Diagnostic Evaluation
After understanding the epidemiology of CSI and the pertinent anatomy, it is necessary to discuss the appropriate evaluation of the potentially injured child. The evaluation of a child with a potential neck injury involves a clinical and radiographic evaluation.
Clinical Evaluation. When faced with a child who has sustained a traumatic impact, the clinician must determine whether the child is at risk for having sustained a CSI. The clinician must make a decision regarding the need for immobilization of the child and the need to pursue diagnostic radiographic evaluation of the Cervical spine. Recent work has narrowed the focus of physical examination findings that are present in adults with CSI. (43,44) Two published series identify low-risk criteria that include a normal physical examination of the neck and no history from the patient of neck complaints. The Canadian group characterized low-risk clinical criteria as being the victim of a low-speed rear end crash, being ambulatory prior to transport, or sitting in the department. The U.S. group included criteria requiring a clear sensorium and absence of a distracting injury (as defined by the treating physician). These clinical criteria did well in excluding the likelihood of an unstable cervical spine fracture in adults.
Unfortunately, there are no data in children to identify low-risk patients who do not require cervical spine radiographic evaluation. The Canadian study did not enroll children. The U.S. study identified 30 children with CSI (none younger than 2 years old, and four children younger than 9 years), and thus, lacks the power to support clinical guidelines. Therefore, while these clinical criteria are very similar to published guidelines and recommendations made after retrospective study of injured children, there are no prospective data to validate these recommendations. (15,25,26,45)
Emergency physicians continuously are faced with injured children and must make decisions regarding immobilization, imaging, and management, despite a paucity of clear criteria to use to evaluate these patients. Therefore, careful clinical judgment and evaluation are required. It is hoped that the emergency physician can refine clinical judgment by reviewing the aggregate of clinical presentations of published series of children with CSIs.
In the 30 pediatric patients with CSI from the U.S. trial, all were not low-risk by clinical criteria. (8) Twenty-one of 25 (five were unable to be evaluated for this criterion) patients had mid-line neck tenderness. Eleven of 28 had a distracting injury. Only eight of 27 had neurologic findings, while none had SCIWORA.
A retrospective review of 72 patients included information on the neck examination of 61. (22) Thirty had radiographically apparent CSI (RACSI) and 30 had SCIWORA. Sixteen of the 31 (51%) with RASCI reported midline neck tenderness, while 24 of 30 (80%) of those with SCIWORA had midline neck tenderness documented.
One review of 50 children with CSI noted that all 30 of the children awake at the time of ED arrival had neck pain or tenderness. (12) Another author reported the retrospective review of 25 children with CSIs. (23) She reported that the criteria of any history of neck pain or vehicle crash with head injury identified all children with CSI.
