title: Pediatric cervical spine injury evaluation after blunt trauma: a clinical decision analysis.
abstract: OBJECTIVE
  Although many adult algorithms for evaluating cervical spine injury use computed tomography (CT) as the initial screening modality, this may not be appropriate in low-risk children, considering radiation risks. We determine the optimal initial evaluation strategy for cervical spine injury in pediatric blunt trauma.
  
  
  METHODS
  We constructed a decision analysis tree for a hypothetical population of patients younger than 19 years with blunt trauma, using 3 strategies: clinical stratification, screening radiographs followed by focused CT if the radiograph result was positive, and CT. For the model inputs, we used the current literature to determine the probabilities of cervical spine injury and estimate the long-term risks of malignancy after CT, as well as test characteristics of radiographic imaging. We used published utilities and conducted 1- and 2-way sensitivity analyses to determine the optimal strategy for evaluation of pediatric cervical spine injury.
  
  
  RESULTS
  In our model of a population with blunt trauma, the expected value of a clinical stratification strategy was the highest of the 3 strategies, making it the overall preferred management. One-way sensitivity analysis of several contributing factors revealed that the only independent factor that altered the dominant strategy was the sensitivity of clinical clearance criteria, lowering the threshold at which screening-radiograph strategy is optimal. Within the patient population considered as having non-negligible risk by clinical stratification and thus requiring imaging, the preferred imaging modality was screening radiograph/focused CT. The probability of cervical spine injury above which CT became the preferred strategy was 24.9%.
  
  
  CONCLUSIONS
  The model highlights that clinical clearance and screening radiographs in a hypothetical trauma pediatric population are preferred strategies, whereas CT scanning is rarely the initial optimal evaluation.
authors.affiliation: Division of Emergency Medicine, Boston Children's Hospital, Boston, MA. Electronic address: megan.hannon@childrens.harvard.edu.
authors.forename: Megan
authors.initials: M
authors.lastname: Hannon
authors.affiliation: Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
authors.forename: Rebekah
authors.initials: R
authors.lastname: Mannix
authors.affiliation: Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
authors.forename: Kate
authors.initials: K
authors.lastname: Dorney
authors.affiliation: Department of Surgery, Boston Children's Hospital, Boston, MA.
authors.forename: David
authors.initials: D
authors.lastname: Mooney
authors.affiliation: Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
authors.forename: Kara
authors.initials: K
authors.lastname: Hennelly
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries*; D002648:Child; D003661:Decision Support Techniques; D003663:Decision Trees; D006801:Humans; D014057:Tomography, X-Ray Computed; D014949:Wounds, Nonpenetrating / Q000175:diagnosis* / Q000000981:diagnostic imaging