ACR Appropriateness Criteria® Suspected Spine Trauma-Child

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.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Evaluation and Management of Thoracolumbar Spine Trauma in Pediatric Patients: A Critical Analysis Review

» Pediatric thoracolumbar trauma, though rare, is an important cause of morbidity and mortality and necessitates early, accurate diagnosis and management.» Obtaining a detailed history and physical examination in the pediatric population can be difficult. Therefore, the threshold for advanced imaging, such as magnetic resonance imaging, is low and should be performed in patients with head injuries, altered mental status, inability to cooperate with examination, and fractures involving more than 1 column of the spine.» The classification of pediatric thoracolumbar trauma is based primarily on adult studies and there is little high-level evidence examining validity and accuracy in pediatric populations.» Injury pattern and neurologic status of the patient are the most important factors when determining whether to proceed with operative management.

Electron density dual-energy CT can improve the detection of lumbar disc herniation with higher image quality than standard and virtual non-calcium images

OBJECTIVES

To compare the diagnostic performance and image quality of dual-energy computed tomography (DECT) with electron density (ED) image reconstruction with those of DECT with standard CT (SC) and virtual non-calcium (VNCa) image reconstructions, for diagnosing lumbar disc herniation (L-HIVD).

METHODS

A total of 59 patients (354 intervertebral discs from T12/L1 to L5/S1; mean age, 60 years; 30 women and 29 men) who underwent DECT with spectral reconstruction and 3-T MRI within 2 weeks were enrolled between March 2021 and February 2022. Four radiologists independently assessed three image sets of randomized ED, SC, and VNCa images to detect L-HIVD at 8-week intervals. The coefficient of variance (CV) and the Weber contrast of the ROIs in the normal and diseased disc to cerebrospinal fluid space (NCR-normal/-diseased, respectively) were calculated to compare the image qualities of the noiseless ED and other series.

RESULTS

Overall, 129 L-HIVDs were noted on MRI. In the detection of L-HIVD, ED showed a higher AUC and sensitivity than SC and VNCa; 0.871 vs 0.807 vs 833 (p = 0.002) and 81% vs 70% vs 74% (p = 0.006 for SC), respectively. CV was much lower in all measurements of ED than those for SC and VNCa (p < 0.001). Furthermore, NCR-normal and NCR-diseased were the highest in ED (ED vs SC in NCR-normal and NCR-diseased, p =  0.001 and p = 0.004, respectively; ED vs VNCa in NCR-diseased, p = 0.044).

CONCLUSION

Compared to SC and VNCa images, DECT with ED reconstruction can enhance the AUC and sensitivity of L-HIVD detection with a lower CV and higher NCR.

CLINICAL RELEVANCE STATEMENT

To our knowledge, this is the first study to quantify the image quality of noiseless ED images. ED imaging may be helpful for detecting L-HIVD in patients who cannot undergo MRI.

KEY POINTS

ED images have diagnostic potential, but relevant quantitative analyses of image quality are limited. ED images detect disc herniation, with a better coefficient of variance and normalized contrast ratio values. ED images could detect L-HIVD when MRI is not an option.

Canadian Association of Radiologists Trauma Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma.

Outcomes of Follow-up Imaging After Pediatric Spinal Trauma Confirmed With Magnetic Resonance Imaging

BACKGROUND

Imaging plays a crucial role in the diagnostic workup of pediatric spinal trauma. Computed tomography and conventional radiographs are widely used as the primary imaging methods. Magnetic resonance imaging (MRI) is a radiation-free alternative with high sensitivity for bony and soft tissue injuries. There is no consensus on the optimal use of follow-up imaging in pediatric spinal trauma without immediate surgical treatment, especially if the injury is primarily confirmed with MRI. This study aimed to assess the diagnostic value of follow-up imaging after MRI-confirmed spinal trauma in children.

METHODS

The medical records and the imaging data of children and adolescents with emergency spinal MRI and follow-up imaging over 8 years were retrospectively reviewed. The primary study outcome was the outcome of follow-up imaging and its effect on management.

RESULTS

The study population consisted of 127 patients. The follow-up imaging did not alter the management in any patient with presumably stable injury in emergency MRI. Short-term follow-up imaging showed no clinically significant progression in thoracolumbar compression fractures. Flexion-extension radiographs had no additional value in cases with stable cervical spinal injury on emergency MRI.

CONCLUSIONS

The clinical utility of short-term follow-up imaging is low in children with stable spinal injury on emergency MRI.

LEVEL OF EVIDENCE

Level III-retrospective observational study.

Triage tools for detecting cervical spine injury in paediatric trauma patients

BACKGROUND

Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy.

OBJECTIVES

To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions.

SELECTION CRITERIA

We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.

Patterns in Follow-Up Imaging Usage for Pediatric Patients with Whiplash-Associated Disorder

BACKGROUND

A clinical concern exists that pediatric patients with whiplash-associated disorder (WAD) might have missed structural injuries or, alternatively, subsequently develop structural injuries over time, despite initially negative imaging findings. The primary objective of this study is to assess follow-up imaging usage for pediatric patients presenting with WAD.

METHODS

A retrospective review of 444 pediatric patients presenting to a level 1 pediatric trauma hospital from January 1, 2010 to December 31, 2019 was performed. Imaging was reviewed at the initial encounter and the 3- and 6-month follow-up appointments.

RESULTS

At the initial evaluation, children aged <6 years were more likely to receive radiographs (P = 0.007) and magnetic resonance imaging (P = 0.048) than were children aged 6-11 and 12-18 years. At the 3- and 6-month follow-up appointments, persistent neck pain was rare, representing <15% of patients at either time. Regardless of pain persistence, 80.2% of patients seen at the 3-month follow-up and 100% of patients at the 6-month follow-up underwent additional imaging studies. At the 3-month follow-up, children with persistent neck pain were more likely to undergo magnetic resonance imaging than were patients without persistent pain (P < 0.001). Also, patients with persistent neck pain were also more likely to not undergo any imaging evaluation (P = 0.002). Follow-up imaging studies did not reveal new structural injuries at either time point.

CONCLUSIONS

Follow-up imaging for pediatric patients with low-grade WAD did not identify new structural pathology-in patients with or without persistent neck pain.

Imaging of Vertebral Artery Dissection in Children: An Underrecognized Condition with High Risk of Recurrent Stroke

Vertebral artery dissection (VAD) is a common cause of a rare condition, pediatric posterior circulation arterial ischemic stroke (PCAIS). VAD is clinically important due to the risk of multifocal and continuing infarcts from artery-to-artery thromboembolism, with the potential for occlusion of arteries that perfuse the brainstem. Early diagnosis is important, as recurrent stroke is a common effect of VAD in children. Although the relative efficacies of different treatment regimens for VAD in children remain unsettled, early initiation of treatment can mitigate the risk of delayed stroke. Clinical diagnosis of PCAIS may be delayed due to multiple factors, including nonspecific symptoms and the inability of younger patients to express symptoms. In fact, subacute or chronic infarcts are often present at initial imaging. Although the most common cause of isolated PCAIS is VAD, imaging of the cervical arteries has been historically underused in this setting. Cervical vascular imaging (MR angiography, CT angiography, and digital subtraction angiography) for VAD must be optimized to detect the sometimes subtle findings, which may be identified at initial or follow-up imaging. Osseous variants of the craniocervical junction and upper cervical spine and other extrinsic lesions that may directly injure the vertebral arteries or lead to altered biomechanics have been implicated in some cases. The authors review characteristic imaging features and optimized imaging of VAD and associated PCAIS and related clinical considerations. Identification of VAD has important implications for evaluation, treatment, and imaging follow-up, as this condition may result in progressive arteriopathy and recurrent stroke. © RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Clinical outcome following magnetic resonance imaging as first-line imaging in low-impact pediatric spine trauma: a single-center retrospective observational study

BACKGROUND

Pediatric spinal trauma is rare, but the consequences of a missed injury can be devastating. Medical imaging is often needed in addition to physical examination. Conventional radiographs are widely recommended, but their negative predictive value is limited. Computed tomography (CT) is more sensitive but has a higher radiation dose. Magnetic resonance imaging (MRI) has superior soft tissue contrast and lacks ionizing radiation, but it is more expensive and time-consuming. Thus, the debate regarding the most suitable imaging method is still ongoing.

OBJECTIVE

This study examined the ability of MRI to exclude injuries requiring surgical treatment as a first-line imaging method in low-impact pediatric spine trauma.

MATERIALS AND METHODS

We retrospectively reviewed the medical records and imaging data of children (under 18 years old) who had suspected spinal trauma and were scanned using MRI in our emergency radiology department over a period of 8 years. We assessed the ability of MRI to detect unstable injuries by searching for later occurrences of primarily missed injuries requiring surgery.

RESULTS

Of 396 patients (median age 12 years, range 0-17), 114 (29%) had MRI findings suggesting an acute injury. Bony injuries were detected in 78 patients (20%) and ligamentous or other soft tissue injuries in 82 patients (21%). In the subgroup of 376 patients (median age 12 years, range 0-17) with at least 6 months of clinical follow-up, no missed injuries demanding surgical intervention or immobilization occurred after spinal MRI as  first-line imaging. No adverse events related to MRI or anesthesia occurred.

CONCLUSION

MRI can detect injuries requiring surgical treatment as a first-line imaging method in suspected low-impact pediatric spinal trauma and is safe to use in this selected population.

Diagnostic Excellence in Pediatric Spine Imaging: Using Contextualized Imaging Protocols

Contextual design and selection of MRI protocols is critical for making an accurate diagnosis given the wide variety of clinical indications for spine imaging in children. Here, we describe our pediatric spine imaging protocols in detail, tailored to specific clinical questions.

Emergency MRI in Spine Trauma of Children and Adolescents-A Pictorial Review

Severe spinal trauma is uncommon in the pediatric population, but due to the potentially devastating consequences of missed injury, it poses a diagnostic challenge in emergency departments. Diagnostic imaging is often needed to exclude or confirm the injury and to assess its extent. Magnetic resonance imaging (MRI) offers an excellent view of both bony and soft tissue structures and their traumatic findings without exposing children to ionizing radiation. Our pictorial review aims to demonstrate the typical traumatic findings, physiological phenomena, and potential pitfalls of emergency MRI in the trauma of the growing spine.

Cervical spine flexion-extension radiography versus magnetic resonance imaging in pediatric patients following blunt traumatic injury

Background

In pediatric trauma patients, 60-80% of spinal cord injuries involve the cervical vertebrae. While the American College of Radiology offers guidelines for best imaging practices in the setting of acute pediatric trauma, there is a lack of uniformity in imaging-decision protocols across institutions. MRI has been shown to demonstrate high sensitivity for both bony and ligamentous injuries while also avoiding unnecessary radiation exposure in the pediatric patient population. However, the efficacy of flexion-extension (FE) radiography following initial MRI has not been evaluated in children. Our hypothesis is that FE radiography conducted following an initial MRI does not contribute significant diagnostic information or reduce time to cervical collar removal and thus can be removed from institutional protocols in order to avoid unnecessary testing and reduce pediatric radiation exposure.

Methods

Trauma data were collected for pediatric patients presenting with suspected acute cervical spine injury from 2014 to 2021. A total of 108 patients were subdivided into 41 patients who received "MRI Only" and 67 patients who received both "MRI and FE" diagnostic cervical spine imaging. Chi-square testing and t-tests were performed to determine differences between MRI and FE radiographic detection rates of bony and ligamentous injuries in the subgroups.

Results

In patients for whom FE did not find any injury, MRI detected bony and ligamentous injuries in 9/63 and 12/65 cases, respectively. In 3/21 (14.3%) cases in which MRI detected a bony and/or ligamentous injury and FE did not, patients eventually required surgical intervention for c-spine stabilization. No patients required surgical fixation when FE radiography showed an abnormality and MRI was normal. Addition of follow-up FE radiography after initial MRI did not have a significant effect on overall hospital length of stay (MRI Only vs MRI+FE: 9.2±12.0 days vs 8.6±13.5 days, p=0.816) or on rates of collar removal at discharge or greater than 48 hours after imaging (MRI Only vs MRI+FE: 41.5% vs 56.7%, p=0.124).

Conclusions

FE radiography following initial MRI did not have a significant effect on reducing time to cervical collar removal or overall hospital length of stay. In addition, in 3 of 6 cases (50.0%) in which surgical fixation was required, MRI detected ligamentous and/or bony injury while FE radiography was normal.

Level of Evidence

This study contributes Level 2b scientific evidence consistent with a well-designed cohort or case-control analytic study.

Vertebral Coplanar Alignment Technique Versus Bilateral Apical Vertebral Derotation Technique in Neuromuscular Scoliosis

STUDY DESIGN

Single-center retrospective analysis of prospectively collected data.

OBJECTIVE

Our aim was to compare the correction capacity in 3 planes of the VCA technique versus the AD technique in neuromuscular scoliosis patients.

METHODS

We analized patients with neuromuscular scoliosis that underwent posterior spinal fusion from 2013 to 2017 using 2 different techniques for correction: vertebral coplanar alignment (VCA) that takes into consideration the fact that the medial cortex is more resistant than the lateral cortex, with more anchor points for better distribution of forces and ligamentotaxis and the more widely spread apical derotation (AD) technique. Clinical, surgical, and radiographic information of patients operated on with the AD technique were compared to those operated on with the VCA technique in the coronal, sagittal and axial plane at pre-op, immediate post-op, and 2 year follow-up.

RESULTS

64 patients met inclusion criteria, 34 patients underwent the VCA technique and 30 patients underwent the AD technique. The 2 cohorts did not differ in terms of demographics, clinical presentation or preoperative alignment. There were no significant differences in the correction ability between both techniques regarding curve magnitude, apical vertebral rotation, or pelvic obliquity. There was a significant decrease in thoracic kyphosis in the AD group compared to the VCA group in the immediate postop period (4.2 ± 26.6º for VCA and 13.2 ± 21.3º for AD (p = 0.048)).

CONCLUSION

Both apical derotation technique and vertebral coplanar alignment allow for correction in the 3 planes for patients with neuromuscular scoliosis. VCA is a less hypokyphosing technique than AD.

ACR Appropriateness Criteria® Ataxia-Child

Childhood ataxia may be due to multifactorial causes of impairment in the coordination of movement and balance. Acutely presenting ataxia in children may be due to infectious, inflammatory, toxic, ischemic, or traumatic etiology. Intermittent or episodic ataxia in children may be manifestations of migraine, benign positional vertigo, or intermittent metabolic disorders. Nonprogressive childhood ataxia suggests a congenital brain malformation or early prenatal or perinatal brain injury, and progressive childhood ataxia indicates inherited causes or acquired posterior fossa lesions that result in gradual cerebellar dysfunction. CT and MRI of the central nervous system are the usual modalities used in imaging children presenting with ataxia, based on the clinical presentation. This document provides initial imaging guidelines for a child presenting with acute ataxia with or without a history of recent trauma, recurrent ataxia with interval normal neurological examination, chronic progressive ataxia, and chronic nonprogressive ataxia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Pediatric Emergency MRI

There is an overall increase in the use of imaging in the pediatric emergency room setting, which is accompanied by a reduction in computed tomography examinations performed mainly due to the increased awareness of the risks of ionizing radiation. Advances in MRI technology have led to shortened scan time, decreased motion sensitivity, and improved spatial resolution. With increased access to MRI in the emergency room setting, the goal of this article is to review major applications of MR in pediatric emergency room patients.

Radiation dose levels of thoracic-lumbar spine CT in pediatric trauma patients and assessment of scan parameters for dose optimization

BACKGROUND

CT is frequently used for assessing spinal trauma in children.

OBJECTIVE

To establish the local diagnostic reference levels of spine CT examinations in pediatric spinal trauma patients and analyze scan parameters to enable dose optimization.

MATERIALS AND METHODS

In this retrospective study, we included 192 pediatric spinal trauma patients who underwent spine CT. Children were divided into two age groups: 0-10 years (group 1) and 11-17 years (group 2). Each group was subdivided into thoracic, thoracolumbar and lumbar CT groups. CT acquisition parameters (tube potential, in kilovoltage [kV]; mean tube current-time product, in milliamperes [mAs]; reference mAs; collimated slice width; tube rotation time; pitch; scan length) and radiation dose descriptors (volume CT dose index [CTDI_vol] and dose-length product [DLP]) were recorded. The CTDI_vol and DLP values of spine CTs obtained with different tube potential and collimated slice width values were compared for each group.

RESULTS

CTDI_vol and DLP values of thoracolumbar spine CTs in group 1 and lumbar spine CTs in group 2 were significantly lower in CTs acquired with low tube potential levels (P<0.05). CTDI_vol and DLP values of thoracolumbar spine CTs in both groups and lumbar spine CTs in group 2 acquired with high collimated slice width values were significantly lower than in corresponding CTs acquired with low collimated slice width values (P<0.05).

CONCLUSION

Pediatric spine CT radiation doses can be notably reduced from the manufacturers' default protocols while preserving image quality.

Variation in pediatric cervical spine imaging across trauma centers-A cause for concern?

BACKGROUND

Traumatic pediatric cervical spine injury can be challenging to diagnose, and the clinical algorithms meant to aid physicians differ from adult trauma protocols. Despite the existence of standardized guidelines, imaging decisions may vary according to physician education, subjective assessment, and experience with pediatric trauma patients. Our study investigates the rates of pediatric posttraumatic cervical spine imaging across trauma centers, hypothesizing that more specialized centers will have lower rates of advanced cervical spine imaging.

METHODS

The 2015 to 2016 Trauma Quality Improvement Program database was reviewed for patients younger than 18 years- to assess rates of cervical spine imaging on presentation across different trauma centers. Propensity stratification logistic regression was performed controlling for patient- and center-specific variables. p Values less than 0.05 were considered significant.

RESULTS

Of 110,769 pediatric trauma patients, 35.2% were female, and the average age was 9.6 years. Overall, 3.6% had cervical spine computed tomography (CT) and less than 1% had cervical spine MRI or X-ray. Compared with all others, Level I trauma centers were significantly less likely to use cervical spine CT for the initial evaluation of younger (≤14 years) but not older trauma patients (adjusted odds ratio [AOR], 0.89; 95% confidence interval [CI], 0.80-0.99; AOR, 0.97; 95% CI, 0.87-1.09); Level I centers had higher odds of cervical spine MRI use, but only for patients 14 years or younger (AOR, 1.63; 95% CI, 1.09-2.44). Pediatric-designated trauma centers had significantly lower odds of cervical spine CT (≤14 years: AOR, 0.70; 95% CI, 0.63-0.78; >14 years: AOR, 0.67; 95% CI, 0.67-0.75) and higher odds of cervical spine X-ray (≤14 years: AOR, 4.75; 95% CI, 3.55-6.36; >14 years: AOR, 4.50; 95% CI, 2.72-7.45) for all ages, but higher odds of cervical spine MRI for younger patients only (≤14 years: AOR, 2.10; 95% CI, 1.38-3.21).

CONCLUSION

Level I and pediatric designations were associated with lower rates of cervical spine CT. Pediatric centers were also more likely to use cervical spine X-ray. This variability of imaging use further supports the need to disseminate and educate providers on pediatric-specific cervical spine evaluation guidelines.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Accuracy of craniocervical measurements on CT for identifying partial or complete craniocervical ligament injuries in pediatric patients

PURPOSE

To assess the accuracy of craniocervical measurements for identifying craniocervical injuries and the frequency of subjective findings of craniocervical injuries on CT in pediatric patients.

METHODS

Case-controlled retrospective review of patients ≤ 16 years old with craniocervical junction injuries. Receiver operator curves were created for common craniocervical measurements on CT comparing patients with complete and partial craniocervical injuries to uninjured cohort. Frequency of subjective CT findings of craniocervical injury was assessed in the injured cohort.

RESULTS

For complete disruption injuries (CD) (n = 27), C1-C2 distance (AUC = 0.90, 95%CI = 0.83-0.97), atlanto-occipital distance (AUC = 0.95-0.98, 95%CI = 0.90-1.00), and basion-dens distance (AUC = 0.90, 95%CI = 0.82-0.98) had excellent accuracy diagnosing injury. Powers ratio (AUC = 0.85, 95%CI = 0.76-0.94) had good, basion-posterior axial line (AUC = 0.74, 95%CI = 0.61-0.86) fair, and atlanto-dental distance (AUC = 0.69, 95%CI = 0.57-0.82) poor accuracy. For partial disruption injuries (PD) (n = 21), basion-dens distance (AUC = 0.75, 95%CI = 0.62-0.88) had fair accuracy diagnosing injury. Powers ratio (AUC = 0.63, 95%CI = 0.47-0.79), C1-C2 distance (AUC = 0.60, 95%CI = 0.45-0.75), atlanto-dental distance (AUC = 0.55, 95%CI = 0.39 = 0.71), atlanto-occipital distance (AUC = 0.63-0.65, 95%CI = 0.47-0.81), and basion-posterior axial line (AUC = 0.60, 95%CI = 0.44-0.76) all had poor accuracy. Eighty-one percent (n = 22) of CD and 38% (n = 8) of PD patients had non-concentric atlanto-occipital joints. One hundred percent of CD patients had ≥ 1 soft tissue finding and eighty-one percent (n = 22) had ≥ 2 findings. Seventy-three percent (n = 16) of PD patients had ≥ 1 soft tissue finding. Eighty-six percent (n = 18) of PD patients had non-concentric atlanto-occipital joints and/or soft tissue findings.

CONCLUSION

Craniocervical measurements have poor accuracy for identifying craniocervical injuries in pediatric patients with incomplete craniocervical ligament disruption. Subjective findings of craniocervical injury are frequently present on CT in pediatric patients and can help increase sensitivity for identifying injury.

Imaging of pediatric cervical spine trauma

While pediatric cervical spine injuries (CSI) are rare, they are associated with high morbidity and mortality and sometimes require expeditious surgical management. In this article, we aim to improve the diagnostic accuracy of pediatric CSI by reviewing normal pediatric cervical anatomy, typical pediatric CSI patterns, and common mimics of pediatric CSI. A literature review was conducted on pediatric CSI, its epidemiology, and the various imaging manifestations and mimics. The most common pediatric CSI occur in the upper cervical spine owing to the higher fulcrum and larger head at a young age, namely prior to age 9 years, while lower CSI occur more frequently in patients older than 9 years. While various craniocervical measurements may be utilized to identify craniocervical disruption, soft tissue injuries may be the only manifestation, thus making pediatric CSI difficult to diagnose on initial imaging. In the acute setting, CT cervical spine is an appropriate initial imaging modality for pediatric CSI evaluation. MRI serves as an additional tool to exclude or identify injuries when initial findings are equivocal. It is essential to recognize the unique anatomy and biomechanics of the pediatric spine and thus discern common pediatric CSI patterns and their mimics.