Department of Surgery, Massachusetts General Hospital, Boston, MA.
Pediatric Surgery Trials and Outcomes Research (PSTOR), MassGeneral Hospital for Children, Boston, MA.
Ann Surg. 2022 Dec 1;276(6):989-994. doi: 10.1097/SLA.0000000000005453. Epub 2022 Jul 6.
The objective of this study was to better understand the variability that exists in the contemporary pediatric cervical spine (c-spine) clearance protocols and how this variability affects clinical practice and outcomes.
Pediatric c-spine injury is a rare but potentially devastating event. In the adult population, validated tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule, are available to aid in safely clearing the c-spine clinically while reducing the utilization of radiography. In the pediatric population, no standardized, validated tool exists, leading to variability in protocols that are put to use.
A systematic literature search was conducted in Cochrane, Embase, PubMed/MEDLINE, and Web of Science electronic databases from January 1, 2009 until April 30, 2021. Data were extracted from studies that met inclusion criteria. Quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.
There were 19 studies included in this systematic review. From these 19 studies, there were 16 unique protocols, 12 of which (75%) utilized some or all NEXUS criteria. Of the protocols that provided a detailed imaging algorithm (N=14), 12 (85.7%) utilized x-rays as the initial imaging modality. Indications for computed tomography and magnetic resonance imaging varied widely across the protocols. The rate of x-rays, computed tomography, and magnetic resonance imaging utilization ranged from 16.7% to 97.8%, 5.4% to 100%, and 0% to 100%, respectively. Ten studies evaluated the efficacy of protocol implementation, with 9 (90%) of these studies showing an overall reduction of imaging rates in the postprotocol period. No clinically significant missed injuries were reported in the included studies.
Details of c-spine clearance protocols differed significantly across the included studies, but many applied some or all NEXUS criteria. Overall, while variable, protocols served to safely treat pediatric patients without missing any clinically significant c-spine injuries, while reducing radiation exposure.
本研究旨在更好地了解当前儿科颈椎（c 脊柱）清除方案中存在的变异性，以及这种变异性如何影响临床实践和结果。
儿科颈椎损伤是一种罕见但潜在破坏性的事件。在成人人群中，有经过验证的工具，如国家急诊 X 射线利用研究（NEXUS）标准和加拿大颈椎规则，可用于在安全清除颈椎的同时减少 X 射线的使用。在儿科人群中，没有标准化、经过验证的工具，导致使用的方案存在差异。
系统检索 Cochrane、Embase、PubMed/MEDLINE 和 Web of Science 电子数据库，检索时间为 2009 年 1 月 1 日至 2021 年 4 月 30 日。从符合纳入标准的研究中提取数据。使用非随机研究方法学指数（MINORS）标准评估纳入研究的质量。
本系统评价共纳入 19 项研究。这 19 项研究中有 16 项独特的方案，其中 12 项（75%）使用了部分或全部 NEXUS 标准。在提供详细影像学算法的方案中（N=14），12 项（85.7%）最初使用 X 射线作为影像学手段。各方案的计算机断层扫描和磁共振成像适应证差异很大。X 射线、计算机断层扫描和磁共振成像的使用率范围分别为 16.7%至 97.8%、5.4%至 100%和 0%至 100%。10 项研究评估了方案实施的效果，其中 9 项（90%）研究表明方案实施后的影像学检查率总体下降。纳入的研究均未报告有临床意义的漏诊损伤。
纳入研究的颈椎清除方案细节差异很大，但许多方案都应用了部分或全部 NEXUS 标准。总体而言，尽管方案存在差异，但它们可以安全治疗儿科患者，而不会漏诊任何有临床意义的颈椎损伤，同时减少辐射暴露。
