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CITATION: Slaar, A., Fockens, M., Wang, J., Maas, M., Wilson, D., Goslings, J., Schep, N., & van Rijn, R. (2017). Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database of Systematic Reviews, 12(1). DOI: 10.1002/14651858.CD011686.pub2.

TOPIC: Cervical Spine Injury
Review:
(R. Miller)

Title: Triage tools for detecting cervical spine injury in pediatric trauma patients
Cochrane Database of Systematic Review
Authors: Annelie Slaar, M. Mathijs Fockens, Junfeng Wang, Mario Maas, David J Wilson, J Carel Goslings, Niels WL Schep, Rick R van Rijn
Author Affiliations: Cochrane Netherlands, Cochrane DTA Working Group, Cochrane Back and Neck, Academic Medical Centre in Amsterdam, Cochrane Child Health
Downloaded From: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011686.pub2/full

WHY THIS ARTICLE IS RELEVANT OR IMPORTANT: The incidence of traumatic cervical spine injury (CSI) in children is very low. However it is very important not to miss this type of injury. To detect CSI, several types of scan imaging techniques can be used (computed tomography (CT) scan, magnetic resonance imaging (MRI) and plain radiography (x-ray)). CT scan and x-ray use radiation that can lead to an increased risk in the development of cancer, especially in children. We therefore need to use plain radiography or CT scan in children only if really necessary. To avoid unnecessary use of those radiographic imaging techniques, it is important to look for clinical tests that can detect whether children are at risk for cervical spine injury and if radiographic imaging needs to be done.

VERY BRIEF REVIEW: At the moment, there is not enough evidence to determine if the Canadian C-spine Rule is accurate in detecting CSI in pediatric patients following blunt trauma. Therefore the evidence does not support the use of the Canadian C-spine Rule can to detect or rule out CSI in pediatric trauma patients. The information available on the accuracy of the NEXUS criteria in a pediatric population is sparse and based on a small number of CSI events. Clinicians must keep in mind that the sensitivity of the NEXUS criteria differs among the three studies, with a wide range of individual confidence intervals for their sensitivity. This means that there is a chance of missing CSI when only relying on the NEXUS criteria to evaluate the need for imaging in children following blunt trauma. We therefore consider that the NEXUS criteria are at best a guide to clinical assessment as the evidence does not support strict or protocol adoption of the tool into pediatric trauma care.

Background: Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population.

Methods: Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy.

Results: Three cohort studies were eligible for analysis, including 3380 patients; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity.

Conclusion: There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocol adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.

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