1Orthopedic Center for Children, St. Christopher’s Hospital for Children, Philadelphia, Pennsylvania2Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland3Center for Orthopedics, Arnold Palmer Hospital, Orlando, Florida4Department of Orthopedic Surgery (P.M.P.), Drexel University College of Medicine (D.J.P., and K.S.M.), Hahnemann University Hospital, Philadelphia, Pennsylvania5Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, and Nationwide Children’s Hospital, Columbus, Ohio6Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware7Department of Neurological Surgery, University of Utah, Primary Children’s Hospital, Salt Lake City, Utah8Department of Neurosurgery, Columbia University, Morgan Stanley Children’s Hospital of NewYork-Presbyterian, New York, NY9Division of Pediatric Surgery, Department of Surgery (A.C.A.), Departments of Radiology (T.N.B., and J.M.J.) and Neurological Surgery and Pediatrics (B.P.B.), and Division of Emergency Medicine, Department of Pediatrics (J.-A.O.N.), University of Texas Southwestern Medical Center at Dallas, Dallas, Texas10Department of Orthopedic Surgery, Children’s Mercy and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri11Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, California12Division of Orthopedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania13Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee14Shriners Hospitals for Children, Philadelphia, Pennsylvania15Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas16Department of Orthopedic Surgery, The Children’s Hospital at Montefiore, Bronx, New York17Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota18Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas19Department of Orthopedic Surgery, University of Tennessee – Campbell Clinic and Le Bonheur Children’s Hospital, Memphis, Tennessee20Department of Orthopedics, Rady Children’s Hospital and University of California-San Diego Medical Center, San Diego, California
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Pediatric cervical spine injury (CSI) that is related to blunt trauma occurs in 1% to 2% of all children who are admitted to the hospital after blunt trauma1-3. Cervical spine clearance for potential injury is performed daily in emergency departments (EDs) throughout the world. However, in a recent survey of level-I pediatric trauma centers in North America, only 46% of institutions had a written pediatric cervical spine clearance protocol4.In pediatric centers, an algorithmic approach or protocol for cervical spine clearance reduces time to cervical collar removal5 and limits patient exposure to ionizing radiation by reducing the use of radiography and computed tomography (CT)6,7. Published protocols and clinical guidelines for pediatric cervical spine clearance differ in criteria for clinical clearance and the use of imaging7-12.The Pediatric Cervical Spine Clearance Working Group (PCSCWG), a subgroup of the Pediatric Cervical Spine Study Group, recognized the need for a consensus on comprehensive standardized guidelines for pediatric cervical spine clearance based on the best available evidence. We established a multidisciplinary group of practitioners with expertise in cervical spine clearance for injured children and applied the Delphi method and the nominal group technique to create consensus statements regarding pediatric cervical spine clearance in young patients who have experienced blunt trauma13,14. The consensus statements were used to develop an algorithm to guide institutional protocols for cervical spine clearance.Materials and MethodsWorking GroupThe PCSCWG is a multidisciplinary panel of fellowship-trained physicians with experience in pediatric cervical spine trauma care who were recruited by the project leaders. The working group consisted of 15 pediatric orthopaedic surgeons, 3 pediatric emergency medicine physicians, 3 pediatric neurosurgeons, 2 pediatric trauma surgeons, and 2 pediatric radiologists. Participants agreed to complete a series of online surveys, participate in an in-person meeting, and collaborate with the project team to write a manuscript.Delphi MethodThe Delphi method and the nominal group technique are approaches to developing consensus and best-practice guidelines for completing complex tasks when there is insufficient scientific evidence to guide decision-making15. A modified version of the Delphi method was applied during a 7-month period with 4 rounds of voting. Consensus was defined as ≥80% agreement among panelists for each statement. The only choices offered were “agree” or “disagree.”Literature ReviewA search of the PubMed database was performed using the following terms: pediatric cervical spine injury, pediatric cervical spine fracture, pediatric cervical spine clearance, pediatric cervical spine trauma, cervical spine immobilization, and pediatric spinal cord. Primary research studies and reviews published from January 1, 1987, to June 30, 2016, were included. Case reports, single-author expert opinion pieces, and non-English-language articles were excluded. The project team reviewed the articles and identified 27 for consideration.Electronic SurveysAfter reviewing the literature, the project team developed a 20-question electronic survey (Survey 1) that was distributed online to panel members via SurveyMonkey in October 2016 (see Appendix). Survey 1 had 3 objectives: (1) to collect demographic data and clinical experience about the participants, (2) to collect practice profile data from the participants’ institutions, and (3) to introduce terminology that would be used for the remainder of the project. In December 2016, a second 66-question electronic survey (Survey 2) was distributed (see Appendix). Lastly, a 9-question electronic survey (Survey 3) was distributed after the January 2017 in-person meeting to clarify the role of flexion-extension imaging, a subject that reached near-consensus during the meeting (see Appendix).