Role of oblique radiographs in blunt pediatric cervical spine injury

Single-lateral cervical radiograph in pediatric trauma is equivalent to multiple views

BACKGROUND

Cervical spine injuries (CSI) are rare within the pediatric population. Due to the significant consequences of missed CSI, children are often imaged excessively. In an attempt to decrease imaging of the cervical spine in children, we reviewed abnormal cervical radiographs (XR) to determine if the diagnosis of CSI could be made using a single-lateral cervical radiograph (LAT). Furthermore, we reviewed cervical computed tomography (CT) and magnetic resonance imaging (MRI) to ensure there were no missed CSI.

METHODS

Electronic medical records of trauma patients treated at a Level I Pediatric Trauma Center with abnormal XR findings followed by confirmatory CT or MRI between 2012 and 2017 were reviewed. All abnormal imaging on XR was compared with the LAT. In addition, all abnormal CTs and MRIs were reviewed to ensure there were no false negative XR.

RESULTS

A total of 3,735 XR were performed with 26 abnormal interpretations. All bony CSI were visualized on LAT. Confirmatory imaging found 13 (50%) were false positive and 13 (50%) were true positive. Secondary analysis of CT identified 12 injuries with prior XR; 8 of 12 LAT identifying the injury and 4 of 12 false positive on CT. Secondary analysis of MRI identified nine injuries with prior XR; 5 of 9 LAT identifying the injury. The four false-negative reads on MRI were ligamentous injuries.

CONCLUSION

Radiographs are commonly performed when evaluating CSI. In our population, initial assessment with a single LAT was equivalent to a multiple view XR. On secondary review, the only false-negative LAT reports were due to ligamentous injuries. This data suggests limiting exposure to LAT would accomplish the goal of reducing imaging without missing bony CSI and when ligamentous injury is suspected MRI should be the confirmatory study rather than CT.

LEVEL OF EVIDENCE

Diagnostic Test, level III.

Posttraumatic Anatomical Injuries of the Craniovertebral Junction and Treatment Implications: Part I

Please check the hierarchy of the section headings and correct if necessary.

Imaging, clearance, and controversies in pediatric cervical spine trauma

Diagnosing cervical spine injury in children can be difficult because the clinical examination can be unreliable, and evidence-based consensus guidelines for cervical spine injury evaluation in children have not been established. However, the consequences of cervical spine injuries are significant. Therefore, practitioners should understand common patterns of cervical spine injury in children, the evidence and indications for cervical spine imaging, and which imaging modalities to use. Herein, we review the epidemiology and unique anatomical features of pediatric cervical spine injury. In addition, we will summarize current practice for clearance and imaging of the pediatric cervical spine in trauma.

Cervical spine evaluation in pediatric trauma

OBJECTIVE

This article will review the current literature as it relates to imaging of the child suspected to have cervical spine injury (CSI) and the imaging findings of pediatric CSI, focusing on strategies to minimize radiation dose while maximizing diagnostic yield.

CONCLUSION

Although CSI is uncommon in children, the clinical implications of failure to correctly diagnose CSI are significant. Clinical decision rules proven effective in predicting CSI in adults cannot be uniformly applied to children.

Clearing the cervical spine in children

Increasing evidence from adult trauma patients has allowed the formation of some international consensus on clearance protocols. The evidence for paediatric trauma remains more fragmented, making the creation of definitive protocols difficult. Spinal injury in children differs from that in adults by injury distribution and prevalence, as well as anatomical and radiological differences. This complicates the process of clearance of the cervical spine in children. The evidence for clearance can be considered in terms of three groups of patients – the alert and asymptomatic child, the conscious child with high-risk criteria and the unconscious or obtunded child. This systematic review summarises the available evidence to clarify the current best practice for each group of patients.

[Imaging of acute spinal injury]

The mechanism location and type of injury varies according to patient age and severity of trauma. The imaging work-up with radiographs, CT and MRI must be adapted to each individual case. In the setting of minor trauma, standard radiographs are obtained when clinically indicated. In all other cases of high energy trauma, spinal trauma with neurological deficit or incomplete or difficult standard radiographic evaluation, CT will be indicated for osseous injuries while MRI will provide optimal evaluation of soft tissues. Dislocations require immediate treatment. The imaging work-up should by no means delay management. Significant sprains are rare. Several diagnostic pitfalls occur at both extremities of life.

Pediatric cervical spine trauma imaging: a practical approach

Cervical spine trauma in children is rare and the diagnosis can be challenging due to anatomical and biomechanical differences as compared to adults. A variety of algorithms have been used in adults to accurately diagnose injuries, but have not been fully studied in pediatric patients. In this article we review suggested imaging protocols and the general characteristics, types of injuries, and measurements used to diagnose cervical spine injuries in children.

[How to read radiography of the traumatic spine?]

In this paper, the imaging features of traumatic injuries of the spine in an emergency department will be reviewed. Three themes are discussed. 1) Review of current indications for additional imaging work-up. Conventional radiographs are not always mandatory, especially at the cervical level since validated criteria are available from the literature. The low sensitivity of conventional radiographs often requires additional imaging by CT (bone lesions) or MRI (disk and ligamentous lesions). The degree of urgency in scheduling these different examinations will be defined by the clinical setting and risk level (low/intermediate/high) of the injury. 2) Review of imaging features associated with stable and unstable lesions. The analysis of conventional radiographs is based on biomechanical concepts. The features of the main lesions will be illustrated by clinical cases and diagrams. 3) Review of key points that must urgently be transmitted to clinicians. The preliminary radiology report is an essential document for the management of patients with traumatic injury to the spine. It will have an impact on the type of immediate management (medical, orthopedic or surgical). A final report validating the initial interpretation should, of course, soon follow.

Initial radiographic evaluation of the spine after trauma: when, what, where, and how to image the acutely traumatized spine

BACKGROUND

Radiographic evaluation of the spine after an acute traumatic event is an integral part of the initial assessment of the patient. Despite this, an imaging protocol that includes detailed recommendations of the views, modalities, and techniques of radiographic work-up is lacking in the peer-reviewed literature.

STUDY PURPOSE

The goal of the current review was to suggest a uniform protocol for initial imaging in the traumatized patient and provide a rationale and guidelines to assist in deciding which studies are indicated and at what time they are best obtained.

METHODS

The authors' reviewed the available modern, published, English literature, including both peer-reviewed articles and commonly used textbooks, for recommendations concerning which imaging studies are most effective and cost-efficient in detecting spinal injuries in the acute trauma setting. A list of radiologic studies was compiled. A panel of spine surgeon members of the Spine Trauma Study Group, all of whom were highly experienced in trauma management, evaluated the utility and necessity of these imaging studies.

CONCLUSIONS

Surgeons agreed that the mainstay of initial radiographic evaluation of the spine after acute trauma remains plain radiographs. CT scanning remains the best mode of delineating the bony details of a spinal injury and should be used to characterize all bony injuries identified on plain radiographs. As CT technology continues to improve, it is likely to play an even greater role as an initial screening tool. The role for MRI continues to expand, particularly in detecting the soft tissue components of injuries.