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Five criteria can identify pediatric blunt trauma victims who are unlikely to need x-rays to exclude cervical spine injury

Even though cervical spine injury (CSI) is rare in children, doctors usually feel compelled to take spinal x-rays of pediatric blunt trauma victims in order to avoid missing CSI, which can produce catastrophic neurologic disability. Applying five criteria for identifying pediatric blunt trauma victims who are at low risk for CSI would reduce unnecessary x-rays by 20 percent without missing any children with CSI, concludes a study supported by the Agency for Healthcare Research and Quality (HS08239).

William R. Mower, M.D., Ph.D., of the University of California, Los Angeles School of Medicine, and his colleagues evaluated the use of National Emergency X-Radiography Utilization Study (NEXUS) criteria for identifying which of over 3,000 children, who were evaluated for blunt trauma at numerous emergency departments around the country, were at low risk for CSI. The criteria identified children at low risk by the absence of all of the following: midline cervical tenderness, altered level of alertness, evidence of intoxication, neurologic abnormality, and presence of a painful distracting injury. Less than 1 percent of the children studied had sustained a CSI. No case of spinal cord injury without x-ray abnormality was reported for any child in the study.

CSI was rare among children 8 years old and younger. Two-thirds of the 30 injured children were teenagers, only four were younger than 9 years, and none was younger than 2 years. The NEXUS criteria correctly identified all pediatric CSI victims (100 percent sensitivity) and correctly designated 603 patients as low risk for CSI (100 percent negative predictive value). However, the researchers caution about the application of NEXUS criteria to evaluate infants and toddlers with blunt trauma, since there were so few of them in this study.

More details are in "A prospective multicenter study of cervical spine injury in children," by Peter Viccellio, M.D., Harold Simon, M.S., Barry D. Pressman, and others, in the August 2001 Pediatrics 108(2).

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