Cervical spine imaging for pediatric patients increased despite wide clinical variability
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Key takeaways:
- Use of cervical spine imaging for pediatric patients with blunt trauma has increased.
- Researchers found “wide variability” in clinical evaluation, which could lead to the potential for overdiagnosis of injuries.
Results published in JAMA Surgery showed use of cervical spine imaging for pediatric patients with blunt trauma has increased despite wide variability in clinical evaluation, which could lead to the potential for overdiagnosis of injuries.
In the PEDSPINE II study, Casey M. Luckhurst, MD, and colleagues analyzed results from 9,389 pediatric patients aged 3 years or younger who presented to a hospital following blunt trauma between January 2007 and July 2017. Researchers also performed descriptive analysis of the population and analyzed use of imaging and injury patterns to develop a prediction model to guide imaging usage and to identify trends in imaging. They compared results with the previous PEDSPINE model developed from a study performed in 2009.
Overall, 1.36% of patients (n = 132) from the current study had cervical spine injury compared with 0.66% in the previous PEDSPINE study. Additionally, 80% of patients (n = 7,113) from the current study underwent cervical spine imaging compared with 63% (n = 7,882) in PEDSPINE.
Researchers found “wide variability” in the use of radiography, including increased usage of MRI and subsequent ligamentous injury. They noted the most common injury was ligamentous injury and patients with cervical spine injury had “significantly higher” mortality.
Luckhurst and colleagues derived a new model to help physicians select the most beneficial imaging modality that also provides likelihood of cervical spine injury and injury subtype.
“Despite improved knowledge surrounding traumatic pediatric [cervical spine injury], wide variability in clinical practice persists,” Luckhurst and colleagues wrote in the study. “There has been increased use of CT and MRI imaging in the interval between PEDSPINE and PEDSPINE II, which has implications of increased cost, increased radiation exposure and most importantly a potential for overdiagnosis of injuries,” they concluded.
Perspective
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The investigators of the PEDSPINE I and II studies used trauma registry data to derive and validate a model for predicting cervical spine injury in young children. Important to their findings is mental status as a predictor of severe injury, which is consistent with other proposed pediatric cervical spine injury prediction models. Traumatic brain injury is reflective of headfirst impact and axial load force, which is associated with cervical spine injury in children.
The PEDSPINE cervical spine injury risk model represents correlation, not causation, given its contingency on retrospective registry data. Registry data also lack complete patient histories, and the available data may not be temporally related to the findings that led to the cervical spine injury imaging and diagnosis. Mechanism of injury is useful for trauma triage in the absence of patient-specific complaints and findings. However, use of mechanism alone to determine radiography use is imprecise and may lead to over-imaging.
Without prospective evaluation, the PEDSPINE I and II findings need to be applied cautiously. Children younger than 3 years are at highest risk for radiation-induced malignancy. A single CT scan in a child of this age more than doubles their lifetime risk of cancer. The National Institute of Child Health and Human Development funded the Pediatric Emergency Care Applied Research Network to prospectively derive and validate a pediatric cervical spine injury risk assessment tool to address these concerns.
References:
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Leonard JC, et al. Pediatrics. 2019;doi:10.1542/peds.2-18-3221.
Luckhurst CM, et al. JAMA Surg. 2023;10.1001/jamasurg.2023.4213.
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