers for definitive care of cervical spine injuries.

Methods: The authors searched the Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury data set for children transported by emergency medical services (EMS) from scene of injury. Neurologic outcomes in children with cervical spine injuries transported directly to pediatric trauma centers were compared with those transported to local hospitals and later transferred to pediatric trauma centers, adjusting for injury severity, indicated by altered mental status, focal neurologic deficits, and substantial comorbid injuries. In addition, transport times and interventions provided in the prehospital, local hospital, and pediatric trauma center settings were compared. Multiple imputation was used to handle missing data.

Results: The PECARN cervical spine injury cohort contains 364 patients transported from scene of injury by EMS. A total of 321 met our inclusion criteria. Of these, 180 were transported directly to pediatric trauma centers, and 141 were transported to local hospitals and later transferred. After adjustments for injury severity, odds of a normal outcome versus death or persistent neurologic deficit were higher for patients transported directly to pediatric trauma centers (odds ratio [OR] = 1.89, 95% confidence interval [CI] = 1.03 to 3.47). EMS transport times to first hospital did not differ and did not affect outcomes. Prehospital analgesia was very infrequent.

Conclusions: Initial destination from scene (pediatric trauma center vs. local hospital) appears to be associated with neurologic outcome of children with cervical spine injuries. Markers of injury severity (altered mental status and focal neurologic findings) are important predictors of poor outcome in children with cervical spine injuries and should remain the primary guide for prehospital triage to designated trauma centers.

Author(s)/Presenter(s)

Leonard, J. R., D. M. Jaffe, N. Kuppermann, C. S. Olsen, J. C. Leonard, PECARN Cervical Spine Study Group

Abstract/Description

Background and objective: Pediatric cervical spine injuries (CSIs) are rare and differ from adult CSIs. Our objective was to describe CSIs in a large, representative cohort of children.

Methods: We conducted a 5-year retrospective review of children <16 years old with CSIs at 17 Pediatric Emergency Care Applied Research Network hospitals. Investigators reviewed imaging reports and consultations to assign CSI type. We described cohort characteristics using means and frequencies and used Fisher's exact test to compare differences between 3 age groups: <2 years, 2 to 7 years, and 8 to 15 years. We used logistic regression to explore the relationship between injury level and age and mechanism of injury and between neurologic outcome and cord involvement, injury level, age, and comorbid injuries.

Results: A total of 540 children with CSIs were included in the study. CSI level was associated with both age and mechanism of injury. For children <2 and 2 to 7 years old, motor vehicle crash (MVC) was the most common injury mechanism (56%, 37%). Children in these age groups more commonly injured the axial (occiput-C2) region (74%, 78%). In children 8 to 15 years old, sports accounted for as many injuries as MVCs (23%, 23%), and 53% of injuries were subaxial (C3-7). CSIs often necessitated surgical intervention (axial, 39%; subaxial, 30%) and often resulted in neurologic deficits (21%) and death (7%). Neurologic outcome was associated with cord involvement, injury level, age, and comorbid injuries.

Conclusions: We demonstrated a high degree of variability of CSI patterns, treatments and outcomes in children. The rarity, variation, and morbidity of pediatric CSIs make prompt recognition and treatment critical.

Author(s)/Presenter(s)

Kim, E. G., K. M. Brown, J. C. Leonard, D. M. Jaffe, C. S. Olsen, N. Kuppermann, PECARN C-Spine Study Group

Abstract/Description

Objective: This study aimed to compare prehospital spinal immobilization techniques applied to age-based cohorts of children with and without cervical spine injury (CSI) after blunt trauma.

Methods: We compared prehospital spinal immobilization in 3 age-based cohorts of children with blunt trauma-related CSI transported to 1 of 17 participating hospitals. We also compared children younger than 2 years with CSI with those at risk for but without CSI after blunt trauma. We identified patients through query of billing and radiology databases. We compared immobilization methods using Fisher's exact test for homogeneity.

Results: We identified 16 children younger than 2 years, 78 children 2 to 7 years old, and 221 children 8 to 15 years old with CSI, and 66 children younger than 2 years without CSI. There were no significant differences in spinal immobilization techniques applied to children younger than 2 years old with and without CSI (P = 0.34). Of the 82 children younger than 2 years, 34 (41%) were fully immobilized in a cervical collar and rigid long board. There was a significant difference between spinal immobilization techniques applied to children with CSI younger than 2 years and 8 to 15 years old (P < 0.01). Six (38%) children with CSI younger than 2 years were fully immobilized versus 49 (63%) children 2 to 7 years old and 175 (79%) children 8 to 15 years old.

Conclusions: In this retrospective, observational study involving several emergency departments and Emergency Medical Services systems, we found that full spinal immobilization is inconsistently applied to children younger than 2 years after blunt trauma regardless of the presence of CSI. Full spinal immobilization is applied more consistently to older children with CSI.

Author(s)/Presenter(s)

Mahajan, P., D. M. Jaffe, C. S. Olsen, J. R. Leonard, L. E. Nigrovic, A. J. Rogers, N. Kuppermann and J. C. Leonard

Abstract/Description

Background: This study aimed to compare children diagnosed with cervical spinal cord injury without radiographic abnormality (SCIWORA) relative to whether there is evidence of cervical spinal cord abnormalities on magnetic resonance imaging (MRI).

Methods: We conducted a planned subanalysis of a cohort of children younger than 16 years with blunt cervical spine injury presenting to Pediatric Emergency Care Applied Research Network centers from January 2000 to December 2004 who underwent cervical MRI and did not have bony or ligamentous injury identified on neuroimaging. We defined SCIWORA with normal MRI finding as children with clinical evidence of cervical cord injury and a normal MRI finding and compared them with children with SCIWORA who had cervical cord signal changes on MRI (abnormal MRI finding).

Results: Of the children diagnosed with cervical spine injury, 55% (297 of 540) were imaged with MRI; 69 had no bony or ligamentous injuries and were diagnosed with SCIWORA by clinical evaluation; 54 (78%) had normal MRI finding, and 15 (22%) had cervical cord signal changes on MRI (abnormal MRI finding). Children with abnormal MRI findings were more likely to receive operative stabilization (0% normal MRI finding vs. 20% abnormal MRI finding) and have persistent neurologic deficits at initial hospital discharge (6% normal MRI finding vs. 67% abnormal MRI finding).

Conclusion: Children diagnosed with SCIWORA but with normal MRI finding in our cohort presented differently and had substantially more favorable clinical outcomes than those with cervical cord abnormalities on MRI.

Author(s)/Presenter(s)

Nigrovic, L. E., A. J. Rogers, K. M. Adelgais, C. S. Olsen, J. R. Leonard, D. M. Jaffe, J. C. Leonard, PECARN

Abstract/Description

Objective: The objective of this study was to estimate the sensitivity of plain radiographs in identifying bony or ligamentous cervical spine injury in children.

Methods: We identified a retrospective cohort of children younger than 16 years with blunt trauma-related bony or ligamentous cervical spine injury evaluated between 2000 and 2004 at 1 of 17 hospitals participating in the Pediatric Emergency Care Applied Research Network. We excluded children who had a single or undocumented number of radiographic views or one of the following injuries types: isolated spinal cord injury, spinal cord injury without radiographic abnormalities, or atlantoaxial rotary subluxation. Using consensus methods, study investigators reviewed the radiology reports and assigned a classification (definite, possible, or no cervical spine injury) as well as film adequacy. A pediatric neurosurgeon, blinded to the classification of the radiology reports, reviewed complete case histories and assigned final cervical spine injury type.

Results: We identified 206 children who met inclusion criteria, of which 127 had definite and 41 had possible cervical spine injury identified by plain radiograph. Of the 186 children with adequate cervical spine radiographs, 168 had definite or possible cervical spine injury identified by plain radiograph for a sensitivity of 90% (95% confidence interval, 85%-94%). Cervical spine radiographs did not identify the following cervical spine injuries: fracture (15 children) and ligamentous injury alone (3 children). Nine children with normal cervical spine radiographs presented with 1 or more of the following: endotracheal intubation (4 children), altered mental status (5 children), or focal neurologic findings (5 children).

Conclusions: Plain radiographs had a high sensitivity for cervical spine injury in our pediatric cohort.

Author(s)/Presenter(s)

Leonard, J. C., N. Kuppermann, C. Olsen, L. Babcock-Cimpello, K. Brown, P. Mahajan, K. M. Adelgais, J. Anders, D. Borgialli, A. Donoghue, J. D. Hoyle, E. Kim, J. R. Leonard, K. A. Lillis, L. E. Nigrovic, E. C. Powell, G. Rebella, S. D. Reeves, A. J. Roger

Abstract/Description

Study objective: Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma.

Methods: We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the model's sensitivity and specificity.

Results: We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses.

Conclusion: We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.