Evidence Table 11The Paediatric patient

Studies from original 2003 guideline

Names and evidence levelRule descriptionParticipantsOutcome measuresSpecificitySensitivityInvestigation ordering ratePrevalenceDerived using primary dataDerived using prospect. DataValidated using primary dataValidated using prospect. DataMultivariate modellingFollow-upNotes
Dietrich et al (1991)348

Level 4 evidence

Case series
Retrospective case series

All children with neck pain or tenderness need full radiographic evaluation of their cervical spine
N=50 patients with cervical fracture

All levels of alertness

Symptomatic and asymptomatic

Children, aged 2 to 19 years old

Single USA children’s Hospital

Non- consecutive.
Cervical spine injury as documented in hospital medical records

Gold Standard

None
Not applicableNot applicableNot applicable100%YesNoNoNoNoNo83% of children had no neurology on initial physical examination Lateral Cervical spine radiograph identified 98% of children
Dwek et al (2000)349

Level 4 evidence

No gold standard applied
Retrospective cohort study

In children with a history of trauma and normal findings on cervical spine radiographs, additional flexion- extension radiographs are of questionable value.
N=247 patients who had plain radiography and flexion / extension views

All levels of alertness – 775 normal GCS

Symptomatic and asymptomatic

CHILDREN ONLY, under 18years old

Single USA trauma centre

Non- consecutive
Cervical injury on 3 view radiography (no peg view in under 4 year olds)

Or on F/E views

Gold standard:

Abnormal results of radiography or abnormality recorded in the notes while admitted
N/AN/AN/A23 or 247 (9%)

All of these found on plain radiographs.
YesNoNoNoNoThe notes were reviewed of each admission to look of any missed injury. No outpatient follow up done4 patients with questionable findings on plain radiography had their spine cleared on flexion / Extension views.
Other than this no useful information was gained from F/E views.

There was no gold standard applied to the Flexion/Extension views or to the plain views so the true number of false negatives is not known unless progress until discharge is an acceptable gold standard.
Laham et al
(1994)350

Level 3 evidence

Retrospective study, with no universally applied gold standard.
Cervical spine X-rays are only indicated in high risk paediatric patients with a head injury who either complains of neck pain or cannot voice such complaints because of significant head injury or preverbal age.N=268

Children with significant head injury defined as one with clinical and radiographic evidence on CT.

Symptomatic and asymptomatic

Children 0–19 years old

Single USA children’s hospital intensive care unit.

Consecutive patient that were admitted to the PICU.
Cervical injury on 3 view radiography

Gold standard:

3-view radiography only (only 80% of children received this)

No follow up
52%100%48%10 out of 268 (3.7%)YesNoNoNoNoNoThe entry criteria of: significant head injury needing admission was made at the discretion of the PICU assessment officer.

GCS was not consistently recorded in these children

215 children had cervical radiographs (80%)
Schwartz et al (1997)351

Level 4 evidence

Case series
Retrospective case series

Radiographic investigation is not necessary in asymptomatic children under 6 after a short fall.
N=did not state how many patient’s charts were reviewed – total of 44 centre-years of notes were searched

All levels of alertness

Symptomatic and asymptomatic Children younger than 6 years old

4 USA hospitals

Non- consecutive – all patients with injury were looked for but only positive cases were studied
ICD-9 codes for cervical vertebral injury, cervical cord injuries and cervical vertebra and cord injury were considered as positive

Gold Standard:

No gold standard applied to exclude injury.
Not appropriate for this type of studyNot appropriate for this type of studyNot appropriate for this type of study8 children were found with cervical spine injury after a fall from a low heightYesNoNONoNoNoThis is a large case series

33 children with cervical spine injury were excluded from the study as they did not meet the criteria for mechanism of injury

This study Is of little relevance to this review.

From: Appendix I, Evidence Tables

Cover of Head Injury
Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults.
NICE Clinical Guidelines, No. 56.
National Collaborating Centre for Acute Care (UK).
Copyright © 2007, National Collaborating Centre for Acute Care.

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