Cervical spine injury (CSI) is a very uncommon event in

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1 ORIGINAL ARTICLE Variability of Prehospital Spinal Immobilization in Children at Risk for Cervical Spine Injury Emily G. Kim, MPH,* Kathleen M. Brown, MD,Þ Julie C. Leonard, MD, MPH,þ David M. Jaffe, MD,þ Cody S. Olsen, MS, and Nathan Kuppermann, MD, MPH,* for the C-Spine Study Group of the Pediatric Emergency Care Applied Research Network (PECARN) Objective: This study aimed to compare prehospital spinal immobilization techniques applied to age-based cohorts of children with and without cervical spine injury (CSI) after blunt trauma. Methods: We compared prehospital spinal immobilization in 3 agebased cohorts of children with blunt trauma-related CSI transported to 1 of 17 participating hospitals. We also compared children younger than 2 years with CSI with those at risk for but without CSI after blunt trauma. We identified patients through query of billing and radiology databases. We compared immobilization methods using Fisher s exact test for homogeneity. Results: We identified 16 children younger than 2 years, 78 children 2 to 7 years old, and 221 children 8 to 15 years old with CSI, and 66 children younger than 2 years without CSI. There were no significant differences in spinal immobilization techniques applied to children younger than 2 years old with and without CSI (P = 0.34). Of the 82 children younger than 2 years, 34 (41%) were fully immobilized in a cervical collar and rigid long board. There was a significant difference between spinal immobilization techniques applied to children with CSI younger than2yearsand8to15yearsold(p G 0.01). Six (38%) children with CSI younger than 2 years were fully immobilized versus 49 (63%) children 2 to 7 years old and 175 (79%) children 8 to 15 years old. Conclusions: In this retrospective, observational study involving several emergency departments and Emergency Medical Services systems, we found that full spinal immobilization is inconsistently applied to children younger than 2 years after blunt trauma regardless of the presence of CSI. Full spinal immobilization is applied more consistently to older children with CSI. Key Words: spinal cord, injury, trauma (Pediatr Emer Care 2013;29: 413Y418) From the *Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA; Division of Emergency Medicine, Department of Pediatrics, George Washington University School of Medicine, Washington, DC; Division of Emergency Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO; Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT; and Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA. Disclosure: The authors declare no conflict of interest. Reprints: Nathan Kuppermann, MD, MPH, Department of Emergency Medicine, UC Davis Medical Center, 4150 V St, PSSB Suite 2100, Sacramento, CA ( nkuppermann@ucdavis.edu). This work was supported by grant 1H34MC from the Health Resources and Services Administration/Maternal and Child Health Bureau (HRSA/MCHB) and the Emergency Medical Services for Children (EMSC) Program. PECARN is supported by the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), Emergency Medical Services for Children (EMSC) Program through the following cooperative agreements: U03MC00001, U03MC00003, U03MC00006, U03MC00007, and U03MC00008, U03MC22684, U03MC22685 Copyright * 2013 by Lippincott Williams & Wilkins ISSN: Cervical spine injury (CSI) is a very uncommon event in children, occurring in less than 1% of children evaluated for trauma. 1Y9 Despite the low likelihood of CSI in children, when such injuries occur, they are more likely to result in death or severe disability owing to the greater frequency of high CSI compared with adults. 4,6Y12 It is unknown whether spinal immobilization is protective against neurological injury after trauma. 13,14 According to the Cochrane Collaborationi, the effect of spinal immobilization on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. 14 Our best available guidance comes then from expert opinion, which recommends immobilization of trauma patients to protect the cervical spine. 15,16 Although there is insufficient evidence to support specific treatment standards, recommendations published by the Congress of Neurological Surgeons in 2002 call for spinal immobilization of all patients in the presence of either suspicion of a CSI or a mechanism with the potential to cause CSI. 15 Other experts have supported immobilization of injured children after blunt trauma. 3,11,13,17 The Congress of Neurological Surgeons recommendations suggest the use of a cervical collar and backboard for the transportation of children at nonnegligible risk of CSI after trauma. 18 Use of either thoracic elevation or an occipital recess to bring the pediatric spine into better neutral alignment has also been suggested. 19,20 Despite the existence of expert recommendations, the application of spinal immobilization equipment in children at risk for CSI is highly variable and often incomplete. 13,21,22 Children younger than 2 years are particularly vulnerable and understudied. These very young children are at risk for severe high-cervical-level injuries 7Y11 and are also less able to communicate physical symptoms or signs of injury. 1 The purpose of this study was to describe prehospital spinal immobilization techniques in a large retrospective cohort of children younger than 2 years with blunt trauma undergoing emergency department (ED) evaluation for CSI and also to compare immobilization of children younger than 2 years with CSI with older children with CSI. METHODS Study Design The current study was a subanalysis of a large retrospective, case-control study of children younger than 16 years and at risk for CSI. 23 The original study followed the guidelines for retrospective chart review studies as outlined by Gilbert et al. 24 All participating centers and the Data Coordinating Center received institutional review board approval to conduct this retrospective study with waiver of written informed consent. Study Setting and Population Children presenting to any of 17 EDs in the Pediatric Emergency Care Applied Research Network (PECARN) 25 after Pediatric Emergency Care & Volume 29, Number 4, April

2 Kim et al Pediatric Emergency Care & Volume 29, Number 4, April 2013 blunt trauma from January 1, 2000, to December 31, 2004, who received cervical spine radiography were eligible for inclusion in the main study. 23 In that study, potential CSI cases were children younger than 16 years with blunt trauma-related CSI identified through query of billing systems for the International Classification of Diseases, Ninth Revision, codes indicating CSI. These codes encompass children with injuries to the cervical vertebrae, ligaments, or spinal cord and children with spinal cord injury without radiographic abnormalities. Children evaluated for trauma-related injuries with current procedural terminology codes for cervical spine radiography but without the International Classification of Diseases, Ninth Revision, codes for CSI were identified as potential non-csi controls. CSI cases were randomly matched to non-csi controls presenting to the same ED within 1 year. Presence or absence of CSI was confirmed by chart review and verified by the study principal investigator and the study neurosurgeon. All chart reviews were conducted by trained research coordinators at each site, with all data abstraction verified by physician site investigator review. For this subanalysis, we compared children younger than 2 years with CSI to randomly matched controls younger than 2 years (without CSI). Two years was used as the age cutoff for the youngest cohort based on standards in spinal immobilization equipment which identify 2 years and younger as a size group. 26 We also compared the children younger than 2 years with CSI to cohorts of children with CSI 2 to 7 years old and 8 to 15 years old. We chose these age groups based on known differences in developmental anatomy and physiology that we hypothesize may affect the application of spinal immobilization. 1,3 We excluded children not transported from the field by an Emergency Medical Services agency and those for whom specific mechanism(s) of spinal immobilization were not documented in the medical record. Study Protocol We abstracted descriptive information including injury mechanisms, relevant clinical variables (Glasgow Coma Scale [GCS] scores, substantial injury to head, substantial injury to torso), and neurological outcome at discharge. We sorted injury mechanisms into the following categories: occupant in a motor vehicle collision; fall; blunt injury to head/neck; diving injury; sports injury; pedestrian struck by moving vehicle; and other. We created a source hierarchy for collection of prehospital spinal immobilization data. Whenever possible, we relied on immobilization techniques documented in the original EMS record. If immobilization was not documented in the EMS record, we relied on the medical record of the first ED to which the patient presented (whether that ED was the study site or a referring hospital ED). We abstracted only those data describing immobilization techniques applied before arrival at the first ED (prehospital immobilization). If data from one source conflicted with another, we relied on the data from the first source temporally. The frequency of full spinal immobilization was compared with other immobilization and no immobilization in statistical analyses. We defined full spinal immobilization as immobilization with a rigid long board and cervical collar as per the published recommendations. 18 Other immobilization was further classified for descriptive analyses into: rigid long board only, cervical collar only, and other (such as car seat or towel rolls). Data Analysis We used Fisher s exact tests of homogeneity to compare the use of prehospital immobilization techniques (full immobilization, other immobilization, or none) for the cohort of children younger than 2 years with CSI to 3 comparison groups separately: (1) children younger than 2 years without CSI, (2) children 2 to 7 years old with CSI, and (3) children 8 to 15 years old with CSI. All tests were 2 tailed, and P G 0.05 was considered significant. We used SAS/STAT software for all analyses (version 9.2; SAS Institute Inc, Cary, NC). RESULTS Study Population The main study identified 540 children with CSI and 1060 randomly selected children evaluated for but not found to have CSI (Fig. 1). This subanalysis included the subset of children with CSI younger than 2 years (n = 27), those children with CSI 2 to 7 years old (n = 140), those children with CSI 8 to 15 years old (n = 373), and those without CSI younger than 2 years (n = 116). Of those children meeting inclusion criteria, 222 children were not transported from the field by EMS and were therefore not included in this analysis. We excluded 53 children because presence or absence of spinal immobilization was not documented or the specific mechanisms of spinal immobilization were not documented. Therefore, our analysis included 16 children with CSI younger than 2 years old, 78 with CSI 2 to 7 years old, 221 with CSI 8 to 15 years old, and 66 children without CSI younger than 2 years. FIGURE 1. Identification of the study population * 2013 Lippincott Williams & Wilkins

3 Pediatric Emergency Care & Volume 29, Number 4, April 2013 Spinal Immobilization in Children at Risk for CSI TABLE 1. Patient Characteristics: Injury Mechanisms, Clinical Variables, and Outcomes* With CSI G 2 Years Old(n=16) Without CSI G 2 Years Old(n=66) With CSI 2Y7 Years Old (n = 78) With CSI 8Y15 Years Old(n=221) Injury mechanism, n (%) Occupant in motor vehicle collision 12 (75) 15 (23) 44 (56) 71 (32) Falls 3 (19) 36 (55) 14 (18) 29 (13) Blunt injury to the head/neck 0 (0) 6 (9) 1 (1) 5 (2) Diving injury 0 (0) 0 (0) 0 (0) 14 (6) Sports injury 0 (0) 1 (2) 1 (1) 44 (20) Pedestrian hit by moving vehicle 1 (6) 3 (5) 13 (17) 18 (8) Other 0 (0) 5 (8) 5 (6) 40 (18) Clinical variables Median GCS score (25th and 75th percentiles) 10 (3, 13) 15 (14, 15) 12 (3, 15) 15 (14, 15) Substantial head injury, n (%) 7 (44) 8 (12) 26 (34) 41 (19) Substantial torso injury, n (%) 2 (13) 1 (2) 16 (21) 23 (11) Outcomes, n (%) Death 6 (38) 0 (0) 17 (22) 10 (5) Persistent neurological deficit 5 (31) 1 (2) 22 (28) 56 (25) Normal 5 (31) 65 (98) 39 (50) 155 (70) *Percentages, medians, and percentiles are calculated from patients with nonmissing data for the finding. Patient Characteristics Injury mechanisms, clinical variables, and outcomes for the 4 comparison groups are presented in Table 1. Most of the children (75%) with CSI younger than 2 years were injured while occupants in motor vehicle collisions. This mechanism of injury was found in 56% and 32% of the children with CSI 2 to 7 years old and 8 to 15 years old, respectively, and 23% of children without CSI younger than 2 years. Falls represented a large portion of the injuries in all groups but particularly among children without CSI younger than 2 years. A number of children 8 to 15 years old sustained CSI by other mechanisms or during sports-related activities, whereas no children with CSI younger than 2 years reported these injury mechanisms. Children with CSI younger than 2 years had lower median GCS scores and sustained substantial injuries to the head more frequently compared with each comparison group. Although a similar percentage of children with CSI in each age group experienced persistent neurological deficits, a much larger percentage of children with FIGURE 2. Rate of spinal immobilization method applied by age for children with CSI. Rates are shown as proportions of each age group; 95% confidence intervals are shown for the rate of full immobilization. * 2013 Lippincott Williams & Wilkins 415

4 Kim et al Pediatric Emergency Care & Volume 29, Number 4, April 2013 TABLE 2. Spinal Immobilization Techniques Technique, n (%) With CSI G 2 Years Old (n = 16) Without CSI G 2 Years Old (n = 66) With CSI 2Y7 Years Old (n = 78) With CSI 8Y15 Years Old (n = 221) Full immobilization 6 (38) 28 (42) 49 (63) 175 (79) None 4 (25) 7 (11) 9 (12) 22 (10) Other immobilization 6 (38) 31 (47) 20 (26) 24 (11) Cervical collar only 2 (13) 9 (14) 4 (5) 8 (4) Rigid long board only 4 (25) 17 (26) 14 (18) 13 (6) Other 0 (0) 5 (8) 2 (3) 3 (1) P* Reference G0.01 *Fisher s exact test P value comparing the 3 categories of immobilization (full/none/other) observed in patients with CSI younger than 2 years to each of the other 3 cohorts individually. CSI younger than 2 years died (38% compared with 22% of children 2Y7 years old and 5% of children 8Y15 years old). Cervical Spine Immobilization Techniques Figure 2 shows the type of spinal immobilization method applied by age for those children with CSI. The rate of full spinal immobilization increased with age, peaking between the ages 8 and 15 years, although no age group uniformly received full spinal immobilization. The rates of no or partial spinal immobilization decreased with age. Children with CSI who were younger than 2 years received no or partial immobilization most frequently. The group of children 2 to 7 years old had the most variation, with increasing rates of full spinal immobilization and decreasing rates of other and no immobilization in the older children. Table 2 describes the distribution of prehospital spinal immobilization techniques applied by study cohort. There were no significant differences in the methods of spinal immobilization applied to children with CSI younger than 2 years when compared with either children without CSI younger than 2 years or children with CSI 2 to 7 years old. There was, however, a significant difference between the spinal immobilization techniques applied to children with CSI younger than 2 years and children with CSI 8 to 15 years old. The youngest children with CSI were less likely to receive full spinal immobilization compared with the oldest children with CSI. Of note, of the 6 children with CSI younger than 2 years who died, only 1 received no spinal immobilization compared with 3 of the 10 children with CSI younger than 2 years who lived. DISCUSSION In this study, we describe spinal immobilization in children at risk for CSI after blunt trauma and demonstrate great variability in the application of spinal immobilization between age groups. Older children with CSI had more uniform application of full spinal immobilization. This highlights the need for improved evidence to guide the prehospital management of children at risk for CSI and then application of evidence-based protocols for spinal immobilization of the youngest trauma victims. Our results support the findings of one study, which described the immobilization techniques of 60 pediatric patients at risk for CSI after blunt trauma during an 18-month period. 22 Of the 54 patients who were transported by EMS in that study, 15% were not immobilized. Patients who were not immobilized were younger than those children who were immobilized, with a median age of 1.5 years. Among the possible reasons for this, authors mentioned a perceived lack of options for immobilizing infants. 22 In our cohort of 82 children younger than 2 years, both with and without documented CSI, fewer than half received full spinal immobilization. Furthermore, one quarter of the children younger than 2 years with documented CSI were not immobilized at all. The frequent failure to fully immobilize children younger than 2 years is concerning and warrants further exploration. Recommendations of the Congress of Neurological Surgeons call for the use of a cervical collar, backboard, and straps to immobilize pediatric trauma patients at risk for CSI. 18 Our data indicate that prehospital providers are adhering to these recommendations more commonly for older children than for younger children. It is unclear whether this is due to the lack of evidence regarding the efficacy of spinal immobilization 14 or possibly due to the perception of limited options for immobilizing young children. 22 The difficulty of achieving neutral alignment when applying spinal immobilization to pediatric patients is well documented. 13,19Y21,27 An early study found that cervical collars alone did not achieve neutral alignment in pediatric mannequins. 21 The combination of a cervical collar and rigid backboard better reduced motion in that study. 21 Another study of lateral radiographs of children with and without CSI demonstrated that use of the standard backboard did not achieve neutral position. 20 The authors suggest using a modified backboard with an occipital recess or padding under the thorax to achieve safer alignment of the cervical spine. 20 Similarly, other investigators found that immobilized children younger than 8 years required back elevation to achieve neutral position; a standard backboard, with or without a cervical collar, did not eliminate flexion in most children in their studies. 19,27 Because there is little evidence substantiating the efficacy of spinal immobilization in children or the best method for spinal immobilization in children, it is possible that EMS agencies are following independently developed and variable transport protocols. This may be a cause of variability in spinal immobilization of children as demonstrated in our study. Variability in the application of spinal immobilization in children younger than 2 years may also reflect EMS discomfort with the youngest children in general. Children younger than 2 years are also unable to describe physical signs and symptoms of CSI. 1 Therefore, it is possible that EMS providers are less able to evaluate younger children at risk for a CSI. Although there are currently no validated screening criteria for CSI in children, several studies indicate that there are mechanisms of injury and clinical findings that could be used to screen younger children. 3,23,28 Among the factors associated with CSI in children after blunt trauma are high-risk motor vehicle collision 28 and altered mental status. 23,28 In our study, most of the younger children sustained CSI while occupants in motor vehicle collisions, * 2013 Lippincott Williams & Wilkins

5 Pediatric Emergency Care & Volume 29, Number 4, April 2013 Spinal Immobilization in Children at Risk for CSI a mechanism of injury found in a smaller proportion of the older cases. This is consistent with previous studies. 2,9,10,12 Also consistent with previous studies, the younger children with CSI frequently had signs of significant head injury and depressed mental status. Our data therefore indicate that younger children with CSI commonly meet criteria identified by the literature as risk factors for CSI, yet are inconsistently immobilized. Investigators have demonstrated anatomical differences in younger children, which make them more vulnerable to injuries of the upper cervical spine. 1,6,9,11 As a consequence of their spinal injury patterns, younger children experience higher mortality rates than do older children or adults. 1,2,6,10 In our study, a similar percentage of children with CSI in each age group experienced persistent neurological deficits, 2 but a larger percentage of children with CSI younger than 2 years died (more than one third of children with CSI G2 years old). The higher mortality rate among the youngest children with CSI and greater difficulty in assessing preverbal children suggest that children younger than 2 years at risk for CSI may stand to benefit the most from careful and informed management in the prehospital setting. Limitations This study has several limitations. It is possible that prehospital spinal immobilization techniques were determined by EMS agency-specific transport protocols. We did not collect or compare transport protocols from EMS agencies serving the hospitals involved in this study. However, the significant variability in spinal immobilization of children with CSI between age groups in our study would suggest underimmobilization of children younger than 2 years occurs across EMS systems. Prehospital transport practices may also have changed since the time that data for this study were gathered. However, we are not aware of any recent literature that suggests this is the case. As a subanalysis of a retrospective chart review, we were limited at times by missing and/or unclear documentation of the time and method(s) of cervical spine immobilization. Details of immobilization technique were missing in 12% of included children brought from the field by EMS, most often owing to EMS documentation being unavailable (50 of 53 excluded cases). Review of the data did not reveal differences in age classifications or comorbid injuries for children excluded owing to missing immobilization details (compared with children included in the analysis). Among patients excluded owing to lack of EMS documentation, those with normal outcomes were missing details of immobilization technique slightly more often than patients who died (10% vs 8%) and less often than those with persistent neurological deficits (10% vs 20%). The reasons for these differences are unclear. Furthermore, our study population did not include all children who arrived to the ED in spinal precautions; rather, only those judged by the ED clinician to be at greater risk for CSI (and who therefore received imaging). These patients were specifically targeted, however, because they are the patients who pose the greatest clinical conundrum for ED clinicians. Available data sometimes conflicted between sources (the EMS prehospital record vs the hospital ED record). To resolve discrepancies, we created a source hierarchy that relied on data from EMS records first to best identify the information pertaining to immobilization techniques applied in the prehospital setting. Our data indicate that full spinal immobilization is less commonly applied to children younger than 2 years, although it is not apparent why this is the case. Finally, although this is the largest study to date of children with CSI younger than 2 years, there were still relatively few children younger than 2 years. Therefore, our ability to generalize the results in this age group is somewhat limited. We were able to demonstrate similar findings among controls younger than 2 years, however, further substantiating our results. CONCLUSIONS Prehospital spinal immobilization is applied inconsistently to children at risk for CSI, particularly those younger than 2 years. It is imperative that we investigate why spinal immobilization is inconsistently applied in the prehospital setting among children at risk for CSI. In addition, further research is needed to identify the superior screening criteria and techniques for spinal immobilization of young children after blunt trauma. ACKNOWLEDGMENTS Participating centers and site investigators are listed in alphabetical order: &Boston Children s Hospital Boston, MA Lise Nigrovic, MD, MPH &State University of New York, Buffalo Buffalo, NY Kathleen Lillis, MD &Children s Hospital of Michigan Detroit, MI Curt Stankovic, MD Prashant Mahajan, MD, MPH &Children s Hospital of Philadelphia Philadelphia, PA Aaron Donoghue, MD &Children s National Medical Center Washington, DC Kathleen Brown, MD &Cincinnati Children s Hospital Medical Center Cincinnati, OH Scott Reeves, MD &DeVos Children s Hospital/Spectrum Health Grand Rapids, MI John Hoyle, MD &Hurley Medical Center Flint, MI Dominic Borgialli, DO, MPH &Johns Hopkins Medical Center Baltimore, MD Jennifer Anders, MD &Medical College of Wisconsin and Children s Hospital of Wisconsin Milwaukee, WI Greg Rebella, MD &Chicago Memorial/ Northwestern Chicago, IL Elizabeth Powell, MD &Primary Children s Medical Center Salt Lake City, UT Kathleen Adelgais, MD &UC Davis Medical Center Sacramento, CA Nathan Kuppermann, MD, MPH Emily Kim, MPH &University of Michigan Ann Arbor, MI Alexander Rogers, MD &University of Rochester Medical Center Rochester, NY Lynn Cimpello, MD &University of Maryland * 2013 Lippincott Williams & Wilkins 417

6 Kim et al Pediatric Emergency Care & Volume 29, Number 4, April 2013 Baltimore, MD Getachew Teshome, MD &Washington University and St. Louis Children s Hospital St. Louis, MO Julie C. Leonard, MD, MPH David Jaffe, MD &Central Data Management and Coordinating Center University of Utah Salt Lake City, UT Cody Olsen, MS Richard Holubkov, PhD J. Michael Dean, MD, MBA PECARN Steering Committee members include the following: N. Kuppermann, chair; E. Alpern, D. Borgialli, K. Brown, J. Chamberlain, J. M. Dean, G. Foltin, M. Gerardi, M. Gorelick, J. Hoyle, D. Jaffe, C. Johns, K. Lillis, P. Mahajan, R. Maio, S. Miller (deceased), D. Monroe, R. Ruddy, R. Stanley, M. Tunik, and A. Walker. MCHB/EMSC liaisons include the following: D. Kavanaugh and H. Park. Members of the Central Data Management and Coordinating Center (CDMCC) include the following: J.M. Dean, R. Holubkov, S. Knight, A. Donaldson, and S. Zuspan Feasibility and Budget Subcommittee (FABS) members include the following: T. Singh, chair; A. Drongowski, L. Fukushima, M. Shults, J. Suhajda, M. Tunik, and S. Zuspan. Grants and Publications Subcommittee (GAPS) members include the following: M. Gorelick, chair; E. Alpern, G. Foltin, R. Holubov, J. Joseph, S. Miller (deceased), F. Moler, O. Soldes, and S. Teach. Protocol Concept Review and Development Subcommittee (PCRADS) members include the following: D. Jaffe, chair; A. Cooper, J. M. Dean, C. Johns, R. Kanter, R. Maio, N. C. Mann, D. Monroe, K. Shaw, and D. Treloar. Quality Assurance Subcommittee (QAS) members include the following: R. Stanley, chair; D. Alexander, J. Burr, M. Gerardi, R. Holubkov, K. Lillis, R. Ruddy, M. Shults, and A. Walker. Safety and Regulatory Affairs Subcommittee (SRAS) members include the following: W. Schalick, chair; J. Brennan, J. Burr, J. M. Dean, J. Hoyle, R. Ruddy, T. Singh, D. Snowdon, and J. Wright. REFERENCES 1. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. 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