X-ray vs. CT in identifying significant C-spine injuries in the pediatric population

Imaging Outcomes of MRI After CT in Pediatric Spinal Trauma: A Single-center Experience

BACKGROUND

Imaging has an essential role in the diagnostic workup of suspected pediatric spinal trauma. The most suitable imaging method is still being debated and needs to be considered regarding the patient, injury, and local resources. Magnetic resonance imaging (MRI) is often performed after computed tomography (CT) in case of neurological symptoms or suspected ligamentous disruption. However, it is unclear if the MRI yields significant additional value after CT if the spinal cord injury is not suspected and if the MRI could be used as the sole imaging modality in an emergency department. This study aimed to assess the diagnostic value of emergency MRI after CT in suspected spinal trauma in children and adolescents.

METHODS

The imaging data and medical records of patients 17 years of age and younger with emergency spinal CT and MRI over 8 years were retrospectively reviewed. The primary study outcome was the diagnostic accuracy of the 2 imaging modalities in detecting surgically treated spinal injuries.

RESULTS

The study population consisted of 100 patients. Computed tomography and magnetic resonance imaging demonstrated all 7 surgically treated injuries, although one of the injuries was initially missed with CT. Magnetic resonance imaging revealed more injuries, but none of the injuries visible on CT required surgical fixation. Magnetic resonance imaging was able to exclude unstable injuries in patients who had highly suspicious or unequivocal findings on CT.

CONCLUSIONS

Magnetic resonance imaging and computed tomography were both highly accurate in detecting unstable pediatric spinal injuries requiring surgical treatment. Magnetic resonance imaging seems not to reveal additional unstable injuries after adequately interpreted spinal CT.

LEVEL OF EVIDENCE

Level III-retrospective observational study.

Comparison between artificial intelligence solution and radiologist for the detection of pelvic, hip and extremity fractures on radiographs in adult using CT as standard of reference

PURPOSE

The purpose of this study was to compare the diagnostic performance of an artificial intelligence (AI) solution for the detection of fractures of pelvic, proximal femur or extremity fractures in adults with radiologist interpretation of radiographs, using standard dose CT examination as the standard of reference.

MATERIALS AND METHODS

This retrospective study included 94 adult patients with suspected bone fractures who underwent a standard dose CT examination and radiographs of the pelvis and/or hip and extremities at our institution between January 2022 and August 2023. For all patients, an AI solution was used retrospectively on the radiographs to detect and localize bone fractures of the pelvis and/or hip and extremities. Results of the AI solution were compared to the reading of each radiograph by a radiologist using McNemar test. The results of standard dose CT examination as interpreted by a senior radiologist were used as the standard of reference.

RESULT

A total of 94 patients (63 women; mean age, 56.4 ± 22.5 [standard deviation] years) were included. Forty-seven patients had at least one fracture, and a total of 71 fractures were deemed present using the standard of reference (25 hand/wrist, 16 pelvis, 30 foot/ankle). Using the standard of reference, the analysis of radiographs by the AI solution resulted in 58 true positive, 13 false negative, 33 true negative and 15 false positive findings, yielding 82 % sensitivity (58/71; 95 % confidence interval [CI]: 71-89 %), 69 % specificity (33/48; 95 % CI: 55-80 %), and 76 % accuracy (91/119; 95 % CI: 69-84 %). Using the standard of reference, the reading of the radiologist resulted in 65 true positive, 6 false negative, 42 true negative and 6 false positive findings, yielding 92 % sensitivity (65/71; 95 % CI: 82-96 %), 88 % specificity (42/48; 95 % CI: 75-94 %), and 90 % accuracy (107/119; 95 % CI: 85-95 %). The radiologist outperformed the AI solution in terms of sensitivity (P = 0.045), specificity (P = 0.016), and accuracy (P < 0.001).

CONCLUSION

In this study, the radiologist outperformed the AI solution for the diagnosis of pelvic, hip and extremity fractures of the using radiographs. This raises the question of whether a strong standard of reference for evaluating AI solutions should be used in future studies comparing AI and human reading in fracture detection using radiographs.

Pediatric C-spine Clearance by CT: A Retrospective Cohort Study

BACKGROUND

Pediatric cervical spinal injury (CSI) remains a significant concern following blunt trauma, with mortality rates as high as 48%. Current protocols involve cervical immobilization and clearance through multidetector computed tomography (MDCT) scans, followed by magnetic resonance imaging (MRI) or clinical examination. However, prolonged collar use poses risks, necessitating timely clearance. This study assessed the efficacy of MDCT in pediatric CSI clearance.

METHODS

A retrospective cohort study, spanning January 2019 to January 2023, included pediatric patients under 18 undergoing cervical CT scans.

RESULTS

MDCT sensitivity was evaluated, with 13.8% positive scans, detecting clinically significant injuries. MRI identified no additional injuries, affirming MDCT reliability. The average clearance time was 24.9 hours, impacting hospitalization durations. Mortality unrelated to CSI was excluded.

CONCLUSION

These results align with recent studies advocating cervical collar removal based on negative MDCT, emphasizing its potential to decrease the time that patients remain in C-collars and expedite hospital courses, including therapy and discharge. The study encourages consideration of MDCT-based protocols for timely pediatric CSI clearance, promoting patient care efficiency and informed medical decision-making.

Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study

Importance

There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients.

Objective

To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model.

Design, Setting, and Participants

This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022.

Exposure

Blunt trauma.

Main Outcomes and Measures

Primary outcome was CSI. The primary and secondary objectives were predetermined.

Results

The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915).

Conclusion and Relevance

This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.

Relationship of cervical soft tissue injury and surgical predication following pediatric cervical spinal trauma and its sequelae on long-term neurologic outcome

Within the sample of 181 patients with cervical CT, CT identified unstable injury with a sensitivity of 100% and specificity of 95%. CT identified operable injury at the CCJ with 86% sensitivity and 91% specificity. CT was considered the gold standard for identification of fractures. Together, the presence of CT imaging suggestive of unstable injury or persistent neurologic complaint had a 100% sensitivity and 81% specificity. Finally, across all patients MRI had 100% sensitivity and 89% specificity for detection of unstable injury requiring surgery.

Can you see with CT? Is cervical spine computed tomographic imaging sufficient in pediatric trauma?

BACKGROUND

Traumatic cervical spine injury (CSI) is fundamentally different in children, and imaging recommendations vary; however, prompt diagnosis is necessary.

METHODS

We conducted a retrospective cohort study, evaluating children who presented after traumatic injury from 7/1/2012 to 12/31/2019 receiving a cervical spine CT. Evaluation of the incidence and clinical significance of CSI undetected on CT subsequently diagnosed on MRI was conducted. Additionally, all with CSI underwent image review to evaluate for potential overlooked, but visible pathology.

RESULTS

1487 children underwent a cervical spine CT, revealing 52 with CSI. 237 underwent MRI due to an abnormal CT or continued clinical concern. Ultimately, three were discovered to have clinically significant CSI missed on CT. In all cases, retrospective review demonstrated a retroclival hematoma when soft tissue windows were formatted in sagittal and coronal views.

CONCLUSIONS

A normal CT may be sufficient to rule-out clinically significant CSI. However, the presence of a retroclival hematoma must be evaluated.

Pediatric spinal injuries- current concepts

Spinal injuries in children contribute to the highest mortality and morbidity among all pediatric injuries. Fortunately, these injuries are a rare clinical entity but pose a difficulty in diagnosis due to challenges in neurological evaluation of a child and varied radiological presentation. Anatomical and biomechanical aspects of developing musculoskeletal system, relative plasticity of the pediatric spine make children vulnerable to spine injuries. Though motor vehicle collisions are common, children also suffer non-accidental trauma, falls and sports injuries. More chances of cervical spine involvement, higher susceptibility of spinal cord to tensile forces and associated multisystem injuries result in devastating consequences in children compared to adults. Injuries like SCIWORA, vertebral apophyseal injuries, birth-related spinal cord injuries are more specific injuries in pediatric age group. A vigilant clinical, neurological and radiological evaluation is mandatory in all children with suspected spinal injuries. Normal radiological features like ossification centers, pseudosubluxation and physiological vertebral wedging should be carefully noted as they could be misinterpreted as injuries. While CT scans help in better understanding of the fracture pattern, Magnetic Resonance Imaging in children is beneficial especially in detecting SCIWORA and other soft tissue injuries. Management principles of these pediatric spinal injuries are similar to adults. Literature evidences support conservative management in injuries like SCIWORA, unless there is an ongoing spinal cord compression. As in adults, the role of high dose methylprednisolone is still controversial in pediatric spinal cord injuries. Stable spinal injuries can be managed conservatively using orthosis or halo. Instrumentation by both anterior and posterior techniques has been described, but it is challenging due to smaller anatomy and poor implant purchase. In addition to pedicle screw instrumentation, wiring techniques are very beneficial especially in younger children.

Traumatic Cervical Facet Fractures and Dislocations

»

Flexion-distraction, axial loading, and rotational forces can cause various degrees of osseoligamentous disruption of the cervical spine, leading to traumatic cervical facet fractures and dislocations.

»

Low-energy forces lead to minimally displaced facet fractures that often can be treated with immobilization only. High-energy forces are more likely to cause unstable injuries with or without neurologic compromise, which may require surgical intervention.

»

The initial treatment of cervical facet injuries requires patient evaluation and management through the Advanced Trauma Life Support (ATLS) protocols, while definitive management varies based on the biomechanical components of the injury, the neurologic status of the patient, and additional patient factors.

»

Cervical facet injuries often require a multidisciplinary approach to optimize long-term functional outcomes and minimize serious complications.

Targeting bone microenvironments for treatment and early detection of cancer bone metastatic niches

Bone tissues are the main metastatic sites of many cancers, and bone metastasis is an important cause of death. When bone metastasis occurs, dynamic interactions between tumor cells and bone tissues promote changes in the tumor-bone microenvironments that are conducive to tumor growth and progression, which also promote several related diseases, including pathological fracture, bone pain, and hypercalcemia. Accordingly, it has obvious clinical benefits for improving the cure rate and reducing the occurrence of related diseases through targeting bone microenvironments for the treatment and early detection of cancer bone metastasis niches. In this review, we briefly analyzed the relationship between bone microstructures and tumor metastasis, as well as microenvironmental changes in osteoblasts, osteoclasts, immune cells, and extracellular and bone matrixes caused when metastatic tumor cells colonize bones. We also discuss novel designs in nanodrugs for inhibiting tumor proliferation and migration through targeting to tumor bone metastases and abnormal bone-microenvironment components. In addition, related researches on the early detection of bone and multi-organ metastases by nanoprobes are also introduced. And we look forward to provide some useful proposals and enlightenments on nanotechnology-based drug delivery and probes for the treatment and early detection of bone metastasis.

Diagnostic Yield of Axial Computed Tomography Scans for Pediatric Axial Skeletal Injuries

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the diagnostic yield of computed tomography (CT) imaging of the axial skeleton in pediatric patients evaluated a level I trauma center.

SUMMARY OF BACKGROUND DATA

CT imaging has become ubiquitous in the assessment of axial skeletal injuries in trauma patients.

METHODS

This is a retrospective study from one Level I trauma center of patients undergoing CT imaging during pediatric trauma assessment. Medical records of pediatric trauma patients 18-year old and younger who underwent axial skeletal CT imaging from 2013 to 2015 were evaluated. The following were assessed: mechanism of injury, age, sex, race/ethnicity, presence of fracture, management of fracture.

RESULTS

A total of 831 patients were assessed, there were 355 (42.7%) females and 476 males (57.3%) with an average age of 15.4 (2 mo-18 yrs). 588 (70.8%) were White, 164 (19.7%) were African-American, 12 (1.4%) were Asians, 67 (8.1%) other, and 46 (5.5%) identified as Hispanic. There were 45 patients (5.4%) who sustained 52 fractures. Common mechanisms were motor vehicle accidents (MVA) 28%, sports injuries (18%), and fall from height (15%). 35.9% of fractures were identified on plain radiographs. Nine injuries were treated surgically (one cervical, two thoracic, two lumbar, and four pelvic); three of these were identified on radiographs. From the 14 patients with cervical spine fractures none were detected on radiographs.

CONCLUSION

In this large series of 831 pediatric patients undergoing axial CT imaging, the rate of axial fractures was 5.4%. The majority of these fractures were managed non-surgically. Only 35.9% of fractures were identified on radiographs.Level of Evidence: 3.

Radiation Reduction Strategies in Pediatric Orthopaedics

INTRODUCTION

Pediatric orthopaedic patients have the potential for significant radiation exposure from the use of imaging studies, such as computed tomography and bone scintigraphy. With the potential for long-term treatment, such as is required for scoliosis or osteogenesis imperfecta, patients are at even greater risk of radiation-induced carcinogenesis.

DISCUSSION

Although an association between radiation and cancer risk is evident, causation is difficult to prove because comorbidities or genetic predispositions may play a role in the higher baseline rates of malignancy later in life. Efforts have been made over the years to reduce exposure using more modern imaging techniques and simple radiation reduction strategies. Educational efforts and clinical practice guidelines are decreasing the rate of computed tomography scan use in pediatrics. Although considerable work is being done on the development of radiation-free imaging modalities, imaging that uses ionizing radiation will, in the near term, be necessary in specific circumstances to provide optimal care to pediatric orthopaedic patients.

CONCLUSION

Knowledge of the ionizing radiation exposure associated with commonly used tests as well as radiation-reduction strategies is essential for the optimal and safe care of pediatric orthopaedic patients.

Implementation of a dual cervical spine and blunt cerebrovascular injury assessment pathway for pediatric trauma patients

BACKGROUND

Pediatric cervical spine (CSI) and blunt cerebrovascular injuries (BCVI) are challenging to evaluate as they are rare but carry high morbidity and mortality. CT scans are the traditional imaging modality to evaluate for CSI/BCVI, but involve radiation exposure and potential future increased risk of malignancy. Therefore, we present results from the implementation of a combined CSI/BCVI pediatric trauma clinical pathway to aid clinicians in their decision-making.

METHODS

We conducted a 2-year retrospective cohort study analyzing data pre and post implementation of the combined CSI/BCVI pathway. Data was obtained from a level 1 pediatric trauma center and included blunt trauma patients under the age of 14. We evaluated the use of cervical spine computed tomography (CT), CT angiography, and plain radiographs, as well as missed injuries and provider pathway adherence.

RESULTS

We included 358 patients: 209 pre-pathway and 149 post-pathway implementation. Patient mean age was 8.9 years and 61% were male (61% males). There were no significant differences in GCS, AIS, and ISS between pre and post pathway groups. Post pathway implementation saw reduced use of cervical spine CT, although this was not clinically significant (33% vs 31%, p = 0.74). However, cervical spine radiography use increased (9% vs 16%, p = 0.03), and there was also an increase in screening for BCVI injuries with higher use of CTA (5% vs 7%, p = 0.52). A total of 12 CSI and 3 BCVI were identified with no missed injuries. Provider adherence to the pathway was modest (54%). Conclusion Implementation of a combined CSI/BCVI clinical pathway for pediatric trauma patients increased screening radiography and did not miss any injuries. However, CT use did not significantly decrease and provider adherence was modest, supporting the need for further implementation analysis and larger studies to validate the pathway's sensitivity and specificity for CSI/BCVI.

Pediatric cervical spine injury in the United States: Defining the burden of injury, need for operative intervention, and disparities in imaging across trauma centers

BACKGROUND

Pediatric cervical spine injury (PCSI) in children is rare. Incidence of PCSI requiring intervention is not known, and imaging practices for screening in United States trauma centers are not well described.

METHODS

The 2016 NTDB was queried for patients younger than 15 years with PCSI. Incidence of PCSI, operative interventions, and imaging rates were analyzed by age and ACS accreditation status.

RESULTS

Of 84,554 children, 873 (1.03%) had PCSI. Patients <4 years were less likely to have PCSI (0.68% vs. 1.1%, RR 0.59, p < 0.001). 165 children (0.20%) required an intervention for PCSI. 12.8% of all children were screened for PCSI with imaging, 9.3% with CT, and 3.2% with plain X-rays. In spite of similar injury and intervention rates, stand-alone pediatric trauma centers were less likely than others to image patients without PCSI (11% vs. 13% p < 0.001), less likely to utilize CT scan (5.8% vs. 10.6% p < 0.001) and more likely to utilize plain films (5.2% vs. 2.4% p < 0.001).

CONCLUSION

Despite exceedingly low rates of PSCI requiring intervention (0.2%), imaging rates for screening are significant. Stand-alone pediatric trauma centers outperform others in limiting unnecessary imaging.

LEVEL OF EVIDENCE

IV.

Pediatric Cervical Spine Injuries and SCIWORA: WFNS Spine Committee Recommendations

Cervical trauma in children have variations from the adults mainly due to anatomic differences. An optimal diagnostic and treatment strategy is critical, particularly when there is a lack of standardized protocols for the management of such cases. This review paper examines the diagnostic and treatment options of pediatric cervical trauma and Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). A literature search for the last 10 years were conducted using key words. Case reports, experimental studies, papers other than English language were excluded. Up-to-date information on pediatric cervical trauma and SCIWORA were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of WFNS Spine Committee. The statements were voted and reached a consensus using Delphi method. This review reflects different aspects of contemporary pediatric cervical trauma decision-making and treatment, and SCIWORA. The mainstay of SCIWORA treatment is nonsurgical with immobilization, avoidance of risky activities. Prognosis generally depends on the initial neurological status and magnetic resonance imaging. Due to a significant discrepancy in the literature on diagnostic and management, future randomized controlled trials are needed to aid in generating standardized protocols.

Increased and unjustified CT usage in paediatric C-spine clearance in a level 2 trauma centre

PURPOSE

Cervical spine injury after blunt trauma in children is rare but can have severe consequences. Clear protocols for diagnostic workup are, therefore, needed, but currently not available. As a step in developing such a protocol, we determined the incidence of cervical spine injury and the degree of protocol adherence at our level 2 trauma centre.

METHODS

We analysed data from all patients aged < 16 years suspected of cervical spine injury after blunt trauma who had presented to our hospital during two periods: January 2010 to June 2012, and January 2017 to June 2019. In the intervening period, the imaging protocol for diagnostic workup was updated. Outcomes were the incidence of cervical spine injury and protocol adherence in terms of the indication for imaging and the type of imaging.

RESULTS

We included 170 children in the first study period and 83 in the second. One patient was diagnosed with cervical spine injury. Protocol adherence regarding the indication for imaging was > 80% in both periods. Adherence regarding the imaging type decreased over time, with 45.8% of the patients receiving a primary CT scan in the second study period versus 2.9% in the first.

CONCLUSION

Radiographic imaging is frequently performed when clearing the paediatric cervical spine, although cervical spine injury is rare. Particularly CT scan usage has wrongly been emerging over time. Stricter adherence to current protocols could limit overuse of radiographic imaging, but ultimately there is a need for an accurate rule predicting which children really are at risk of injury.

Neck Injuries

Neck injuries are relatively uncommon but have the potential to cause serious and permanent disability. In athletes, injuries are most common in contact sports, and occur with direct axial loading with a forward-flexed neck. Soft tissue and peripheral nerve injuries are typically minor and self-limiting, with excellent recovery potential and return to activities based on symptoms. Concern for devastating spinal cord injuries has led to routine immobilization using spine boards and hard cervical collars. This approach may provide more harm than benefit when applied universally, and a more commonsense protocol can be used to better address potential neck injuries.

Cervical spine evaluation in pediatric trauma: A cost-effectiveness analysis

OBJECTIVE

The emergent evaluation of children with suspected traumatic cervical spine injuries (CSI) remains a challenge. Pediatric clinical pathways have been developed to stratify the risk of CSI and guide computed tomography (CT) utilization. The cost-effectiveness of their application has not been evaluated. Our objective was to examine the cost-effectiveness of three common strategies for the evaluation of children with suspected CSI after blunt injury.

METHODS

We developed a decision analytic model comparing these strategies to estimate clinical outcomes and costs for a hypothetical population of 0-17 year old patients with blunt neck trauma. Strategies included: 1) clinical pathway to stratify risk using NEXUS criteria and determine need for diagnostic testing; 2) screening radiographs as a first diagnostic; and 3) immediate CT scanning for all patients. We measured effectiveness with quality-adjusted life years (QALYs), and costs with 2018 U.S. dollars. Costs and effectiveness were discounted at 3% per year.

RESULTS

The use of the clinical pathway results in a gain of 0.04 QALYs and a cost saving of $2800 compared with immediate CT scanning of all patients. Use of the clinical pathway was less costly and more effective than immediate CT scan as long as the sensitivity of the clinical prediction rule was greater than 87% and when the sensitivity of x-ray was greater than 84%.

CONCLUSION

A strategy using a clinical pathway to first stratify risk before further diagnostic testing was less costly and more effective than either performing CT scanning or screening cervical radiographs on all patients.

A Review on the Etiology and Management of Pediatric Traumatic Spinal Cord Injuries

CONTEXT

Pediatric traumatic spinal cord injury (SCI) is an uncommon presentation in the emergency department. Severe injuries are associated with devastating outcomes and complications, resulting in high costs to both the society and the economic system.

EVIDENCE ACQUISITION

The data on pediatric traumatic spinal cord injuries has been narratively reviewed.

RESULTS

Pediatric SCI is a life-threatening emergency leading to serious outcomes and high mortality in children if not managed promptly. Pediatric SCI can impose many challenges to neurosurgeons and caregivers because of the lack of large studies with high evidence level and specific guidelines in terms of diagnosis, initial management and of in-hospital treatment options. Several novel potential treatment options for SCI have been developed and are currently under investigation. However, research studies into this field have been limited by the ethical and methodological challenges.

CONCLUSION

Future research is needed to investigate the safety and efficacy of the recent uprising neurodegenerative techniques in SCI population. Owing to the current limitations, there is a need to develop novel trial methodologies that can overcome the current methodological and ethical limitations.

Diffusion Tensor Imaging: Tool for Tracking Injured Spinal Cord Fibres in Rat

Spinal cord injury (SCI) is a severe disorder of the CNS leading to tissue damage and disability. Because it is critical to understand the pathological processes, it is important to find efficient ways to diagnose the severity of injured spinal cord tracts in situ from beginning up to a certain level of recovery following therapeutic interventions. In the current study, we set-up the criteria for diffusion tensor imaging (DTI) in order to capture changes of nerve fibre tracts in rat spinal cord compression injury. We tested four DTI parameters, such as fractional anisotropy, mean diffusivity, axial diffusivity and radial diffusivity at the lesion site, in time course of 7 weeks. Afterwards, we compared DTI data with histological results and locomotor outcomes to examine their consistency and capability of reflecting the lesion development in time. Our data confirm that DTI is a valuable in vivo imaging tool capable to distinguish damaged white matter tracts after mild SCI in rat. Fractional anisotropy showed decreased values for injury site, while the mean diffusivity had higher values, with increased both axial and radial diffusivity in comparison to control subjects. Thus, the combination of DTI parameters can reflect the severity of lesion in time and may correlate with histological evaluation of spared tissue, but not with locomotor recovery following mild injury associated with spontaneous recovery.

Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts

The clinical presentation and diagnostic workup in pediatric cervical spine injuries (CSI) are different from adults owing to the unique anatomy and relative immaturity. The current article reviews the existing literature regarding the uniqueness of these injuries and discusses the current guidelines of radiological evaluation. A PubMed search was conducted using keywords "paediatric cervical spine injuries" or "paediatric cervical spine trauma." Six hundred and ninety two articles were available in total. Three hundred and forty three articles were considered for the review after eliminating unrelated and duplicate articles. Further screening was performed and 67 articles (original articles and review articles only) related to pediatric CSI were finally included. All articles were reviewed for details regarding epidemiology, injury patterns, anatomic considerations, clinical, and radiological evaluation protocols. CSIs are the most common level (60%-80%) for pediatric Spinal Injuries (SI). Children suffer from atlantoaxial injuries 2.5 times more often than adults. Children's unique anatomical features (large head size and highly flexible spine) predispose them to such a peculiar presentation. The role of National Emergency X-Ray Utilization Study, United State (NEXUS) and Canadian Cervical Spine Rule criteria in excluding pediatric cervical injury is questionable but cannot be ruled out completely. The minimum radiological examination includes 2- or 3-view cervical X-rays (anteroposterior, lateral ± open-mouth odontoid views). Additional radiological evaluations, including computerized tomography (CT) and magnetic resonance imaging (MRI) are obtained in situations of abnormal physical examination, abnormal X-rays, inability to obtain adequate X-rays, or to assess cord/soft-tissue status. The clinical criteria for cervical spine injury clearance can generally be applied to children older than 2 years of age. Nevertheless, adequate caution should be exercised before applying these rules in younger children. Initial radiographic investigation should be always adequate plain radiographs of cervical spine. CT and MRI scans should only be performed in an appropriate group of pediatric patients.