Validation of the Subaxial Cervical Spine Injury Classification score in children: a single-institution experience at a level 1 pediatric trauma center

Martin G. Piazza Department of Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;
Department of Neurosurgery, UPMC Children’s Hospital of Pittsburgh, Pennsylvania;

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Vijay M. Ravindra Department of Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;
Division of Pediatric Neurosurgery, Rady Children’s Hospital, San Diego, California;
Department of Neurological Surgery, Naval Medical Center San Diego, California;

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Emma R. Earl Department of Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;
Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah;

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Allison Ludwick Department of Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;

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Gabriela Sarriera Valentin Department of Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;
Larner College of Medicine at the University of Vermont, Burlington, Vermont; and

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Andrew T. Dailey Department of Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;

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John R. W. Kestle Department of Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;

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Katie W. Russell Division of Pediatric Surgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah

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Douglas L. Brockmeyer Department of Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;

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Rajiv R. Iyer Department of Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;

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OBJECTIVE

The Subaxial Cervical Spine Injury Classification (SLIC) score has not been previously validated for a pediatric population. The authors compared the SLIC treatment recommendations for pediatric subaxial cervical spine trauma with real-world pediatric spine surgery practice.

METHODS

A retrospective cohort study at a pediatric level 1 trauma center was conducted in patients < 18 years of age evaluated for trauma from 2012 to 2021. An SLIC score was calculated for each patient, and the subsequent recommendations were compared with actual treatment delivered. Percentage misclassification, sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and area under the receiver operating characteristic (ROC) curve (AUC) were calculated.

RESULTS

Two hundred forty-three pediatric patients with trauma were included. Twenty-five patients (10.3%) underwent surgery and 218 were managed conservatively. The median SLIC score was 2 (interquartile range = 2). Sixteen patients (6.6%) had an SLIC score of 4, for which either conservative or surgical treatment is recommended; 27 children had an SLIC score ≥ 5, indicating a recommendation for surgical treatment; and 200 children had an SLIC score ≤ 3, indicating a recommendation for conservative treatment. Of the 243 patients, 227 received treatment consistent with SLIC score recommendations (p < 0.001). SLIC sensitivity in determining surgically treated patients was 79.2% and the specificity for accurately determining who underwent conservative treatment was 96.1%. The PPV was 70.3% and the NPV was 97.5%. There was a 5.7% misclassification rate (n = 13) using SLIC. Among patients for whom surgical treatment would be recommended by the SLIC, 29.6% (n = 8) did not undergo surgery; similarly, 2.5% (n = 5) of patients for whom conservative management would be recommended by the SLIC had surgery. The ROC curve for determining treatment received demonstrated excellent discriminative ability, with an AUC of 0.96 (OR 3.12, p < 0.001). Sensitivity decreased when the cohort was split by age (< 10 and ≥ 10 years old) to 0.5 and 0.82, respectively; specificity remained high at 0.98 and 0.94.

CONCLUSIONS

The SLIC scoring system recommended similar treatment when compared with the actual treatment delivered for traumatic subaxial cervical spine injuries in children, with a low misclassification rate and a specificity of 96%. These findings demonstrate that the SLIC can be useful in guiding treatment for pediatric patients with subaxial cervical spine injuries. Further investigation into the score in young children (< 10 years) using a multicenter cohort is warranted.

ABBREVIATIONS

AUC = area under the ROC curve; DLC = discoligamentous complex; GCS = Glasgow Coma Scale; IQR = interquartile range; ISS = Injury Severity Score; NPV = negative predictive value; PPV = positive predictive value; ROC = receiver operating characteristic; SLIC = Subaxial Cervical Spine Injury Classification.
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