Choosing Wisely:

Don’t obtain imaging of the cervical spine following trauma in a patient who is awake and alert without considering the use of clinical decision-making tools for cervical spine clearance.

Rationale and Comments: Consideration should be given to avoid unnecessary radiation exposure when appropriate. For instance, clinical decision-making tools incorporate three or more variables from history, physical examination, or simple clinical tests to guide patient management. Results from the National Emergency X-Radiography Utilization Study (NEXUS) and the Pediatric Emergency Care Applied Research Network (PECARN) provide a high negative predictive value for significant cervical spine injuries in pediatric patients. Low-risk criteria from NEXUS include: no posterior midline cervical spine tenderness, no evidence of intoxication, normal level of consciousness, no focal neurological deficit, and no painful distracting injuries. PECARN developed a model that was highly sensitive for a normal cervical spine in the absence of: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, high-risk motor vehicle crash, and diving. In comparison to NEXUS, the PECARN model takes into account mechanism of injury and specific extent and location of other associated injuries.
Sponsoring Organizations:
  • American Academy of Pediatrics – Section on Neurological Surgery
  • Sources:
  • Expert consensus
  • Disciplines:
  • Emergency medicine
  • References: • Hoffman JR, Mower WR, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94-99.
    • Leonard JC, Kupperman N, et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med. 2011;58(2):145-155.

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