What is the PECARN (Pediatric Emergency Care Applied Research Network) c-spine rule?

PECARN C-Spine Rule for Pediatric Trauma Evaluation

The PECARN c-spine rule is the most validated clinical decision tool for identifying children at risk for cervical spine injury following trauma, recommending imaging for patients with any of these high-risk factors: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, predisposing conditions, diving mechanism, or high-risk motor vehicle crash. 1

PECARN C-Spine Rule Components

The PECARN c-spine rule applies to children from 0 to <16 years of age and identifies patients at high risk for cervical spine injury who require imaging if any of the following are present:

1. Altered mental status
2. Focal neurologic findings
3. Neck pain
4. Torticollis
5. Substantial torso injury
6. Conditions predisposing to cervical spine injury
7. Diving mechanism
8. High-risk motor vehicle crash

Performance and Validation

The PECARN c-spine rule has demonstrated excellent performance characteristics:

• Sensitivity of 96-100% for detecting clinically important cervical spine injuries 1, 2
• Negative predictive value of 99.8% 2
• Superior performance compared to other decision rules like NEXUS in pediatric populations

Age-Specific Considerations

Children <8 years

• Most injuries occur in the upper cervical spine due to:
  • Incomplete ossification
  • Unfused synchondroses
  • Ligamentous laxity
  • Large head-to-body ratio 1
• Higher risk of SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) 1

Children ≥8 years

• Spinal column development is more mature
• Most injuries involve the lower cervical spine 1

Comparison to Other Clinical Decision Rules

Rule	Age Group	Key Differences
PECARN	0 to <16 years	Most validated for pediatrics; focuses on 8 specific risk factors
NEXUS	≥2 years	Includes midline tenderness which may be less reliable in children
Pieretti-Vanmarcke	≤3 years	Uses weighted scoring system

Common Pitfalls and Caveats

1. Midline tenderness: Unlike NEXUS, PECARN does not include midline tenderness as a criterion since it's very prevalent in children and not a reliable predictor of cervical injury 1

2. Overuse of imaging: If strictly applied as a rule for imaging, PECARN would lead to imaging rates of approximately 68% of children with suspected c-spine injury 3

3. Prehospital application: When applied by EMS providers, the PECARN rule shows high sensitivity (96%) and negative predictive value (99.8%), but lower specificity (38.5%) 2

4. Spinal motion restriction: Currently applied to 41.5% of children with blunt trauma, despite only 1.6% having actual cervical spine injuries 4

Implementation in Clinical Practice

For optimal application of the PECARN c-spine rule:

• Apply the rule to determine need for imaging rather than need for spinal motion restriction
• Consider observation for patients with isolated findings
• Be particularly cautious with children <2 years who cannot reliably communicate symptoms
• Remember that up to 50% of intracranial injuries occur without fracture 1

The PECARN c-spine rule represents the most robust and validated approach to evaluating pediatric cervical spine injury risk, balancing the need to identify injuries while minimizing unnecessary radiation exposure.