Introduction

Evaluating children with blunt trauma for cervical spine injury (CSI) is a high-stakes and high-variability process. While CSI is rare, the consequences of missed injuries are serious, and so is the harm from overuse of imaging, especially CT. The PECARN CSI prediction rule is a promising tool to standardize care and reduce unnecessary imaging. But can it work across specialties? This study from Ahmad et al. examined how well pediatric Emergency Medicine and surgical providers agree when using the rule.

What Did They Do?

This was a planned secondary analysis of a large, prospective multicenter study by the PECARN network, involving 18 pediatric EDs. The authors assessed interrater reliability (IRR) between Emergency Medicine (EM) and surgical providers for history and physical examination findings related to CSI in children with blunt trauma. They used Kappa and prevalence-adjusted bias-adjusted Kappa (PABAK) to evaluate agreement. They also compared clinical suspicion for CSI and hypothetical imaging recommendations between the two groups.

Key Findings

Emergency Medicine and Surgical providers had high agreement when assessing most of the variables used in the PECARN cervical spine injury prediction rule. Here are selected findings:

Clinical Variable	How Often They Agreed	Level of Agreement (Kappa)	Adjusted Agreement (PABAK)
Motor vehicle crash	99%	Almost perfect (0.97)	Almost perfect (0.98)
Neck tenderness on exam	92%	Substantial (0.70)	Almost perfect (0.84)
Altered mental status	92%	Substantial (0.74)	Almost perfect (0.84)
Self-reported neck pain	89%	Substantial (0.66)	Substantial (0.78)
Signs of head injury	86%	Moderate (0.57)	Substantial (0.72)
Substantial torso injury	92%	Moderate (0.52)	Substantial (0.84)
Focal neurologic deficits	97%	Moderate (0.54)	Almost perfect (0.93)

What This Means

For most findings, EM and surgery providers saw the same things, and that supports team-based use of the PECARN rule.
Even variables like neck tenderness and altered mental status, which are more subjective, had substantial or better agreement.
Providers were less aligned in their overall clinical suspicion for CSI (only 64% agreement), but that didn’t affect whether they’d order the same imaging in most cases.

Imaging Recommendations Based on PECARN Rule

Imaging Recommendation	EM Providers	Surgical Providers	Same Decision?
Clinically cleared (no imaging)	702	753	✅ Yes (570 patients)
CT scan recommended	205	215	✅ Yes (146 patients)
Plain radiograph	587	526	✅ Yes (385 patients)
Total agreement	—	—	73.7% of cases

Why Does This Matter?

The PECARN CSI rule is only as useful as it is reliable. If EM and surgery providers assess patients differently, shared protocols won’t help streamline care or reduce over-imaging. This study suggests that, for most variables, there is good agreement between specialties, particularly when using a standardized rule. That’s promising for implementation efforts, especially in trauma teams using shared decision-making models. However, the variability in suspicion and imaging choice in one-quarter of patients signals room for improvement.

Bottom Line

This study shows moderate to substantial interrater reliability between EM and surgical providers when using the PECARN CSI prediction rule in pediatric trauma. The findings support broader implementation of the rule across trauma teams—but also remind us that shared assessments and communication matter, especially when decisions hinge on nuanced physical exam findings.

References

Ahmad FA, Browne LR, Glomb NW, et al. Interrater reliability between surgeons and pediatric emergency providers in the cervical spine assessment of injured children. J Trauma Acute Care Surg. 2025;00:00–00. doi:10.1097/TA.0000000000004695

This blog post was written by the author with editorial assistance from ChatGPT-4o (July 2025 version). The title graphic was also generated using AI-assisted tools – obviously!