A multidisciplinary approach to the development of a cervical spine clearance protocol: Process, rationale, and initial results

Abstract

Background/Purpose: Assessment of potential spine injuries is inconsistent and controversial. Subsequent morbidity includes prolonged immobilization and missed injuries. To address these issues, a multidisciplinary team was organized to design a cervical spine management/clearance pathway. The process, algorithm, and initial results are described. Methods: Team members consisted of pediatric surgeons, orthopedic surgeons, neurosurgeons, emergency room physicians, and trauma nurse practitioners. Nationwide standards, guidelines, and experiences across disciplines were reviewed, and a consensus pathway evolved for cervical spine clearance in children 8 years and younger. A short-term retrospective review (5 months) was performed to assess initial performance. Time required for clearance, number and type of imaging studies, and number of missed injuries were compared between a group of patients before (n = 71) and after (n = 56) the implementation of the pathway. Results: Strict guidelines for cervical spine immobilization and clearance criteria were defined. After implementation of this pathway, time required for cervical clearance in nonintubated children decreased (before, 12.3 ± 1.5 v after, 7.5 ± 0.9 hours; P =.014). A clear trend toward earlier clearance in intubated patients existed (before [n = 6], 40.0 ± 16.8 v after [n = 6], 19.4 ± 8.1 hours; P =.10); there need to be larger numbers to determine statistical significance. The 2 study groups were similar in age; mechanism of injury; Glasgow coma scale score; and number of plain x-rays, computed tomography scans, and magnetic resonance imaging studies obtained. Neither group had missed injuries. Conclusions: standards for cervical spine immobilization, assessment, and clearance. Implementation of such guidelines decreased time for cervical spine clearance, and ongoing analysis of sensitivity is encouraging. J Pediatr Surg 38:358-362. Copyright 2003, Elsevier Science (USA). All rights reserved.