Cervical Spine Clearance in Pediatric Trauma Centers: The Need for Standardization and an Evidence-Based Protocol Mitesh Shah MD Martin J Herman MD Jonathan.

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Presentation transcript:

Cervical Spine Clearance in Pediatric Trauma Centers: The Need for Standardization and an Evidence-Based Protocol Mitesh Shah MD Martin J Herman MD Jonathan Phillips MD, Chair of the Pediatric Cervical Spine Study Group

Introduction Cervical spine injuries uncommon 1-2% incidence Devastating consequences Death Paralysis Evaluation of cervical spine injuries begins with cervical spine clearance Efficient and safe clearance of the uninjured patient Limit radiation exposure Identification of injured patients

Literature on Pediatric Cervical Spine Clearance Protocols NO Consensus Trauma Surgery and Neurosurgery literature Awake child vs obtunded child Radiographs vs CT Standardized protocol J Trauma, 2009 J Trauma, 2011

Starting Point for this Study 191 centers 57% had written cervical spine spine clearance protocols Varied imaging strategies Concluded Need for standardization dailyrecord.co.uk

Methods Electronic survey of members of the Pediatric Cervical Spine Study Group 10 questions FREE Key Questions Who clears the cervical spine for pediatric trauma patients? What imaging modalities are used for cervical spine clearance? Does the institution have a written cervical spine clearance protocol?

Results 27 surgeons answered the survey 25 different centers Eliminated 2 surveys same institution 25 different centers 21 LEVEL ONE centers 4 LEVEL TWO centers All centers with an academic affiliation

Who clears the cervical spine for pediatric trauma patients? SPINE Consult Service 63% Rotating Schedule Orthopedic Surgery Neurosurgery 30% Orthopedic Surgery 7% Neurosurgery

What imaging modalities are used for cervical spine clearance? All had FULL-time access to CT 80% FULL-time access to MRI

Does your institution have a written cervical spine clearance protocol? Only 46 % of centers had a written standardized pediatric cervical spine clearance protocol

Limitations Small sample size Survey Relevance of information Questions open to interpretation Recall bias Relevance of information Is there a need for improvement of current clearance methods when the rate of missed injury is low?

Conclusions Pediatric cervical spine clearance protocols Vary widely among institutions Personnel assessing patients Imaging modalities Standardized, written clearance protocols are NOT used by the majority of institutions FUTURE consideration should be given to creating and validating a standardized protocol for Cervical Spine clearance in children

References Selected References Eubanks J, Gilmore A, Bess S, Cooperman D: Clearing the Pediatric Cervical Spine Following Injury.Journal of the American Academy of Orthopedic Surgeons 2006;14:552-64. Hannon M, Mannix R, Dorney K, Mooney D, Hennelly K. Pediatric Cervical Spine Injury Evaluation After Blunt Trauma: A Clinical Decision Analysis. Ann Emerg Med. 2014 Oct 16. pii: S0196-0644(14)01259-1.(Epub ahead of print). Henry M, Scarlata K, Riesenburger RI, Kryzanski J, Rideout L, Samdani A, Jea A, Hwang SW: Utility of STIR MRI in Pediatric Cervical Spine Clearance after Trauma. Journal of Neurosurgery: Pediatrics 2013;12(1):1333-338 Jones TM, Anderson PA, Noonan KJ: Pediatric Cervical Spine Trauma. Journal of the American Academy of Orthopedic Surgeons 2011;19:600-11. Kreykes NS, Letton, Jr RW: Current Issues in the Diagnosis of Pediatric Cervical Spine Injury. Seminars in Pediatric Surgery 2010;19:257-64. Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC; Pediatric Emergency Care Applied Research Network (PECARN) Cervical Spine Study Group. Cervical spine injury patterns in children. Pediatrics. 2014 May;133(5):e1179-88. doi: 10.1542/peds.2013-3505. Puisto V, Kaarianen S, Impinen A, et al: Incidence of spinal and spinal cord injuries and their surgical treatment in children and adolescents: A population based study. Spine (Phila 1976). 2010;35:104-107. Sun R, Skeete D, Wetjen K, Lilienthal M, Liao J, Madsen M, Lancaster G, Shilyansky J, Choi K. A pediatric cervical spine clearance protocol to reduce radiation exposure in children. J Surg Res. 2013 Jul;183(1):341-6. (Epub 2013 Jan 16). Vanderhave K, Chiravuri S, Caird M, Farley F, Graziano G, Hensinger R, Patel R: Cervical Spine Trauma in Children and Adults: Perioperative Considerations. Journal of the American Academy of Orthopedic Surgeons 2011;19:319-27.