As with the evaluation of any other trauma patient, first focus on the critical systems and stabilization of the airway, breathing and circulation. Patients who have mental status changes or require control of severe bleeding, airway or breathing are unlikely to be candidates to have their spines closely evaluated; they will benefit from rapid transport to a trauma center.
When patients, even pediatric patients, present with a mechanism for spinal column injury but otherwise without obvious injury, it may be beneficial to spend additional time performing a thorough on-scene evaluation. This may help identify more subtle symptoms of a spine injury, thus creating a heightened sense of awareness and care during the immobilization process.
There are six predictors of cervical spine injury:3
- Neck pain
- Substantial torso injury
- Conditions predisposing to cervical spine injury
- Shallow-water diving accidents
- High-risk MVCs (ejection, high speeds, etc.).
These six are 98% sensitive for injury and 28% specific, meaning that one of the six predictors is present in 98% of cervical spine injuries, but the presence of one of the six signifies only a 28% chance of injury. Torticollis is a stiff neck that is generally associated with one-sided muscle spasm. Patients with torticollis often have their heads tilted toward the injured side. When this develops following an accident, it suggests muscle or ligament injury. Any bone-density disorder can increase the patient’s injury potential. In children, osteogenesis imperfecta is a hereditary disorder that causes bones to become brittle and fracture easily. Osteogenesis imperfecta is often mistaken for multiple fractures associated with child abuse until a diagnosis is made. Other conditions that increase a child’s risk of spine injury include previous child abuse, preterm birth (first year), osteomyelitis, and deficiency of calcium, copper or Vitamin D.
During the physical exam of a child, begin at the feet and work toward the chest and head. Allow the patient to be as much a part of their own exam as they can, and move slowly to build their trust. In children, positive findings during a complete spine assessment are reliable as an indicator for spine injury; however, because of the immature bone structures of the child’s spinal column, the absence of positive findings is not always reliable as a sign of no injury. General signs and symptoms of spinal cord injury include flaccid extremities, paralysis, numbness, paresthesias (tingling or burning), weakness, priapism and incontinence. Vertebrae and ligament injuries are typically extremely painful and tender to the touch, and are associated with swelling.4
While pediatric patient spine clearance has not specifically been researched, it has been discussed in published literature. In 2006, the Journal of Trauma published “A Statewide Prehospital Emergency Medical Service Selective Patient Spine Immobilization Protocol,” by a team led by physician John Burton. This paper presented research on spine assessment protocols in Maine. During this study, EMS providers used an approved spine assessment to determine the need for immobilization, and the study proved 87% sensitive for identifying spine injury.6 During this study all patients deemed reliable were candidates for the spine assessment, regardless of age. Patients ranged from 0–109 years, and of the 20 not immobilized and later found to have spine injury, none were pediatric.6 This supported a 1999 paper from authors led by Marc Muhr, EMT-P, that demonstrated paramedics could safely rule out the need for spine immobilization.7 Muhr’s study included 118 patients under 18 and had no minimum age for inclusion. Thus, for those regions with spine assessment protocols in place, it is reasonable to discuss with local medical directors if inclusion criteria should be based on patient reliability, mentation and ability to follow commands rather than age.
During a physical exam providers may observe motor deficit. While the degree of motor deficit has not traditionally been documented during prehospital care, doing so can allow neurosurgeons to compare how patient motor strength changes over time. Additionally, prehospital providers with extended transport times may be able to document measurable improvements or declines in motor function depending on the type of injury a patient has sustained. Table 1 identifies the motor strength assessment scale from the American Spinal Injury Association.