[size=6]An 8-year-old child was struck by a car yesterday and has a GCS of 7 with bilateral intraparenchymal hemorrhages on head CT. A concurrent cervical spine CT showed no evidence of injury. The most appropriate next step in management of the cervical spine is:

 

a Flexion-extension imaging

 

b Discontinue cervical spine precautions

 

c Clinical exam when GCS improves

 

d MRI[/size]

D

D

D

[size=6]An 8-year-old child was struck by a car yesterday and has a GCS of 7 with bilateral intraparenchymal hemorrhages on head CT. A concurrent cervical spine CT showed no evidence of injury. The most appropriate next step in management of the cervical spine is:

 

a Flexion-extension imaging

 

b Discontinue cervical spine precautions

 

c Clinical exam when GCS improves

 

d MRI[/size]

C

correct answer

b Discontinue cervical spine precautions

 

The currently accepted management of children who are obtunded due to blunt trauma includes

 

MRI of the cervical spine. Although the sensitivity of CT for significant cervical spine injury in adults is 98.5%, the elevated risk for ligamentous injury and the paucity of data regarding the dependability of CT in children has prompted most pediatric clinicians to obtain an MRI to clear the cervical spine when a reliable clinical exam is not available. A recent large, multi-center retrospective study by Russell, et al. as well as a prospective study from 72 hospitals in which almost 13,000 CTs were evaluated, found that the sensitivity of CT for injuries that required operative fixation or halo placement was 98.7%. However, reliance on CT for spine clearance depends upon interpretation by a radiologist with expertise in pediatric trauma imaging.

 

Leaving this patient in a cervical collar until their mental status is improved, or even until deemed stable for an MRI, could result in pressure injury. Flexion-extension imaging is not appropriate, particularly in an obtunded patient.