July 2025

Clinical Question

Does caregiver concern for clinical deterioration correlate with critical illness in children presenting to hospital?

Title of Paper

Association between caregiver concern for clinical deterioration and critical illness in children presenting to hospital: a prospective cohort study

Journal and Year

Lancet Child & Adolescent Health, 2025

Lead Author

Erin Mills

Acute Behavioural Disturbance in Emergency Departments

Clinical question

In children presenting with suspected C-spine injury, is CT imaging sufficient to clear the spine without needing further MRI imaging?

Background:

Paediatric C-spine injury is pretty rare but when it does occur it can be pretty devastating.

As we know, children are not just little adults, and there are some anatomical differences that do alter the types of spinal injury that can affect children. Of note, they have bigger heads and have increased ligamentous laxity which can result in altered injury patterns and the concept of SCIWORA - spinal cord injury without radiographic abnormality. The radiographic abnormality refers to XR and CT imaging, so therefore this necessitates MRI imaging to exclude this phenomenon.

Clearing a child’s spine after trauma can prevent unnecessary immobilization, reduce the risks from extra tests, and lessen the burden on healthcare systems. The term SCIWORA was first devised in 1982, 43 years ago, and imaging has come a long way since then. Some retrospective single centre studies undertaken have shown sensitivity rates of 100% for CT C-spine imaging, and in adults this is already pretty standard practice. So, can we run the kids through the donut of truth and clear the C-spine? This paper looks at that question.

Title:

An analysis of potential cervical spine clearance in children with computed tomography alone

Lead author and Journal:

Russell et al.

Journal of Trauma and Acute Care Surgery, 10th June 2025

Methods:

Study Design

This was a retrospective cohort study across 23 hospitals in a healthcare system covering a 500 mile radius comprising a combination of paediatric and adult hospitals covering levels 1 - 4 trauma centres, which is akin to your major trauma centre and trauma units or whatever nomenclature you use. They collected data over 12 years from January 2012 to December 2023 and included all patients under the age of 18 having an x-ray or CT imaging for suspected C-spine injury in the ED or within 24 hours of presentation. Data was collected from an electronic data warehouse, which missed some data such as GCS, and they gathered some of this data by cross-referencing it with trauma registries.

Outcomes

Primary outcome was any clinically significant cervical spine injury - requiring surgery or immobilisation device within 7 days of index presentation.

Imaging was assessed as ‘normal’ or ‘abnormal’ based on the radiologist interpretation, and full case analysis was undertaken of patients with clinically significant cervical spine injury. A multidisciplinary review was conducted by a paediatric neuroradiologist and two spinal surgeons to assess the imaging in all children with ‘negative’ CT imaging who then went on to have surgical intervention, which you don’t tend to perform needlessly.

Results:

There were 25,132 patients who met the inclusion criteria, of whom 14,232 patients underwent CT imaging and 10,900 had XR imaging. We’ll look at the wider cohort and the CT cohort.

In the total wider cohort there were 112 patients - 0.4% - who had a clinically significant C-spine injury. Nearly all, 108, had surgery, and 4% had immobilisation using HALO placement. These patients were more likely to be intubated, suggestive probably of more significant mechanisms of trauma, obtunded with a reduced GCS and were more likely to be non-white in this cohort.

Looking at our population, 67% of these were male, and the median age was 15. There were no injuries in infants under 1, 12% were in the 1-4 group, 13% in 5-9, 20% in 10-14 and the majority, 55%, in those aged 15-17 years of age. It’s important to note the age, because after the age of 8 or 9 paediatric C-spine injuries tend to more closely mirror those of adults, and so they looked at both these groups in separate secondary analyses.

They undertook a regression analysis which revealed a statistically significant interaction between age and sex, which suggested the probability of clinically significant C-spine injury increased more with advancing years in males compared to females, and this was primarily attributable to sport-related injuries, which tracks with who I see coming through the door on a Sunday afternoon in muddy rugby shorts and head-blocks.

In the cohort who had CT imaging alone, 109, or 0.8% met the primary outcome of a clinically significant CSI. All imaging was read by board-certified paediatric radiologists reading imaging in those younger than 15.

There were four ‘missed’ images initially missed on CT and then diagnosed on MRI - three of them were adolescents with a GCS of 15 who were playing sports with persistent midline tenderness. On post-hoc expert review of the imaging, there were abnormal findings concerning injury visible on all three CTs. There was a fourth patient who arrived obtunded and was transferred to a paediatric trauma centre and received an MRI on arrival. Post-hoc review noted findings consistent with atlanto-occipital dislocation. These children all went on to have discectomies or spinal fusion surgery.

The overall sensitivity of CT for diagnosing a clinically significant C-spine injury was 96% with a 95% CI of 92.7-99.9%, and the negative predictive value was 100%, with 95% CIs of 99.9-100%.

Limitations

This study had a few limitations - it was retrospective, relied upon a single hospital system with access to paediatric radiologists, and was based on an electronic data warehouse which did not capture GCS - this was often cross-referenced to pre-existing trauma databases, which limited their ability to capture this component of predicting significant C-spine injury.

The follow-up period was 7 days, so there is the possibility of a child holding their head in their hands for 8 days and then presenting to an ED, but I feel that is probably unlikely.

Additionally, the way in which the adjudicating panel looked through the four images was in the context of them going on to have spinal surgery; this will tip the hat towards there being an abnormality, but they have outlined the analysis with these four cases presented as missed, so I’m probably just being a little churlish.

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