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Developing a clinical algorithm for early management of cervical spine injury in child trauma victims
ORIGINAL CONTRIBUTION cervical spine, injury, management; radiograph, cervical spine, algorithm; trauma, cervical spine, child
Developing a Clinical Algorithm for Early Management of Cervical Spine Injury in Child Trauma Victims To define a subset of injured children for whom emergency cervical spine radiography m a y be unnecessary, we performed a retrospective chart and radiologic review. Two entry methods were used: 1) All injured children, from birth through 16 years, who had received cervical spine radiographs at The Children's Memorial Hospital from September 1983, to September 1984, were included. 2) All patients from birth to 16 years with proven or suspected cases of cervical spine injury who had received cervical spine radiographs and who had been treated at either the Children's Memorial Hospital or the Northwestern University Spine Trauma Unit during period 1974 to 1984 also were included. Each child's chart was reviewed, and 84 clinical variables were recorded. All radiographs were reviewed by a pediatric neuroradiologist. Of 206 children studied, 59 had cervical spine injuries. A clinical algorithm was derived using the following eight variables: neck pain; neck tenderness; limitation of neck mobility; history of trauma to the neck; and abnormalities of reflexes, strength, sensation, or mental status. The following decision rule was selected: Positive findings in any of these eight variables mandates cervical spine radiography. This algorithm correctly identified 58 of 59 children with cervical spine injury, yielding a sensitivity of 98% and specificity of 54%. Cervical spine radiographs could have been avoided in 79 children (38% of the entire sample). This algorithm performed better than did models derived from logistic regression analysis of the same data. Validation trials are required prior to the implementation of this or other clinical decision algorithms in practice. [Jaffe DM, Binns H, Radkowski MA, Barthel MJ, Engelhard HH Ill: Developing a clinical algorithm for early management of cervical spine injury in child trauma victims. Ann Emerg Med March 1987;16:270-276.]
David M Jaffe, MD* Helen Binns, MD* Mary Ann Radkowski, MD1Martha J Barthel, RN, MSN* Herbert H Engelhard ltl, MD1 Chicago, illinois From the Departments of Pediatrics,* Radiology,t and SurgeryJ The Children's Memorial Hospital, Northwestern University Medical School, Chicago, Illinois. Received for publication May 28, 1985. Revision received September 8, 1986. Accepted for publication October 20, 1986. Presented at the University Association for Emergency Medicine Annual Meeting in Kansas City, Missouri, May 1985. Address for reprints: David M Jaffe, MD, Department of Pediatrics, The Children's Memorial Hospital, 2300 Children's Plaza, Chicago, Illinois 60614.
INTRODUCTION The emergency physician commonly faces the problem of performing safe yet thorough evaluations of children who have suffered head trauma or multiple trauma. It is often routine to immobilize the neck and to obtain cervical spine radiographs on every child trauma victim. At times, however, cervical spine immobilization and radiography interfere with expedient management and contribute unnecessarily to the discomfort and cost experienced by children and their families. Cervical spine injuries in children are rare. The incidence increases with age, 1 and it is estimated that only 1% to 4% of all spine injuries among survivors occur in the pediatric age g r o u p . 2-5 The emergency medicine literature contains conflicting recommendations about optimal cervical spine management of injured patients. Williams et al 6 reported that 13 of 50 patients with cervical spine fractures were not diagnosed during their initial evaluations. The recommended obtaining a lateral cervical spine radiograph for "all victims of high-speed vehicular accidents; all multiply traumatized patients; all traumatized patients with head injury or altered sensorium; all patients who have fallen from heights, including those with diving injuries; all who injure their shoulders, neck or head in contact sports; and, of course, all trauma victims who complain of neck pain or neuropathy." On the other hand, Fischer7 failed to find any cases of cervical spine injury in a mixed pediatric and adult sample of 333 awake patients who sustained 16:3 March 1987
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CERVICAL SPINE INJURY ALGORITHM Jaffe et al
FIGURE 1. Relationship between age and level of cervical spine injury. N = 58 patients with bony cervical spine injury. head trauma but had no neck symptoms or signs. He concluded that "alert p a t i e n t s . . , without signs or symptoms of cervical injury do not require cervical radiographic evaluation." A recent unpublished abstract delineated two clinical situations mandating cervical spine radiographs in injured children: any injured child with neck pain, and any car crash victim with head injury, In absence of these situations, they suggested that cervical spine radiography may be unnecessary. 8 Further study of spine injuries in children is required to provide adequate guidance for safe, humane, efficient, and cost-effective e m e r g e n c y neck management. The purpose of our study was to develop a set of clinical criteria for predicting the presence of cervical spine injury a m o n g child t r a u m a victims and to identify a group of children for w h o m , after careful clinical assessment, cervical radiographic study might be eliminated safely.
METHODS Two methods were used to select children for study. All child trauma victims evaluated at the Children's Memorial Hospital from September 1983, to September 1984, whose ages ranged f r o m birth t h r o u g h 16 years and w h o had cervical spine radiographs were eligible. Cases were identified by selecting all children w h o were billed for cervical spine radiographs as indicated on Department of Radiology logs for the 12-month study period. Because this sample of 139 patients yielded only one child with a cervical spine injury, a second method was used to increase the n u m b e r of cases of true cervical spine injury. All children, ages birth through 16 years, with cervical spine injury treated at either the Children's Memorial Hospital or the N o r t h w e s t e r n University Spine Trauma Unit during the tenyear period 1974 to 1984 were included. The medical records at both institutions were identified by either admission or discharge diagnoses of cervical spine fracture, cervical spinal cord injury, or rule-out cervical fracture or cord injury. Patients w i t h m i s s i n g charts or inadequate or missing radio58/271
40 oo 35 Fzi,i 30
i
B
D
2s i, 0
HIGH (CI-C3)
B
~ ' ~ LOW (C4-C7)
20
m
m 10 z
5
1
1
r ]L
0-3
4-12
1
1.3-16
AGE GROUPS (YEARS) graphs were excluded from analysis. Cases obtained from both sampling methods were combined for analysis. All radiographs were reviewed by a pediatric neuroradiologist. Cervical injuries were classified as either high or low. Injuries of cervical vertebrae 1 through 3 were designated as high; injuries of cervical vertebrae 4 through 7 were low. If C4 was involved along with higher-level vertebrae, however, the injury was classified as high. Each child's chart was reviewed, and 84 variables describing demographic information, circumstances of injury, and clinical information obtained at the t i m e of e x a m i n a t i o n were recorded. When children had been evaluated at other hospitals prior to transfer to one of the two study hospitals, the earliest recorded examination was used to obtain clinical data. Categorical data were crosstabulated and evaluated w i t h the chisquare statistic. 9 Continuous variables were analyzed using Student's t test. 10 Models derived from logistic regression analysis H were compared to the algorithm derived from chi-square associations and clinical analysis. For the logistic regressions models, missing data were coded as abnormal if any of the measured variables for the p a t i e n t were a b n o r m a l . All o t h e r missing values were coded as normal. Sensitivity, specificity, and percent 'expendable' radiographs were calculated for both model types. 12
identified. Nineteen were excluded because their radiographs could not be located, four because their radiographs were inadequate in quality, and three because the medical records could not be located. The final study sample consisted of 206 children. Sixty-nine percent (143) were boys. The sample was divided into three age groups: birth through three years (28%); 4 through 12 years (42%); and 13 through 16 years (30%). Fifty-nine of the 206 children in our sample (29%)sustained cervical spine injuries (Table 1).
RESULTS
Radiologic Data
Two hundred and thirty-two children who met the entry criteria were
The m e a n n u m b e r of radiographs obtained for the entire sample of 206
Annals of Emergency Medicine
TABLE 1. Sample characteristics N Total Sex Male Female
%
206 143 63
69 31
Age 0 to 3 4 to 12
58 87
28 42
13 to 16
61
3O
59 147
29 71
Cervical spine injury Yes No
I6:3 March 1987
FIGURE 2. Distribution of patients by
circumstances of injury for children with. and w i t h o u t cervical spine injury.
CIRCUMSTANCES OF INJURY
~']NO 03 Iz ILl
N
C-SPINE INJURY
C-SPINE INJURY
h 0
rr~
hi m
z~
2
TABLE 2. Type of cervical injury in 59 cases
Type of Injury
Age Group (yr) 0 to 3 4 to 12 13 to 16
Total No. Of Type
Subluxation/dislocation
1
4
2
7
Fracture
0
2
16
18
Fracture/subluxation
6
4
23
33
Cord alone
0
0
1
1
children was 3.7 (SD = 1.7). Significantly more radiographs were obtained for children without cervical spine injury than for those whose cervical spines were injured (3.9 versus 3.3; P < .05). There were no differences in number of views taken for children in the different age categories. Additional views were obtained or repeated in 121 children (59%). Repeat views were equally likely to have been obtained whether or not a child had a cervical spine injury. In 92% of the cases, two or more views of the cervical spine had been obtained. Only 15 children had a single radiograph, and this was always the lateral view; 11 were positive. Only four pa16:3 March 1987
tients (2%) were judged to have had no bony cervical injury on the basis of a single lateral view. One patient had cervical spine injury without bony abnormality. Among the remaining patients, the lateral view revealed the abnormality in 55 of the 58 cases (95%), the anteroposterior (AP) view in 13 (22%), and the other views in eight cases. In all cases, the presence of cervical spine injury was detected by either the lateral or AP view. Forty-six children received plain tomography, and ll had computerized tomography of the cervical spine. These studies occasionally revealed subtle additional pedicle or lamina fractures. However, the presence of Annals of Emergency Medicine
these fractures was implied by abnormalities seen on the lateral or AP views. Four children with cervical spine injury had preexisting radiologic abnormalities of the cervical spine. Two with subluxation of CI on C2 had os odontoideum: one child with a C7 vertebral fracture had block vertebrae of C5-C6; and one child with a C5 teardrop fracture had a congenital bar of C6-C7. The frequencies of four types of cervical spine injuries by age category are shown (Table 2). In all age groups, the most commonly encountered injury was the combined fracture and dislocation, followed in frequency by fracture alone in adolescents and by subluxation/dislocation in younger children. There was a significant association between age and level of vertebral injury (P < .0001). High injuries predominated in younger children, and low injuries predominated in older children. There were no low cervical spine injuries in children less than 4 years old, and only one under 13 years of age (Figure l).
Clinical Data Circumstances of injury are shown (Figure 2). Sports accidents and falls were responsible for 73% of the cervical spine injuries in our sample. Nineteen percent occurred as a result of car or m o t o r c y c l e crashes. Although we saw 27 children who were pedestrians hit by m o t o r vehicles, none of these children sustained cervical spine injury. Twenty-three (39%) of the spine-injured children had normal neurological o u t c o m e s , 14 (24%) had incomplete quadraplegia, and 13 (22%) had complete quadraplegia. Two of these quadraplegic children died. Outcome data were not available for nine children (15%). To develop the clinical algorithm, we selected five variables that were significantly associated with presence of cervical spine injury by chi-square analysis: neck pain; neck tenderness; a n d a b n o r m a l i t i e s of r e f l e x e s , strength, or sensation. Three other variables, while not significant by chisquare analysis, were included in the 272/59
CERVICAL SPINE INJURY ALGORITHM Jaffe et al
model because of their clinical importance. These were history of direct trauma to the neck, limitation of neck mobility, and abnormality of mental status (Table 3). We chose the following decision rule in order to maximize the sensitivity of our algorithm: Immobilize and obtain cervical spine radiographs on every child who has one or more of the eight findings shown in Table 3. The algorithm must have high sensitivity, even at the expense of specificity, in order to avoid the potentially serious and costly consequences of missing even a small number of truly injured cervical spines in children. Applying this algorithm to our sample, we were able to identify 58 of 59 patients with cervical spine injury. The sensitivity of the algorithm was 98%, while specificity was 54% (Table 4). Radiographs of the cervical spine would have been avoided in 79 children, representing 38% of the entire sample or 54% of the children without cervical spine injury, Logistic regression analysis was performed beginning with the same eight variables that were selected on the basis of theoretical and empirical association with the presence of cervical spine injury. The logistic regression coefficients for two models are shown (Table 5). Only two variables achieved significance at the .05 level - - neck tenderness and limitation of neck motion. Many of the variables had negative signs. These data suggest deficiencies of logistic regression models based on these variables. Furthermore, when these models were used to categorize patients in the sample, very low threshold probabilities were required to achieve high sensitivity. Patient classification according to two logistic regression models selected to provide near-comparable sensitivity to the clinical algorithm is shown (Table 6). In the seven-variable model, three neck injuries were missed (sensitivity = 95%) and 92 radiographs were expendable (specificity = 60%): To improve the sensitivity to 97% with logistic regression analysis (thereby r e d u c i n g the n u m b e r of missed cervical spine injuries), all but 14 of the children in the sample required radiographs (specificity = 9%). To achieve 100% sensitivity, all but seven required radiographs.
DISCUSSION Our study was consistent with sev60/273
TABLE 3. Association with cervical spine injury No.*
No.t
%$
P§
Neck pain
59
24
41
< .0005
Neck tenderness
43
19
44
< .000I
Abnormal Reflexes
41
33
80
< .0001
39 39
34 34
87 87
< .0001 < .0001
34
14
41
NS
25
5
20
Strength Sensation History of neck trauma Limitation of neck mobility
NS
Abnormal mental status 29 7 24 *Number having the finding. tNumber having the finding and cervical spine injury. :~% of all patients having the finding who had cervical spine injury. §Chi-square test.
NS
TABLE 4. Eight-variable clinical algorithm Cervical Spine Injury Yes
Yes 58
No 68
No
1
79
Radiograph Recommended Sensitivity: 98% Specificity: 54% 'Expendable' radiographs: 38%
eral others in the pediatric literature that document the low yield of radiographs in certain broad clinical situations. Both for head trauma 13 and for first asthma attacks 14 attempts have been made to define a more narrow set of clinical indications for obtaining radiographs to increase the positive yield, thereby reducing the cost, discomfort, waiting time, and radiation exposure associated with unnecessary radiographic evaluation. Because it would be undesirable and potentially tragic to miss even a small fraction of truly injured cervical spines in children, any clinical algorithm for this injury must have high (nearly 100%) sensitivity. Motivated by our experience of seeing m a n y children with minor head injuries forcibly taped to a spine immobilization board (often with substantial neck motion occurring during the struggle), we attempted to find an algorithm that would exclude this type of minor injury from an automatic spine immobilization and radioAnnals of Emergency Medicine
graph protocol. Our data demonstrated that in nearly all instances, a careful neck and neurological examination will lead rapidly to suspect the diagnosis in those few children who have spine injuries. Methodological issues must be considered in order to understand some of the cautions that should accompany the presentation of this clinical algorithm. First, the sampling methods introduced potential biases. All but one of the records of children positive for cervical spine injury (positives) were obtained from the ten-year series of children treated at two institutions. The records of children negative for cervical spine injury (negatives) were sampled largely from a one-year consecutive series of injured children at one institution. It would have been preferable to have obtained the sample of "negatives" by selecting child trauma victims randomly from among the entire group of injured children treated at both institutions throughout the ten-year period. Unavailability of corn16;3 March 1987
TABLE 5. Logistic regression coefficient for models associated with eight- and seven-variable decision rules
Eight-Variable Models Logistic Regression Standard Coefficients Error
Variable History of neck trauma Neck pain
Seven-Variable Models Logistic Regression Standard Coefficients Error
-.2246 .1589
.4492 .7122
-.5024 -.2172
.4224 .6894
.4915 ,5033
.7260 .8137
1.050 .5466
.6720 .7482
Limitation of neck mobility
1.882"
.7233
2.060*
.7600
Neck tenderness
1,579"
.6099
1.279"
.5938
.6126 - 1.925 .4367
.9236 .6151 .5284
-.4506
.7920
-.6700
.3888
Abnormal sensation Abnormal reflexes
Abnormal strength Abnormal mental status Constant
Log (likelihood) 77.581184 *Coefficients are significant (one-tailed test; P ~< .05).
-83,193910
TABLE 6. Models derived from logistic regression
Seven-Variable Model (Threshold Probability = .0433) Cervical Spine Injury Yes
No
Yes
56
58
No
3
89
Radiograph Recommended Sensitivity: 95% Specificity: 60% 'Expendable' radiographs: 44%
Eight-Variable Model (Threshold Probability = .0393) Cervical Spine Injury Yes
Yes 57
No 135
No
2
12
Radiograph Recommended Sensitivity: 97% Specificity: 9% 'Expendable' radiographs: 7%
puterized logs for the earlier years of the study made this impossible. We attempted to avoid making comparisons between the "positive" and "negative" groups that were likely to have been affected by this sampling bias. For example, most of the children in the "positive" group (95%) were evaluated initially at an outside 16:3 March 1987
institution and referred for care to one of two study hospitals, whereas only 32% in the "negative" group were seen first at outside institutions. It was therefore not possible fairly to compare some variables, such as circ u m s t a n c e s of conveyance to the emergency department, method and quality of neck immobilization, and
Annals of Emergency Medicine
the like between the "positive" and "negative" groups. Similarly, the socioeconomic status of the patients was confounded by referral patterns and consequently was not comparable between the two groups. Finally, the Children's Memorial Hospital population is, by definition, younger in age than that of the Northwestern Spine Trauma Unit population. Because almost all the children in the "negative" group came from the Children's Memorial Hospital, presence or absence of cervical injury in this sample cannot validly be related to age. Fortunately, the most important clinical variables, such as presence of neck signs or symptoms and neurological abnormalities, used to construct this clinical model should not have been affected by the sampling methods. Logistic regression analysis is a standard statistical method for developing discriminant or predictive models using categorical variables. We compared models derived from logistic regression to the clinical algorithm based on an intuitive and empirical approach to the traumatized child. To achieve comparable sensitivity, the logistic regression models required obtaining radiographs on nearly all the children, whereas our clinical algorithm permitted the elimination of 38% of the radiographs in this sample. The one child missed by our algorithm was a 2-year old girl who fell 274/61
CERVICAL SPINE INJURY ALGORITHM Jaffe et al
nine feet off of a set of m o n k e y bars. She struck her head and back on the p l a y g r o u n d surface, and s u s t a i n e d a fracture/dislocation of the base of the odontoid. She was transported to the Northwestern University Spine Traum a Unit w i t h her neck immobilized. The m e d i c a l record lacked information concerning specific neck findings, presumably because her neck was not e x a m i n e d while in a cervical collar. She had n o r m a l m e n t a l s t a t u s and neurological examination, was subsequently treated with halo traction, and never developed neurological abnormalities. This troublesome case raises issues concerning m a n a g e m e n t of children transported with their neck immobilized. T h e r e are two d i s t i n c t options: obtain cervical spine radiographs on all immobilized patients; or perform a careful neck and neurological examination, maintaining in-line traction, and order radiographs only for those patients w i t h abnormalities in one or more of the eight model variables. The data in our study did not allow us to evaluate the examination process used for children whose necks were immobilized. Eighty-six percent of the patients in this s a m p l e w i t h cervical spine injury were immobilized for transport. It was still possible to obtain clinical findings of cervical lesions in all but one of these children. We do n o t k n o w w h e n in the course of their treatment these sympt o m s and signs were elicited. T h u s while the data suggest that it is possible to perform an accurate physical e x a m i n a t i o n on m o s t n e c k - i m m o bilized children, t h e y are n o t conclusive for this group of children. Several other aspects of these data deserve discussion. Children w i t h o u t spine injury had statistically more radiographs taken than did those w i t h spine injury. Absence of abnormalities on views with suboptimal technique often prompts repetition or addition of films. (Twelve children in our sample received seven or m o r e n e c k radiographs, and one child had 12!) Age-related differences in level of cervical s p i n e i n j u r y s u c h as t h o s e f o u n d in t h i s s t u d y h a v e b e e n attributed to developmental a n a t o m y of the spine. T h e r e l a t i v e l y larger and h e a v i e r heads; the greater l a x i t y of ligaments and joint capsules; the m o r e h o r i z o n t a l o r i e n t a t i o n of t h e facet joints in the upper three cervical vertebrae; and t h e r e l a t i v e l y h i g h e r 62/275
fulcrum of cervical m o v e m e n t in infants and children as compared to adol e s c e n t s a n d a d u l t s all p r e d i s p o s e these younger children to sustain high cervical spine injuries, is Our sample contained only one child w i t h significant spinal cord injury in absence of bony abnormalities. A 13-year-old boy who was injured during a football game had transient leftside w e a k n e s s t h a t r e s o l v e d spontaneously after approximately 30 minutes. H i s d i a g n o s i s was s p i n a l cord contusion. This low rate of cord injury w i t h o u t bony spine injury is consistent w i t h m o s t of the previously reported series of pediatric spine injuries, i-3,16 although some investigators have f o u n d s i g n i f i c a n t l y larger percentages of isolated cord injuries.S, 17 The absence of cervical spine injury among the 27 pedestrians struck by m o t o r vehicles, w h i l e i n i t i a l l y puzzling, can be understood in light of the w e l l - d o c u m e n t e d h i g h case f a t a l i t y rate (more than 75%) for child pedestrian trauma victims with spinal injury.5 Because most of these children die before reaching the hospital, they are underrepresented in any series of survivors. A s u b s t a n t i a l a m o u n t of s e v e r e trauma occurred in the group w i t h o u t cervical spine pathology. Head trauma accounted for the majority of the severe noncervical injuries in this series. CPR was required in 14 children, eight of w h o m had no cervical injury. Similarly, life-threatening problems were recorded in 20 children, l l of w h o m had no cervical injury. Another measure of injury severity, the Injury Severity Score (ISS) was determined for each p a t i e n t J 8 ISS scores exceeding 30 represent severe injury. Of 27 c h i l d r e n in our s a m p l e w i t h scores exceeding 30, 13 did not have cervical injury. O u r d e c i s i o n m o d e l would mandate cervical spine i m m o bilization and radiographic study of all of these severely injured patients by virtue of their altered m e n t a l status or abnormal neurological examinations.
an i m m o b i l i z e d p a t i e n t , it is prem a t u r e to r e c o m m e n d its widespread adoption at this time. It is hoped that this t y p e of work, w h e n replicated, will p e r m i t e m e r g e n c y physicians to d e v e l o p a n d to t r u s t t h e i r clinical skills when evaluating the necks of injured children, and to safely reduce t h e m o n e t a r y a n d p a t i e n t comfort costs of truly u n n e c e s s a r y spine immobilization and radiography.
SUMMARY
ing a Test: How to Read the Medical Literature.
We have developed a clinical decision algorithm to assist the emergency p h y s i c i a n i n p e r f o r m i n g n e c k evaluations of injured children. It is b a s e d on e i g h t r e a d i l y o b s e r v a b l e clinical s y m p t o m s and signs. Because this algorithm requires validation trials, and because it was unable to detect one true cervical spine injury in Annals of Emergency Medicine
The authors acknowledge the assistance of A Todd Davis, MD, in manuscript review; of John Hewitt, PhD, in data processing; of Christopher Winship, PhD, and Larry Radbill for statistical consultation; and of Dee Lindner for manuscript preparation.
REFERENCES 1. Anderson JM, Schutt AH: Spinal injury in children. A review of 156 cases seen from 1950 through 1978. Mayo Clin Proc 1980;55:499-504. 2. Hasue M, Hoshino R, Omata S, et al: Cervical spine injuries in children. Fukushima J Med Sci 1974;20:115-123. 3. Henrys P, Lyne ED, Lifton C, et ah Clinical review of cervical spine injuries in children. Clinical Orthop 1976;129:172-176. 4. Jergens ME, Morgan MT, McElroy CE: Selective use of radiography of the skull and cervical spine. West J Med 1977;127:1-4. 5. Kewalramani LS, Kraus JF, Sterling HM: Acute spinal-cord lesions in a pediatric population. Epidemiologicaland clinical features. Paraplegia 1980;18:206-219. 6. Williams CF, Bernstein TW, Jelenko C III: Essentiality of the lateral cervical spine radiograph. Ann Emerg Med 1981;10:198-204. 7. Fischer RP: Cervical radiographic evaluation of alert patients following blunt trauma. Ann Emerg Med 1984;13:905-907. 8. Rachesky IJ, Boyce WT, Duncan B, et al: Clinical Prediction of Cervical Spine Injuries in Children. Presented at the 251h Annual Meeting of the Ambulatory Pediatric Association, Washington~ DC, May, 1985. 9. Siegel S: Non-Parametric Statistics. New York, McGraw-Hill Book Company, 1956. 10. Hays WL: Statistics. New York, Holt, Rinehart and Winston, 1963. I1. Bishop YM, Fienberg SE, Holland PW: Discrete Multivariate Analysis: Theory and Practice. Cambridge, Massachusetts, MIT Press,
1975. 1Z. Riegelman RK: Studying a Study and TestBoston, Little, Brown and Go, 1981. 13. Leonidas JC, Ting W, Binkiewicz A, et ah Mild head trauma in children: When is a roentgenogram necessary.Pediatrics I982;69:139-143. 14. GersheI JC, Goldman HS, Stein REX, et al: The usefulness of chest radiographs in first asthma attacks. N Engl [ M e d 1983~309: 336-339. 15. Hill SA, Miller CA, Kosnik EJ, et al: Pediatric neck injuries. A clinical study. J Neurosurg 16:3 March 1987
t984~60:700-706.
100:56-65.
16. Hubbard DD: Injuries of the spine in children and adolescents. Clinical Orthop 1974;
17. Burke DC: Traumatic spinal paralysis in children. Paralysis 1974;lh268-276.
I8. 1985 NASS Coding Manual. U.S. Department of Transportation National Highway Traffic Safety Administration, Washington, DC, 1985.
Fellowship List Now Available A list of toxicology fellowship programs is now available from the ACEP Toxicology Committee. Please contact Liz Sibley, ACEP, PO Box 619911, Dallas, T× 75261-9911; 214/550-0911.
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Developing a Clinical Algorithm for Early Management of Cervical Spine Injury in Child Trauma Victims To define a subset of injured children for whom emergency cervical spine radiography m a y be unnecessary, we performed a retrospective chart and radiologic review. Two entry methods were used: 1) All injured children, from birth through 16 years, who had received cervical spine radiographs at The Children's Memorial Hospital from September 1983, to September 1984, were included. 2) All patients from birth to 16 years with proven or suspected cases of cervical spine injury who had received cervical spine radiographs and who had been treated at either the Children's Memorial Hospital or the Northwestern University Spine Trauma Unit during period 1974 to 1984 also were included. Each child's chart was reviewed, and 84 clinical variables were recorded. All radiographs were reviewed by a pediatric neuroradiologist. Of 206 children studied, 59 had cervical spine injuries. A clinical algorithm was derived using the following eight variables: neck pain; neck tenderness; limitation of neck mobility; history of trauma to the neck; and abnormalities of reflexes, strength, sensation, or mental status. The following decision rule was selected: Positive findings in any of these eight variables mandates cervical spine radiography. This algorithm correctly identified 58 of 59 children with cervical spine injury, yielding a sensitivity of 98% and specificity of 54%. Cervical spine radiographs could have been avoided in 79 children (38% of the entire sample). This algorithm performed better than did models derived from logistic regression analysis of the same data. Validation trials are required prior to the implementation of this or other clinical decision algorithms in practice. [Jaffe DM, Binns H, Radkowski MA, Barthel MJ, Engelhard HH Ill: Developing a clinical algorithm for early management of cervical spine injury in child trauma victims. Ann Emerg Med March 1987;16:270-276.]
David M Jaffe, MD* Helen Binns, MD* Mary Ann Radkowski, MD1Martha J Barthel, RN, MSN* Herbert H Engelhard ltl, MD1 Chicago, illinois From the Departments of Pediatrics,* Radiology,t and SurgeryJ The Children's Memorial Hospital, Northwestern University Medical School, Chicago, Illinois. Received for publication May 28, 1985. Revision received September 8, 1986. Accepted for publication October 20, 1986. Presented at the University Association for Emergency Medicine Annual Meeting in Kansas City, Missouri, May 1985. Address for reprints: David M Jaffe, MD, Department of Pediatrics, The Children's Memorial Hospital, 2300 Children's Plaza, Chicago, Illinois 60614.
INTRODUCTION The emergency physician commonly faces the problem of performing safe yet thorough evaluations of children who have suffered head trauma or multiple trauma. It is often routine to immobilize the neck and to obtain cervical spine radiographs on every child trauma victim. At times, however, cervical spine immobilization and radiography interfere with expedient management and contribute unnecessarily to the discomfort and cost experienced by children and their families. Cervical spine injuries in children are rare. The incidence increases with age, 1 and it is estimated that only 1% to 4% of all spine injuries among survivors occur in the pediatric age g r o u p . 2-5 The emergency medicine literature contains conflicting recommendations about optimal cervical spine management of injured patients. Williams et al 6 reported that 13 of 50 patients with cervical spine fractures were not diagnosed during their initial evaluations. The recommended obtaining a lateral cervical spine radiograph for "all victims of high-speed vehicular accidents; all multiply traumatized patients; all traumatized patients with head injury or altered sensorium; all patients who have fallen from heights, including those with diving injuries; all who injure their shoulders, neck or head in contact sports; and, of course, all trauma victims who complain of neck pain or neuropathy." On the other hand, Fischer7 failed to find any cases of cervical spine injury in a mixed pediatric and adult sample of 333 awake patients who sustained 16:3 March 1987
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CERVICAL SPINE INJURY ALGORITHM Jaffe et al
FIGURE 1. Relationship between age and level of cervical spine injury. N = 58 patients with bony cervical spine injury. head trauma but had no neck symptoms or signs. He concluded that "alert p a t i e n t s . . , without signs or symptoms of cervical injury do not require cervical radiographic evaluation." A recent unpublished abstract delineated two clinical situations mandating cervical spine radiographs in injured children: any injured child with neck pain, and any car crash victim with head injury, In absence of these situations, they suggested that cervical spine radiography may be unnecessary. 8 Further study of spine injuries in children is required to provide adequate guidance for safe, humane, efficient, and cost-effective e m e r g e n c y neck management. The purpose of our study was to develop a set of clinical criteria for predicting the presence of cervical spine injury a m o n g child t r a u m a victims and to identify a group of children for w h o m , after careful clinical assessment, cervical radiographic study might be eliminated safely.
METHODS Two methods were used to select children for study. All child trauma victims evaluated at the Children's Memorial Hospital from September 1983, to September 1984, whose ages ranged f r o m birth t h r o u g h 16 years and w h o had cervical spine radiographs were eligible. Cases were identified by selecting all children w h o were billed for cervical spine radiographs as indicated on Department of Radiology logs for the 12-month study period. Because this sample of 139 patients yielded only one child with a cervical spine injury, a second method was used to increase the n u m b e r of cases of true cervical spine injury. All children, ages birth through 16 years, with cervical spine injury treated at either the Children's Memorial Hospital or the N o r t h w e s t e r n University Spine Trauma Unit during the tenyear period 1974 to 1984 were included. The medical records at both institutions were identified by either admission or discharge diagnoses of cervical spine fracture, cervical spinal cord injury, or rule-out cervical fracture or cord injury. Patients w i t h m i s s i n g charts or inadequate or missing radio58/271
40 oo 35 Fzi,i 30
i
B
D
2s i, 0
HIGH (CI-C3)
B
~ ' ~ LOW (C4-C7)
20
m
m 10 z
5
1
1
r ]L
0-3
4-12
1
1.3-16
AGE GROUPS (YEARS) graphs were excluded from analysis. Cases obtained from both sampling methods were combined for analysis. All radiographs were reviewed by a pediatric neuroradiologist. Cervical injuries were classified as either high or low. Injuries of cervical vertebrae 1 through 3 were designated as high; injuries of cervical vertebrae 4 through 7 were low. If C4 was involved along with higher-level vertebrae, however, the injury was classified as high. Each child's chart was reviewed, and 84 variables describing demographic information, circumstances of injury, and clinical information obtained at the t i m e of e x a m i n a t i o n were recorded. When children had been evaluated at other hospitals prior to transfer to one of the two study hospitals, the earliest recorded examination was used to obtain clinical data. Categorical data were crosstabulated and evaluated w i t h the chisquare statistic. 9 Continuous variables were analyzed using Student's t test. 10 Models derived from logistic regression analysis H were compared to the algorithm derived from chi-square associations and clinical analysis. For the logistic regressions models, missing data were coded as abnormal if any of the measured variables for the p a t i e n t were a b n o r m a l . All o t h e r missing values were coded as normal. Sensitivity, specificity, and percent 'expendable' radiographs were calculated for both model types. 12
identified. Nineteen were excluded because their radiographs could not be located, four because their radiographs were inadequate in quality, and three because the medical records could not be located. The final study sample consisted of 206 children. Sixty-nine percent (143) were boys. The sample was divided into three age groups: birth through three years (28%); 4 through 12 years (42%); and 13 through 16 years (30%). Fifty-nine of the 206 children in our sample (29%)sustained cervical spine injuries (Table 1).
RESULTS
Radiologic Data
Two hundred and thirty-two children who met the entry criteria were
The m e a n n u m b e r of radiographs obtained for the entire sample of 206
Annals of Emergency Medicine
TABLE 1. Sample characteristics N Total Sex Male Female
%
206 143 63
69 31
Age 0 to 3 4 to 12
58 87
28 42
13 to 16
61
3O
59 147
29 71
Cervical spine injury Yes No
I6:3 March 1987
FIGURE 2. Distribution of patients by
circumstances of injury for children with. and w i t h o u t cervical spine injury.
CIRCUMSTANCES OF INJURY
~']NO 03 Iz ILl
N
C-SPINE INJURY
C-SPINE INJURY
h 0
rr~
hi m
z~
2
TABLE 2. Type of cervical injury in 59 cases
Type of Injury
Age Group (yr) 0 to 3 4 to 12 13 to 16
Total No. Of Type
Subluxation/dislocation
1
4
2
7
Fracture
0
2
16
18
Fracture/subluxation
6
4
23
33
Cord alone
0
0
1
1
children was 3.7 (SD = 1.7). Significantly more radiographs were obtained for children without cervical spine injury than for those whose cervical spines were injured (3.9 versus 3.3; P < .05). There were no differences in number of views taken for children in the different age categories. Additional views were obtained or repeated in 121 children (59%). Repeat views were equally likely to have been obtained whether or not a child had a cervical spine injury. In 92% of the cases, two or more views of the cervical spine had been obtained. Only 15 children had a single radiograph, and this was always the lateral view; 11 were positive. Only four pa16:3 March 1987
tients (2%) were judged to have had no bony cervical injury on the basis of a single lateral view. One patient had cervical spine injury without bony abnormality. Among the remaining patients, the lateral view revealed the abnormality in 55 of the 58 cases (95%), the anteroposterior (AP) view in 13 (22%), and the other views in eight cases. In all cases, the presence of cervical spine injury was detected by either the lateral or AP view. Forty-six children received plain tomography, and ll had computerized tomography of the cervical spine. These studies occasionally revealed subtle additional pedicle or lamina fractures. However, the presence of Annals of Emergency Medicine
these fractures was implied by abnormalities seen on the lateral or AP views. Four children with cervical spine injury had preexisting radiologic abnormalities of the cervical spine. Two with subluxation of CI on C2 had os odontoideum: one child with a C7 vertebral fracture had block vertebrae of C5-C6; and one child with a C5 teardrop fracture had a congenital bar of C6-C7. The frequencies of four types of cervical spine injuries by age category are shown (Table 2). In all age groups, the most commonly encountered injury was the combined fracture and dislocation, followed in frequency by fracture alone in adolescents and by subluxation/dislocation in younger children. There was a significant association between age and level of vertebral injury (P < .0001). High injuries predominated in younger children, and low injuries predominated in older children. There were no low cervical spine injuries in children less than 4 years old, and only one under 13 years of age (Figure l).
Clinical Data Circumstances of injury are shown (Figure 2). Sports accidents and falls were responsible for 73% of the cervical spine injuries in our sample. Nineteen percent occurred as a result of car or m o t o r c y c l e crashes. Although we saw 27 children who were pedestrians hit by m o t o r vehicles, none of these children sustained cervical spine injury. Twenty-three (39%) of the spine-injured children had normal neurological o u t c o m e s , 14 (24%) had incomplete quadraplegia, and 13 (22%) had complete quadraplegia. Two of these quadraplegic children died. Outcome data were not available for nine children (15%). To develop the clinical algorithm, we selected five variables that were significantly associated with presence of cervical spine injury by chi-square analysis: neck pain; neck tenderness; a n d a b n o r m a l i t i e s of r e f l e x e s , strength, or sensation. Three other variables, while not significant by chisquare analysis, were included in the 272/59
CERVICAL SPINE INJURY ALGORITHM Jaffe et al
model because of their clinical importance. These were history of direct trauma to the neck, limitation of neck mobility, and abnormality of mental status (Table 3). We chose the following decision rule in order to maximize the sensitivity of our algorithm: Immobilize and obtain cervical spine radiographs on every child who has one or more of the eight findings shown in Table 3. The algorithm must have high sensitivity, even at the expense of specificity, in order to avoid the potentially serious and costly consequences of missing even a small number of truly injured cervical spines in children. Applying this algorithm to our sample, we were able to identify 58 of 59 patients with cervical spine injury. The sensitivity of the algorithm was 98%, while specificity was 54% (Table 4). Radiographs of the cervical spine would have been avoided in 79 children, representing 38% of the entire sample or 54% of the children without cervical spine injury, Logistic regression analysis was performed beginning with the same eight variables that were selected on the basis of theoretical and empirical association with the presence of cervical spine injury. The logistic regression coefficients for two models are shown (Table 5). Only two variables achieved significance at the .05 level - - neck tenderness and limitation of neck motion. Many of the variables had negative signs. These data suggest deficiencies of logistic regression models based on these variables. Furthermore, when these models were used to categorize patients in the sample, very low threshold probabilities were required to achieve high sensitivity. Patient classification according to two logistic regression models selected to provide near-comparable sensitivity to the clinical algorithm is shown (Table 6). In the seven-variable model, three neck injuries were missed (sensitivity = 95%) and 92 radiographs were expendable (specificity = 60%): To improve the sensitivity to 97% with logistic regression analysis (thereby r e d u c i n g the n u m b e r of missed cervical spine injuries), all but 14 of the children in the sample required radiographs (specificity = 9%). To achieve 100% sensitivity, all but seven required radiographs.
DISCUSSION Our study was consistent with sev60/273
TABLE 3. Association with cervical spine injury No.*
No.t
%$
P§
Neck pain
59
24
41
< .0005
Neck tenderness
43
19
44
< .000I
Abnormal Reflexes
41
33
80
< .0001
39 39
34 34
87 87
< .0001 < .0001
34
14
41
NS
25
5
20
Strength Sensation History of neck trauma Limitation of neck mobility
NS
Abnormal mental status 29 7 24 *Number having the finding. tNumber having the finding and cervical spine injury. :~% of all patients having the finding who had cervical spine injury. §Chi-square test.
NS
TABLE 4. Eight-variable clinical algorithm Cervical Spine Injury Yes
Yes 58
No 68
No
1
79
Radiograph Recommended Sensitivity: 98% Specificity: 54% 'Expendable' radiographs: 38%
eral others in the pediatric literature that document the low yield of radiographs in certain broad clinical situations. Both for head trauma 13 and for first asthma attacks 14 attempts have been made to define a more narrow set of clinical indications for obtaining radiographs to increase the positive yield, thereby reducing the cost, discomfort, waiting time, and radiation exposure associated with unnecessary radiographic evaluation. Because it would be undesirable and potentially tragic to miss even a small fraction of truly injured cervical spines in children, any clinical algorithm for this injury must have high (nearly 100%) sensitivity. Motivated by our experience of seeing m a n y children with minor head injuries forcibly taped to a spine immobilization board (often with substantial neck motion occurring during the struggle), we attempted to find an algorithm that would exclude this type of minor injury from an automatic spine immobilization and radioAnnals of Emergency Medicine
graph protocol. Our data demonstrated that in nearly all instances, a careful neck and neurological examination will lead rapidly to suspect the diagnosis in those few children who have spine injuries. Methodological issues must be considered in order to understand some of the cautions that should accompany the presentation of this clinical algorithm. First, the sampling methods introduced potential biases. All but one of the records of children positive for cervical spine injury (positives) were obtained from the ten-year series of children treated at two institutions. The records of children negative for cervical spine injury (negatives) were sampled largely from a one-year consecutive series of injured children at one institution. It would have been preferable to have obtained the sample of "negatives" by selecting child trauma victims randomly from among the entire group of injured children treated at both institutions throughout the ten-year period. Unavailability of corn16;3 March 1987
TABLE 5. Logistic regression coefficient for models associated with eight- and seven-variable decision rules
Eight-Variable Models Logistic Regression Standard Coefficients Error
Variable History of neck trauma Neck pain
Seven-Variable Models Logistic Regression Standard Coefficients Error
-.2246 .1589
.4492 .7122
-.5024 -.2172
.4224 .6894
.4915 ,5033
.7260 .8137
1.050 .5466
.6720 .7482
Limitation of neck mobility
1.882"
.7233
2.060*
.7600
Neck tenderness
1,579"
.6099
1.279"
.5938
.6126 - 1.925 .4367
.9236 .6151 .5284
-.4506
.7920
-.6700
.3888
Abnormal sensation Abnormal reflexes
Abnormal strength Abnormal mental status Constant
Log (likelihood) 77.581184 *Coefficients are significant (one-tailed test; P ~< .05).
-83,193910
TABLE 6. Models derived from logistic regression
Seven-Variable Model (Threshold Probability = .0433) Cervical Spine Injury Yes
No
Yes
56
58
No
3
89
Radiograph Recommended Sensitivity: 95% Specificity: 60% 'Expendable' radiographs: 44%
Eight-Variable Model (Threshold Probability = .0393) Cervical Spine Injury Yes
Yes 57
No 135
No
2
12
Radiograph Recommended Sensitivity: 97% Specificity: 9% 'Expendable' radiographs: 7%
puterized logs for the earlier years of the study made this impossible. We attempted to avoid making comparisons between the "positive" and "negative" groups that were likely to have been affected by this sampling bias. For example, most of the children in the "positive" group (95%) were evaluated initially at an outside 16:3 March 1987
institution and referred for care to one of two study hospitals, whereas only 32% in the "negative" group were seen first at outside institutions. It was therefore not possible fairly to compare some variables, such as circ u m s t a n c e s of conveyance to the emergency department, method and quality of neck immobilization, and
Annals of Emergency Medicine
the like between the "positive" and "negative" groups. Similarly, the socioeconomic status of the patients was confounded by referral patterns and consequently was not comparable between the two groups. Finally, the Children's Memorial Hospital population is, by definition, younger in age than that of the Northwestern Spine Trauma Unit population. Because almost all the children in the "negative" group came from the Children's Memorial Hospital, presence or absence of cervical injury in this sample cannot validly be related to age. Fortunately, the most important clinical variables, such as presence of neck signs or symptoms and neurological abnormalities, used to construct this clinical model should not have been affected by the sampling methods. Logistic regression analysis is a standard statistical method for developing discriminant or predictive models using categorical variables. We compared models derived from logistic regression to the clinical algorithm based on an intuitive and empirical approach to the traumatized child. To achieve comparable sensitivity, the logistic regression models required obtaining radiographs on nearly all the children, whereas our clinical algorithm permitted the elimination of 38% of the radiographs in this sample. The one child missed by our algorithm was a 2-year old girl who fell 274/61
CERVICAL SPINE INJURY ALGORITHM Jaffe et al
nine feet off of a set of m o n k e y bars. She struck her head and back on the p l a y g r o u n d surface, and s u s t a i n e d a fracture/dislocation of the base of the odontoid. She was transported to the Northwestern University Spine Traum a Unit w i t h her neck immobilized. The m e d i c a l record lacked information concerning specific neck findings, presumably because her neck was not e x a m i n e d while in a cervical collar. She had n o r m a l m e n t a l s t a t u s and neurological examination, was subsequently treated with halo traction, and never developed neurological abnormalities. This troublesome case raises issues concerning m a n a g e m e n t of children transported with their neck immobilized. T h e r e are two d i s t i n c t options: obtain cervical spine radiographs on all immobilized patients; or perform a careful neck and neurological examination, maintaining in-line traction, and order radiographs only for those patients w i t h abnormalities in one or more of the eight model variables. The data in our study did not allow us to evaluate the examination process used for children whose necks were immobilized. Eighty-six percent of the patients in this s a m p l e w i t h cervical spine injury were immobilized for transport. It was still possible to obtain clinical findings of cervical lesions in all but one of these children. We do n o t k n o w w h e n in the course of their treatment these sympt o m s and signs were elicited. T h u s while the data suggest that it is possible to perform an accurate physical e x a m i n a t i o n on m o s t n e c k - i m m o bilized children, t h e y are n o t conclusive for this group of children. Several other aspects of these data deserve discussion. Children w i t h o u t spine injury had statistically more radiographs taken than did those w i t h spine injury. Absence of abnormalities on views with suboptimal technique often prompts repetition or addition of films. (Twelve children in our sample received seven or m o r e n e c k radiographs, and one child had 12!) Age-related differences in level of cervical s p i n e i n j u r y s u c h as t h o s e f o u n d in t h i s s t u d y h a v e b e e n attributed to developmental a n a t o m y of the spine. T h e r e l a t i v e l y larger and h e a v i e r heads; the greater l a x i t y of ligaments and joint capsules; the m o r e h o r i z o n t a l o r i e n t a t i o n of t h e facet joints in the upper three cervical vertebrae; and t h e r e l a t i v e l y h i g h e r 62/275
fulcrum of cervical m o v e m e n t in infants and children as compared to adol e s c e n t s a n d a d u l t s all p r e d i s p o s e these younger children to sustain high cervical spine injuries, is Our sample contained only one child w i t h significant spinal cord injury in absence of bony abnormalities. A 13-year-old boy who was injured during a football game had transient leftside w e a k n e s s t h a t r e s o l v e d spontaneously after approximately 30 minutes. H i s d i a g n o s i s was s p i n a l cord contusion. This low rate of cord injury w i t h o u t bony spine injury is consistent w i t h m o s t of the previously reported series of pediatric spine injuries, i-3,16 although some investigators have f o u n d s i g n i f i c a n t l y larger percentages of isolated cord injuries.S, 17 The absence of cervical spine injury among the 27 pedestrians struck by m o t o r vehicles, w h i l e i n i t i a l l y puzzling, can be understood in light of the w e l l - d o c u m e n t e d h i g h case f a t a l i t y rate (more than 75%) for child pedestrian trauma victims with spinal injury.5 Because most of these children die before reaching the hospital, they are underrepresented in any series of survivors. A s u b s t a n t i a l a m o u n t of s e v e r e trauma occurred in the group w i t h o u t cervical spine pathology. Head trauma accounted for the majority of the severe noncervical injuries in this series. CPR was required in 14 children, eight of w h o m had no cervical injury. Similarly, life-threatening problems were recorded in 20 children, l l of w h o m had no cervical injury. Another measure of injury severity, the Injury Severity Score (ISS) was determined for each p a t i e n t J 8 ISS scores exceeding 30 represent severe injury. Of 27 c h i l d r e n in our s a m p l e w i t h scores exceeding 30, 13 did not have cervical injury. O u r d e c i s i o n m o d e l would mandate cervical spine i m m o bilization and radiographic study of all of these severely injured patients by virtue of their altered m e n t a l status or abnormal neurological examinations.
an i m m o b i l i z e d p a t i e n t , it is prem a t u r e to r e c o m m e n d its widespread adoption at this time. It is hoped that this t y p e of work, w h e n replicated, will p e r m i t e m e r g e n c y physicians to d e v e l o p a n d to t r u s t t h e i r clinical skills when evaluating the necks of injured children, and to safely reduce t h e m o n e t a r y a n d p a t i e n t comfort costs of truly u n n e c e s s a r y spine immobilization and radiography.
SUMMARY
ing a Test: How to Read the Medical Literature.
We have developed a clinical decision algorithm to assist the emergency p h y s i c i a n i n p e r f o r m i n g n e c k evaluations of injured children. It is b a s e d on e i g h t r e a d i l y o b s e r v a b l e clinical s y m p t o m s and signs. Because this algorithm requires validation trials, and because it was unable to detect one true cervical spine injury in Annals of Emergency Medicine
The authors acknowledge the assistance of A Todd Davis, MD, in manuscript review; of John Hewitt, PhD, in data processing; of Christopher Winship, PhD, and Larry Radbill for statistical consultation; and of Dee Lindner for manuscript preparation.
REFERENCES 1. Anderson JM, Schutt AH: Spinal injury in children. A review of 156 cases seen from 1950 through 1978. Mayo Clin Proc 1980;55:499-504. 2. Hasue M, Hoshino R, Omata S, et al: Cervical spine injuries in children. Fukushima J Med Sci 1974;20:115-123. 3. Henrys P, Lyne ED, Lifton C, et ah Clinical review of cervical spine injuries in children. Clinical Orthop 1976;129:172-176. 4. Jergens ME, Morgan MT, McElroy CE: Selective use of radiography of the skull and cervical spine. West J Med 1977;127:1-4. 5. Kewalramani LS, Kraus JF, Sterling HM: Acute spinal-cord lesions in a pediatric population. Epidemiologicaland clinical features. Paraplegia 1980;18:206-219. 6. Williams CF, Bernstein TW, Jelenko C III: Essentiality of the lateral cervical spine radiograph. Ann Emerg Med 1981;10:198-204. 7. Fischer RP: Cervical radiographic evaluation of alert patients following blunt trauma. Ann Emerg Med 1984;13:905-907. 8. Rachesky IJ, Boyce WT, Duncan B, et al: Clinical Prediction of Cervical Spine Injuries in Children. Presented at the 251h Annual Meeting of the Ambulatory Pediatric Association, Washington~ DC, May, 1985. 9. Siegel S: Non-Parametric Statistics. New York, McGraw-Hill Book Company, 1956. 10. Hays WL: Statistics. New York, Holt, Rinehart and Winston, 1963. I1. Bishop YM, Fienberg SE, Holland PW: Discrete Multivariate Analysis: Theory and Practice. Cambridge, Massachusetts, MIT Press,
1975. 1Z. Riegelman RK: Studying a Study and TestBoston, Little, Brown and Go, 1981. 13. Leonidas JC, Ting W, Binkiewicz A, et ah Mild head trauma in children: When is a roentgenogram necessary.Pediatrics I982;69:139-143. 14. GersheI JC, Goldman HS, Stein REX, et al: The usefulness of chest radiographs in first asthma attacks. N Engl [ M e d 1983~309: 336-339. 15. Hill SA, Miller CA, Kosnik EJ, et al: Pediatric neck injuries. A clinical study. J Neurosurg 16:3 March 1987
t984~60:700-706.
100:56-65.
16. Hubbard DD: Injuries of the spine in children and adolescents. Clinical Orthop 1974;
17. Burke DC: Traumatic spinal paralysis in children. Paralysis 1974;lh268-276.
I8. 1985 NASS Coding Manual. U.S. Department of Transportation National Highway Traffic Safety Administration, Washington, DC, 1985.
Fellowship List Now Available A list of toxicology fellowship programs is now available from the ACEP Toxicology Committee. Please contact Liz Sibley, ACEP, PO Box 619911, Dallas, T× 75261-9911; 214/550-0911.
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