Journal of Pediatric Surgery 49 (2014) 333–337

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Journal of Pediatric Surgery

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Cervical spine computed tomography utilization in pediatric trauma patients

Kathleen M. Adelgais a,⁎, Lorin Browne b, Maija Holsti c, Ryan R. Metzger d,Shannon Cox Murphy e, Nanette Dudley c

a Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, COb Department of Pediatrics, Pediatric Emergency Medicine Section, Medical College of Wisconsin, Milwaukee, WIc Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UTd Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UTe Primary Care Partners, Grand Junction, CO

a b s t r a c ta r t i c l e i n f o

Abbreviations: CSI, Cervical Spine Injury; CSCT, Cerraphy; CSXR, Cervical Spine Radiographs; GED, GeneralPediatric Trauma Center; GCS, Glasgow Coma Scale; ISAbbreviated Injury Scale.⁎ Corresponding author. Department of Pediatrics, U

School of Medicine, Aurora, CO 80045, USA. Tel.: +1 303E-mail address: kathleen.adelgais@childrenscolorado

0022-3468/$ – see front matter © 2014 Elsevier Inc. Alhttp://dx.doi.org/10.1016/j.jpedsurg.2013.10.006

Article history:

Received 8 October 2013Accepted 9 October 2013

Key words:PediatricComputed tomographyTrauma

Background: Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervicalspine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCTbetween a pediatric trauma center (PTC) and referral general emergency departments (GEDs).Methods: Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI andCSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT wereassessed using multivariate logistic regression.Results: 5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were

similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9,p b 0.05) and more frequent ICU admissions (44.3% vs. 26.1% p b 0.05). CSI rate was 2.1% (107/5148) andremained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI = 8.3, 10.9)and increased from 6.8% to 42.0% (mean 26.9%, CI = 25.4, 28.4) at the GED. Initial care at a GED remainedstrongly associated with CSCT.Conclusions: Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially amongpatients initially evaluated at a GED.

© 2014 Elsevier Inc. All rights reserved.

Trauma is one of the most common causes of morbidity andmortality in the pediatric population. Differences exist in thefrequency of injury and type of injuries between pediatric and adultblunt trauma patients. The largest prospective study of cervical spineinjury (CSI) performed in the United States found a rate of 1% amongpatients less than 18 years of age compared to 2.4% among patients19 years and older [1–3]. Though CSI rates are lower in pediatricpatients, they have higher rates of ligamentous injury due to increasedligamentous laxity [4]. For these reasons, differences may exist in theevaluation of CSI in pediatric and adult patients.

Due to significant morbidity and mortality from CSI, care must betaken in the evaluation of patients with potential CSI. Several studieshave attempted to determine which patients require radiographicevaluation of the cervical spine. The largest of these, The NationalEmergency X-Radiography Utilization Study (NEXUS), developed aset of criteria to define patients at low risk for CSI, however, the study

vical Spine Computed Tomog-Emergency Departments; PTC,S, Injury Severity Score; AIS,

niversity of Colorado Denver724 2578..org (K.M. Adelgais).

l rights reserved.

investigators recommended caution when using these criteria withchildren given the lower numbers of enrolled patients b 18 years [5].

Several studies suggest that cervical spine CT (CSCT) is a moreefficient and effective screen for CSI in the adult patient [6–8]. Thesestudies have led to changes in the recommendations of the AmericanCollege of Surgeons Committee on Trauma on the evaluation of thecervical spine for injury to include routine use of CSCT for adult blunttrauma patients [9]. These are in contrast to current publishedguidelines recommending that pediatric blunt trauma patients bescreened initially using plain radiography with adjunctive CT of selectareas if concern for injury exists [10–12]. These guidelines are basedon a published sensitivity of plain radiography for CSI in pediatricblunt trauma patients between 89% and 95% [13–15].

As the use of CT in evaluating the adult blunt trauma patient hasincreased, there is also evidence that the use of CT in the evaluation ofchildren is on the rise [16,17]. CSCT results in a significant increase inthe dose of ionizing radiation to the thyroid compared to that seenwith cervical spine radiography CSXR [18,19]. This higher dose alongwith increased usage could lead to a significant overall exposure ofionizing radiation to the pediatric population [20,21].

The objective of our study was to compare the utilization of CSCTand plain radiography between a pediatric trauma center (PTC) andreferral general emergency departments (GEDs) in a pediatric trauma

Table 1Comparison of Patient Characteristics between PTC and GED.

Hospital PTC (n = 2142) GED (n = 3006)

Patient CharacteristicsAge, median years (IQR) 8 (3, 12) 6 (2, 11)Male % (95% CI) 63.1% (60, 65) 64.9% (63, 67)C-spine Injury % (95% CI)a 1.4 (1, 2) 2.6 (2, 3)GCS, median (IQR) 15 (14, 15) 15 (14, 15)Injury Severity Score, median (IQR)a 9 (5, 17) 16 (9, 21)Head Injury AIS, median (IQR) 2 (2, 3) 3 (3, 4)Admission to ICU % (95% CI)a 26.1 (23, 28) 44.3 (41, 45)Admitted directly to OR % (95% CI)a 9.1% (2, 4) 11.6.% (6, 8)Trauma 1 Activation % (95% CI)a 18.0 (34, 39) 24.1 (17, 21)Mechanism of InjuryMVC % (n) 27.3 (585) 27.2 (610)Fall % (n) 19.1 (410) 25.1 (756)Pedestrian % (n) 13.6 (293) 8.2 (247)Sports Injury % (n) 13.8 (296) 7.3 (220)Non-Accidental Trauma % (n)a 1.4 (36) 5.3 (160)

a p b 0.05.

334 K.M. Adelgais et al. / Journal of Pediatric Surgery 49 (2014) 333–337

population. We hypothesized that referral GEDs utilize CT more oftento screen the cervical spine for injury among their pediatric traumapatients compared to the PTC.

1. Methods

This study was a retrospective review of patient medical recordsand radiographic studies of trauma patients evaluated at PrimaryChildren’s Medical Center (PCMC), an American College of SurgeonsLevel 1 pediatric trauma center (PTC) between January 1, 2002 andDecember 31, 2011. This study was approved by the University ofUtah Institutional Review Board.

2. Data source

The PCMC trauma registry is a database containing patientinformation, physiologic data and clinical outcomes including survivalstatus at hospital discharge and duration of hospital stay. Patient datafrom medical charts are abstracted and entered directly into thetrauma registry by registrars who have completed the AbbreviatedInjury Scale (AIS) Course through the Association of the Advancementof Automotive Medicine. For the purposes of this study, all patientswith a level-1 or -2 trauma activation were enrolled. PCMC employscommonly used criteria to define trauma activation levels: Trauma 1:shock, significant penetrating injury, acute intracranial hematomawith mass effect, obvious severe open cranial injury, intubation, GCSb10, traumatic paralysis, proximal extremity amputation, or trau-matic arrest. Trauma 2 activations include GCS 11 to 14, severehypothermia, stable withmultiple injuries or high-energymechanismof injury [22]. Trauma 3 patients are stable, without the above criteriaand were not included in our study. We obtained and analyzed datafrom the registry including demographics; year of enrollment,measures of injury severity including Injury Severity Scores (ISS),AIS for head and neck injury; mechanism of injury; emergencydepartment disposition; hospital of initial presentation; use of CSXRand CSCT; presence and type of CSI; operative management of CSI. CSIwas defined as any fracture, ligamentous injury with and withoutsubluxation, spinal cord injury, spinal cord injury without radio-graphic association (SCIWORA), or a combination of these. Cervicalspine strain was not considered a CSI for the purposes of this study.

3. Data analysis

Our primary outcome was the percentage of patients with a CSCTon initial evaluation at the PTC or GED and the change in thatpercentage over time. For the purposes of this study, patients whopresented to the PTC after an evaluation at a GEDwithout a CSCTwereclassified as no CSCT. Secondary outcomes included use of CSXR toevaluate the cervical spine, incidence of patients with CSI andoperative management for CSI.

Descriptive statistics, including medians, interquartile range, andpercentages were initially calculated for gender, age, GCS, mechanismof injury, ISS, Head injury AIS, emergency department disposition, andtrauma level categorization as a function of initial site of care (i.e., PTCvs. GED). Preliminary analyses to test for group differences betweenPTC and GED patients were also conducted. These included MannWhitney U test for age, a chi-square test for gender, and contingencytables for GCS, mechanism of injury, CSI, ISS, Head Injury AIS,disposition, and trauma level categorization.

To test whether certain factors were associated with use of CSCT,we calculated odds ratios (ORs) and corresponding 95% confidenceintervals (CIs) for the predictor variables using multivariate logisticregression modeling. In the model, we dichotomized age into twocategories: less than 8 years and equal to or greater than 8 years asthis is the age when children become anthropomorphically similar toadults with the cervical spine fulcrum located at the C3–C4 level [23].

Similarly we dichotomized GCS into b12 and 13 or above, a cutofffrequently used to distinguish patients with more mild traumaticbrain injury from those with more moderate to severe injury. ISS andHead Injury AIS were also dichotomized for the purposes of themultivariate regression. Factors tested in the model included age,gender, initial site of care, year, presence of CSI, GCS, ISS, Head InjuryAIS, and trauma triage category. Reference categories were age b 8 -years, male, PTC, year 2011, no CSI, GCS ≥ 13, ISS b15, Head Injury AISb3, and Trauma Level 2. All statistical analyses were performed usingSPSS (SPSS, Inc., Chicago, IL, Version 20.0).

4. Results

During the study period, a total of 5148 Trauma I and II patientswere evaluated at the PTC. Of those patients, 2142 (41.6%) presenteddirectly to the PTC and 3006 (58.4%) were evaluated initially at a GED.The patient characteristics of the two groups are presented in Table 1.The groups were similar with regard to age, gender, and initial GCSupon presentation. Patients evaluated at a GED had a higher medianISS (14 vs. 9, p b 0.05) and median AIS for head and neck injury (3 vs.2, p b 0.05). They were more likely to be admitted to the ICU (44.3%vs. 26.1%, p = 0.001) and have non-accidental trauma as theirmechanism of injury (5.3% vs. 1.4%, p b 0.001). Over the study period,ISS for both PTC and GED patients remained stable.

4.1. Use of radiographic imaging

Over the study period, a total of 15.2% (CI = 14, 16) of patientshad CSR at the GED compared to 76.2% (CI = 74, 78) at the PTC. Theproportion of patients with CSCT at the PTC increased from 3.5% to16.1% (mean 9.6% 95% CI = 8, 11) compared to the GED whereutilization increased from 6.8% to a maximum of 42.0% (mean 22.6%,CI = 25, 28) over the study period. Fig. 1 shows the trend ofutilization of CSCT during the study period. A comparison of PTC andGED patients who underwent CSCT is shown in Table 2. The twogroupswere similar with regard to percent with CSI, median Head AIS,and percent admitted to the ICU. Patients undergoing CSCT whopresented to the PTC tended to be older (median years 11 vs. 8), andhad a lower median ISS (14 vs.16) than those presenting to the GED.

4.2. Rate of CSI

Overall, 120 (2.3%) patients had a cervical spine injury. Totalpercentage of patients with CSI over the study period presenting tothe PTC was 1.4% compared to 2.6% of patients presenting to thereferral GED (p b 0.05). Despite mild fluctuations, overall the

0%

10%

20%

30%

40%

50%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Per

cent

of

pati

ents

wit

h C

SI a

nd C

SCT

Year

GED CSIPTC CSI

GED CSCTPTC CSCT

Fig. 1. Unadjusted rates of patients with C-spine injury and C-spine CT by year andhospital type. PTC = Pediatric Trauma Center; GED = General EmergencyDepartment.

Table 3Comparison of CSI types and outcome between PTC and GED.

Hospital PTC (n = 2142) GED (n = 3006) p

CSI Injury % (n) 1.70 (36) 2.70 (84) 0.03Fracture % (n) 0.61 (13) 1.73 (52) 0.003Ligamentous % (n) 0.32 (7) 0.60 (18) 0.39Cord injury % (n) 0.28 (6) 0.30 (9) 0.77Combination % (n) 0.47 (10) 0.01 (3) 0.26

CSI surgery % (n) 0.91 (20) 1.00 (31) 0.09

Table 4Multivariable Analysis of Factors Associated with CSCT in Pediatric Trauma Patients(pseudo r2: 0.205).

Factor N (%) aOR 95% CI p

Hospital TypeGED 3006 (58.3) 3.56 2.87, 4.40 b0.001PTC (ref.) 2142 (41.7) 1.00

Patient CharacteristicsSex: Female 1295 (36.9) 1.07 0.89, 1.29 0.45Age N 8 years 1553 (44.2) 2.11 1.77, 2.52 b0.001Presence of CSI 68 (1.9) 4.26 2.47, 7.35 b0.001GCS ≤12 866 (24.6) 2.00 1.46, 2.75 b0.001

335K.M. Adelgais et al. / Journal of Pediatric Surgery 49 (2014) 333–337

proportion of patients with CSI remained stable over the study period(Fig. 1). Of those patients with CSI, 78 had fractures, 25 had isolatedligamentous injuries, 15 had isolated cord injuries, and 13 werediagnosed with a combination of injury types. Table 3 compares injurytypes and outcomes between the PTC and the GED. Patientspresenting to the GED were more likely to have a fracture thanpatients at the PTC (p = 0.003). Overall, 51 patients (1.0%) hadoperative treatment for their cervical spine injuries and theproportion of patients undergoing operative management was similarbetween both groups (0.9% vs. 1.0%).

4.3. Factors associated with cervical spine CT

Several factors were found to be associated with use of CSCT in amultivariate analysis (Table 4). Patients who received care at a GEDwere 3.5 times more likely to have a CSCT when controlling forpresence of CSI, age, gender, hospital type, year, ISS, Head Injury AIS,initial GCS, and trauma triage category (95% CI 2.87, 4.40). Otherfactors associated with use of CSCT included presence of CSI, GCS b12,and age ≥ 8 years. The year the patient was evaluated was alsostrongly associated with use of CSCT with a decreased likelihood ofuse of CSCT for all years from 2002 to 2007.

5. Discussion

Trauma is the most common cause of morbidity and mortality inchildren N 1 year of age. The overwhelming majority of pediatrictrauma is blunt in nature. Although CSI is uncommon, a timelyevaluation of the cervical spine is important for any child sustainingblunt traumatic injuries.

We found a substantial increase in the utilization of CSCT to screenfor CSI among pediatric trauma patients evaluated in our referral

Table 2Characteristics of patients with CSCT.

Hospital PTC (n = 206) GED (n = 794)

Patient CharacteristicsAge, median years (IQR) 11 (5, 14) 8 (3, 12)Male % (95% CI) 69.4 (56, 76) 62.9 (56, 66)C-spine Injury % (95% CI) 8.7 (2, 11) 5.9 (3, 7)GCS, median (IQR) 14 (7, 14) 15 (3, 15)Injury Severity Score, median (IQR) 14 (6, 25) 16 (10, 21)Head Injury AIS, median (IQR) 3 (2, 4) 3 (2, 4)Admission to ICU % (95% CI) 48.0 (40, 58) 49.7 (42, 51)Admitted directly to OR % (95% CI) 8.7 (2, 10) 9.6 (7, 13)Trauma 1 Activation % (95% CI) 35.4 (28, 42) 30.2 (27, 33)

ISS N15 1480 (42.1) 1.036 0.83, 1.29 0.74Head Injury AIS ≤3 2047 (58.3) 1.105 0.89, 1.37 0.37

Trauma Triage CategoryTrauma 1 938 (26.7) 1.09 0.79, 1.50 0.60Trauma 2 (ref.) 2576 (73.3) 1.00

Year2002 304 (5.9) 0.05 0.02, 0.18 b0.0012003 389 (7.6) 0.12 0.07, 0.22 b0.0012004 519 (10.1) 0.29 0.18, 0.42 b0.0012005 518 (10.1) 0.35 0.24, 0.52 b0.0012006 562 (10.9) 0.41 0.28, 0.59 b0.0012007 990 (19.2) 0.43 0.30, 0.60 b0.0012008 521 (10.1) 0.82 0.58, 1.17 .282009 528 (10.3) 0.74 0.52, 1.06 .102010 433 (8.4) 0.84 0.58, 1.22 .372011 (ref) 385 (7.5) 1.00

GED’s over a 10-year period, compared to a smaller increase observedfor those presenting to the PTC. This is the first study to specificallyevaluate factors associated with use of CSCT in a population ofpediatric trauma patients.

The rise in use of CT in pediatric patients occurred predominatelyin the last decade. Larson et al. demonstrated an increase in use of CTin non-pediatric specific emergency department visits from 1995 to2008, with an exponential rise after 2002 [24]. Similarly, Blackwell etal. found an increase in the use of head CT among a national sample ofpatients despite no significant change in the rate of patients diagnosedwith head injury. They also found that CT use was more frequent inGED compared to pediatric-specific emergency departments [25]. Inour study, we found a rise in pediatric CSCT use over the study periodat both the PTC and the GEDs. The majority of the rise in CSCT amongGED sites was prior to 2008 at which time it plateaued toapproximately 40%. The use of CSCT increased more notably at thePTC from 2008. Protocol changes in imaging and a more recentpublication from 2007 suggesting the need to measure the atlanto-occipital junction with CT have recently changed the use of CSCT atthe PTC [26]. Despite this, the use of CSCT in GED increased to a muchgreater extent and plateaued at a higher rate than that at the PTC,despite a constant rate of observed CSI in our study population overthe decade.

Use of CSCT has been on the rise in other regions as well. Broder etal. noted a 344% increase in use of CSCT within their own institutionfrom 2000 to 2006 [27]. Mannix et al. examined hospital and patientcharacteristics and found that in their region, pediatric patientsevaluated at general hospitals compared to the PTC were two timesmore likely to have a CSCT [26]. That study was limited to lower acuitypatients that were discharged to home from the ED. We found that

336 K.M. Adelgais et al. / Journal of Pediatric Surgery 49 (2014) 333–337

although CSCT was associated with the presence of CSI, it was notindependently associated with ISS and Head Injury AIS.

We found other factors associated with increased use of CSCT inour study. Children 8 years and older were 1.5 times more likely tohave a CSCT than younger children. Other studies have found similarincreases in use of CSCT among older children and adolescents.However one study also found increased CSCT use in the very young,particularly among patients seen in non-pediatric specific facilities[27,29]. Our study was limited to patients entered into our pediatrictrauma registry and we could not compare use of CSCT among adultsas site specific CT use is not currently tracked in our state traumaregistry [30].

Current pediatric trauma recommendations indicate that thecervical spine should be initially screened with plain radiographyand that CSCT should be used only to evaluate areas of concern [10–12]. In our study, only 5.9% of patients who were evaluated at the GEDwith CSCT also had plain radiography. In the majority of cases, a CSCTwas the only cervical spine imaging obtained during their evaluation.In contrast, 42.2% of patients evaluated at the PTC had CSR obtained inassociation with their CSCT.

The majority of pediatric patients are cared for in non-pediatricfacilities where pediatric protocolsmay not be available. Studies in theliterature have found differences in the way patients are cared for byphysicians with special training in pediatric emergency care [31–33].To date, there are multiple studies suggesting that the use of CSCT inadult blunt trauma patients is more cost-effective and timelycompared to plain radiographs, especially if that patient has in-dications for cranial CT [6,7]. For this reason, certain centersdeveloped trauma protocols to screen the head and the cervicalspine simultaneously [7,34]. In pediatric patients, where the risk ofcervical spine injury is approximately 1%, plain films have a sensitivityof 90% or greater in identifying CSI and the additional yield of CSCT islow and not necessarily more timely [15,35,36].

Despite this, the use of CT to evaluate the pediatric patient hasincreased with notable implications [36,37]. Exposure to ionizingradiation in younger patients increases their lifetime risk of fatalmalignancy [20,21]. The exposure of the cervical spine to ionizingradiation has particular risk for the thyroid gland. Current estimates ofthyroid cancer from ionizing radiation suggest that the risk isincreased even down to levels of 4–10 cGy [38,39]. Doses of ionizingradiation from CSCT are approximately 5 cGy compared to amaximum of 0.0006 cGy from CSXR (a 4-view radiograph series)[18,19]. Pediatric patients evaluated at non-pediatric specific facilitiescompared to pediatric specific facilities may be exposed to higherdoses as well [16,17,24]. In the era of As Low As ReasonablyAchievable (ALARA), current data suggest only that pediatric-specificfacilities are making changes in CT imaging algorithms to reduce dose,however, there are no studies to date that show a difference in actualradiation dose in CSCT [40]. With the development of predictivemodels of CSI in pediatric trauma patients, we can better targetappropriate imaging strategies and keep to ALARA principles toreduce radiation exposure in children [41].

This study has certain limitations. First, our study was subject toreferral bias as our analysis was limited to a population of pediatrictrauma patients ultimately cared for at the PTC. We are unable tomake conclusions regarding patients that were discharged home fromoutside facilities, yet another study demonstrated the CSCT rateremained higher in low acuity patients evaluated at GEDs comparedto the PTC [28]. Also, there may be a lower ascertainment of thenumber of plain films obtained at the outside facilities. The standardof care for transferred patients is to send radiographs and medicalrecords along with the patient, but we cannot be certain that a highernumber of cervical spine plain films were obtained and nottransferred.

We classified patients in the analysis who were transferredwithout a CSCT and subsequently had a study performed at the PTC

as not having a CSCT to reflect the practice at the institution doing theprimary evaluation. Although this would result in selection bias byunderestimating the use of CSCT at the PTC, the total number of thesepatients is small, 2.3% (138) of the entire study population.

Lastly, we did not capture indications for imaging. Although wenote a higher use of CSCT among patients with CSI, we do not knowthe frequency of reported neck tenderness or physical exam findingsamong those patients who had CSCT. There was an increase in useamong patients with a lower GCS suggesting use of CSCT to imagepatients with altered mental status.

6. Conclusion

Despite a stable rate of CSI between 2002 and 2011, usage of CSCTincreased six-fold among pediatric trauma patients initially evaluatedat referral hospitals while the rate of CSCT remained relatively low atthe pediatric trauma center. This trend is noted even after adjustingfor several hospital and patient specific characteristics. Themajority ofpediatric patients are evaluated at GEDs and as a result, higher rates ofCSCT pose a risk of ionizing radiation exposure affecting patient safety.Targeted education on current existing recommendations on thedirected use of CSCT for the evaluation of the cervical spine in childrenmay hopefully result in a similar trend of decreased use of CT as thatseen in the evaluation of closed head injury [42]. Current AmericanAcademy of Pediatrics and American College of Emergency Physicianguidelines for pediatric patients in the ED setting recommendreducing radiation exposure using ALARA principles [43]. Collabora-tion to develop pediatric specific imaging protocols may furtherreduce use of unnecessary CT among pediatric trauma patients.

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