What to do with a 2 YO in a C-collar?

Again, I find myself in the situation where I have to call the neurosurgery resident to evaluate a toddler in a C-collar because she keeps crying every time I touch her; making her exam unreliable. Thinking he's going to get a flex-ex, I find out that he cleared her clinically. Am I missing something?

Some basic questions to help solve this problem. First, what's the rate of C-spine injury (CSI) with or without spinal cord (SC) involvement in the setting of blunt trauma in this age group? Second,in which kids should I be worried about a CSI? Third, when are imaging studies indicated? Finally how do we clear the c-spine in a non-verbal child (whether imaging done or not)?

Polk-Williams et al reviewed the National Trauma Data Bank and identified over 95 thousand children younger than 3 years who sustained blunt trauma. The overall rate of CSI was 1.6%, with most injuries occurring in the setting of MVC's (rate of CSI doubles to 3.2%). Overall rate of SC injury (with or without a spinal column injury) was 0.4%. As expected most CSI (66%) occurred in the setting of MVC's, the second most common mechanism was falls (15%).

Ok, so CSI are uncommon, but occur more frequently with MVC (logical). But what do I do with this girl who fell off a trampoline? She has a GCS of 15, no distracting injuries, a relatively non-worrisome mechanism, but still cries every time I get close?

A multi center study of the American Association for the Surgery of Trauma looked at children younger than 3 years of age who sustained blunt trauma to clarify the approach to C-spine clearance (rate of CSI in that study was 0.66%). Based on predictors of CSI, they devised a weighted score that can be used to stratify kids based on risk for CSI and thus help determine who needs imaging and who doesn't. The score includes GCS<14 (3 points), GCSeye=1 (2 points), MVC (2 points), age 2 years or older (1 point). Based on the study, a score of 0 or 1 corresponded to a negative predictive value for CSI injury of 99.9%, and these children may be cleared without imaging studies. 70 percent of the population they studies fell into this category. Importantly, the few who escaped capture by this scoring system had other signs that prompted radiologic evaluation (splinting of neck and evidence of substantial head trauma). So based on that data, my girl in the ED, who had her eyes (and lungs) spontaneously wide open, could have been cleared without C-spine xrays. Which is fine, but I still needed to do an exam. Which is where I still am not sure that a screaming kid could have been cleared clinically. So, although based on these numbers, the chance of this girl having a CSI is minute, I'm not sure I would be comfortable clearing her C-spine without a good physical exam. References:

Polk-Williams A. et al. Cervical spine injury in young children: a National Trauma Data Bank review. Journal of Pediatric Surgery (2009). 43(9):1718-21

Pieretti-Vanmarcke R. et al. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: A multi-center study of the American Association for the Surgery of Trauma. The Journal of Trauma (2009). 67(3):543-550

Laparoscopic repair of inguinal hernias in female children: the Inversion/ligation technique

The open repair for inguinal hernias in children is a time honored technique used by most pediatric surgeons. Different variations of laparoscopic repair techniques have been adopted by some pediatric surgeons, with the main criticism of those techniques being a high rate of recurrence (4% compared to 1% with the open repair).

Despite my overall skepticism with laparoscopic repair techniques and their outcome, one particular version used for repair of hernias in females is quite appealing.

The inversion-ligation technique for repair entails passing a laparoscopic grasper into the inguinal canal through the internal ring, grasping the distal aspect of the sac, and inverting it into the abdomen. The inverted sac is then twisted and doubly ligated with an endo-loop.

Lipskar et al looked at the outcome of 173 girls who underwent a total of 241 hernia repair operations. The mean age was 5 years. One third of patients were found to have a contralateral patent processus vaginalis/hernia. All were successfully repaired in an average time of 40 minutes and 90% were discharged home the same day. Recurrence rate was 0.8%.

The appealing part of this operation is that, unlike other laparoscopic hernia repair techniques, the hernia sac is not left within the canal, which may be a major contributor to the reported high recurrence rate in other techniques. Because of the absence of any important structures (vas etc..), the hernia sac in girls can be bluntly pulled off the round ligament and inverted.

Lipskar et al. Laparosocpic inguinal hernia inversion and ligation in female children: a review of 173 consecutive cases at a single institution. Journal of Pediatric Surgery (2010) 45,1370-1374