Comparison of Cervical Spine Injury Clinical Prediction Rules for Children After Blunt Trauma

Infographic · Mar 2026 · 2 min read

In brief

This multi-center study compared three clinical prediction rules for identifying cervical spine injury in 22,430 children after blunt trauma. The PECARN rule demonstrated highest sensitivity (93.3%) and lowest projected CT imaging rate (6.9%), outperforming NEXUS and Canadian C-spine rules for pediatric risk stratification.

PECARN CSI rule demonstrated highest sensitivity (93.3%) and NPV (99.8%) for detecting pediatric cervical spine injury after blunt trauma.
Applying PECARN rule would result in lowest CT imaging rate (6.9%) compared to NEXUS (10.8%) and Canadian C-spine rule (13.2%).
Cervical spine injury remains rare in children (1.9% prevalence), making accurate risk stratification essential to avoid unnecessary imaging.
NEXUS had lowest sensitivity (85.7%), missing more injuries than PECARN or Canadian C-spine rules in this 22,430-patient cohort.
PECARN rule optimally balances injury detection with radiation exposure reduction in pediatric trauma patients.

Written by the GCMD Library team from the infographic.

A multi-section infographic with teal, maroon, and yellow color blocks. Features cartoon illustrations of an injured child, medical staff with a patient on a stretcher, and a child in a CT scanner. Information is organized in hierarchical sections with bullet points and large statistics.

Lois K Lee, Fahd A Ahmad, Lorin R Browne, Monica Harding, Lawrence Cook, Kathleen Adelgais, Rebecca K Burger, Alexander Rogers, Leah Tzimenatos, Lauren C Riney, Daniel Rubalcava, Caleb E Ward, Kenneth Yen, Julie C Leonard

Importance: Pediatric cervical spine injury (CSI) is a rare occurrence; however, CSI can result in significant disability and death. It is essential to determine the optimal CSI clinical prediction rule to risk stratify children with potential CSI after blunt trauma who require cervical spine imaging.

Objective: To compare the test characteristics and projected imaging rates between 3 prospectively derived CSI clinical prediction rules: the Pediatric Emergency Care Applied Research Network CSI prediction rule (PECARN CSI rule), the National Emergency X-Radiography Utilization Study (NEXUS), and the Canadian Cervical Spine (c-spine) rule (CCR).

Design, setting, and participants: This comparative effectiveness study was a planned secondary analysis of a prospective observational study enrolling from December 2018 to October 2021 in 18 PECARN emergency departments. Eligible participants were children up through age 17 years presenting after blunt trauma. Data were analyzed between March 2024 and January 2025.

Exposures: Enrollment in the primary study to develop and validate the PECARN CSI prediction rule.

Main outcome measures: Test characteristics with 95% CIs (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV]) and area under the curve (AUC) for the receiver operator curves (ROC) for the detection of CSI using each of the 3 rules. We also estimated the projected c-spine imaging rate (radiography or computed tomography [CT]) based on criteria for each of the 3 rules.

Results: There were 22 430 eligible children enrolled (median [IQR] age 8 [2.0-13.0] years; 13 068 male [58.3%]) and 433 (1.9%) had CSI. C-spine imaging was performed 12 768 children (56.9%): 8912 (39.7%) had radiography and 3856 (17.2%) were imaged with CT. The sensitivity of the 3 rules was: PECARN CSI rule, 93.3% (95% CI, 90.9%-95.7%); NEXUS, 85.7% (95% CI, 82.4%-89.0%); and CCR, 90.8% (95% CI, 88.0%-93.5%). The NPV of the 3 rules was: PECARN, 99.8% (95% CI, 99.7%-99.9%); NEXUS, 99.6% (95% CI, 99.5%-99.7%); and CCR, 99.7% (95% CI, 99.6%-99.8%). Strictly applying each rule resulted in projected CT imaging of 1549 children (6.9%) for PECARN, 2419 (10.8%) for NEXUS, and 2968 (13.2%) for CCR.

Conclusions and relevance: In this comparative effectiveness study of CSI prediction rules in children, the PECARN CSI rule had the highest sensitivity and NPV for identifying children at risk for CSI after blunt trauma, with the lowest projected CT imaging rate.

The text in the image

Comparison of Cervical Spine Injury Clinical Prediction Rules for Children After Blunt Trauma | Comparative Effectiveness Study | 2018-2021 | 22,430 patients with blunt trauma | 0-17 years old | 433 children diagnosed w/ cervical spine injury (CSI) | 18 PECARN emergency departments | 3 CSI prediction rules performs best for radiologic imaging | Pediatric Emergency Care Applied Research Network (PECARN) | Canadian C-Spine Rule | National Emergency X-Radiography Utilization Study (NEXUS) | PECARN CSI had the best diagnostic performance: | Highest sensitivity | Best negative predictive value | Lowest projected CT imaging rate | Conclusion: The PECARN cervical spine injury rule performs best for identifying pediatric cervical spine injury after blunt trauma while minimizing CT imaging. | https://pmc.ncbi.nlm.nih.gov/articles/PMC12717614/ | LK Lee et. al. | Department of Emergency Medicine, Boston Children's Hospital, United States | @LizzyPAC8 | @globalcastmd | @StayCurrentMD | Cincinnati Children's