Using CT of the cervical spine for early evaluation of pediatric patients with head trauma

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.

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

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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.

Evaluation of lateral atlantodental interval asymmetry in the pediatric age group: normative values

OBJECTIVE The revelation of normative radiographic measurements for the developing pediatric spine is incomplete. The purpose of this analysis was to determine the normal range of asymmetry of the lateral atlantodental interval (LADI) and define age- and sex-related differences. METHODS A total of 3072 children aged 0-18 years who underwent CT scanning of the cervical spine were identified at Riley Hospital for Children between 2005 and 2017. Patients were stratified by sex and age (in years) into 36 cohorts. Following this stratification, patients within each group were randomly selected for inclusion until 15 patients in each group had been measured (quota sampling). A total of 540 patients were included for study. Right and left linear measurements were performed in the CT axial plane at the C-1 midlateral mass level. RESULTS The overall mean difference between the right and left LADI was 0.09 ± 1.23 mm (range -6.05 to 4.87 mm). The magnitude of this asymmetry remained statistically insignificant across age groups (p = 0.278) and sex (p = 0.889). The intraclass correlation coefficient was 0.805 (95% CI 0.779-0.829). CONCLUSIONS Asymmetry of the LADI is not unusual in asymptomatic children. There is no appreciable difference in magnitude of this asymmetry across age ranges and sex. Measurement of LADI asymmetry shows "good" reliability and is easy to perform. Pediatric neurosurgeons, emergency department physicians, and radiologists should be aware of normative values of asymmetry when interpreting CT scans of the cervical spine. This may prevent unnecessary further workup with dynamic CT or MRI.

Measurements in cervical vertebrae CT of pediatric cases: normal values

PURPOSE

This study aims to determine the normal limits of atlanto-dental interval (ADI), basion-dens interval (BDI), basion-cartilaginous dens interval (BCDI), and prevertebral soft tissue thickness (PVSTT) according to age groups for normal pediatric cases.

MATERIALS AND METHODS

CT images of 256 pediatric patients aged between 1 and 15 years were retrospectively evaluated. ADI, BDI, BCDI and PVSTT measurements were performed.

RESULTS

Upper normal limit (UNL) values for ADI were 2.65-4.8 mm. UNL values for PVSTT were found to be 6.9 mm at C1 level, 6.7 mm at C2 level, 9.3 mm at C3 level, 14.2 mm at C4 level, 14.1 mm at C5 level, 13.8 mm at C6 level and 12.8 mm at C7 level. The maximum value of BDI in the group with non-ossified os terminale was 12 mm, and in the group with ossified os terminale it was 10 mm. The UNL of BCDI determined for females was 5.1 mm, while the UNL for males was 5.6 mm.

CONCLUSION

We propose the obtained values as the UNL values for ADI, BDI, BCDI and PVSTT on CT images in the pediatric population from 1 to 15 years.

Triage tools for detecting cervical spine injury in pediatric trauma patients

BACKGROUND

Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population.

OBJECTIVES

To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma.

SEARCH METHODS

We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility.

SELECTION CRITERIA

We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy.

MAIN RESULTS

Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity.

AUTHORS' CONCLUSIONS

There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.

The benefit of neck computed tomography compared with its harm (risk of cancer)

BACKGROUND

The purpose of this study was to compare the benefit of neck computed tomography (CT) of identifying important cervical spine injuries (CSIs) with its harm of radiation exposure and cancer risk.

METHODS

A PubMed search for published studies relating to CSI in trauma, cervical spine imaging, CT, and cancer risk was conducted. Article abstracts were reviewed, and selected published studies relating to the study objective were retrieved.

RESULTS

Of 100,000 trauma patients, neck CT scans were obtained in 3,767 to 26,785 patients. Of 100,000 patients with trauma on whom a neck CT scan was performed, a CSI was identified in 2,470 to 33,898 patients. Clinically important CSI ranged from 4,724 to 27,119 per 100,000 CT scans. For every 100,000 neck CT scans performed, additional cancer cases occur in a low end estimate of a thyroid cancer cases to a high end estimate of 100 male and 700 female cancer cases. In females, cancer risks are higher than in males, and these are closer to, but still less than, the incidence of clinically important CSI found by CT.

CONCLUSION

CT's benefit of identifying important CSIs in the published studies exceeds its cancer harm risk. However, at their extremes, the numbers are disturbingly close. Limiting neck CT scanning to a higher-risk group would increase the gap between benefit and harm, whereas performing CT routinely on low-risk cases approaches a point where its harm equals or exceeds its benefit.

LEVEL OF EVIDENCE

Systematic review, level IV.

Estimation of normal computed tomography measurements for the upper cervical spine in the pediatric age group

OBJECT

Upper cervical spine injuries in the pediatric age group have been recognized as extremely unstable from ligamentous disruption and as potentially lethal. Few measurement norms have been published for the pediatric upper cervical spine to help diagnose this pathological state. Instead, adult measurement techniques and results are usually applied inappropriately to children. The authors propose using high-resolution reconstructed CT scans to define a range of normal for a collection of selected upper cervical spine measurements in the pediatric age group.

METHODS

Sagittal and coronal reformatted images were obtained from thin axial CT scans obtained in 42 children (< 18 years) in a 2-month period. There were 25 boys and 17 girls. The mean age was 100.9 months (range 1-214 months). Six CT scans were obtained for nontrauma indications, and 36 were obtained as part of a trauma protocol and later cleared for cervical spine injury. Six straightforward and direct linear distances-basion-dental interval (BDI); atlantodental interval (ADI); posterior atlantodental interval (PADI); right and left lateral mass interval (LMI); right and left craniocervical interval (CCI); and prevertebral soft-tissue thickness at C-2-that minimized logistical and technical distortions were measured and recorded. Statistical analysis including interobserver agreement, age stratification, and sex differences was performed for each of the 6 measurements.

RESULTS

The mean ADI was 2.25 ± 0.24 mm (± SD), the mean PADI was 18.3 ± 0.07 mm, the mean BDI was 7.28 ± 0.10 mm, and the mean prevertebral soft tissue width at C-2 was 4.45 ± 0.43 mm. The overall mean CCI was 2.38 ± 0.44 mm, and the overall mean LMI was 2.91 ± 0.49 mm. Linear regression analysis demonstrated statistically significant age effects for PADI (increased 0.02 mm/month), BDI (decreased 0.02 mm/month), and CCI (decreased 0.01 mm/month). Similarly significant effects were found for sex; females demonstrated on average a smaller CCI by 0.26 mm and a smaller PADI by 2.12 mm. Moderate to high interrater reliability was demonstrated across all parameters.

CONCLUSIONS

Age-dependent and age-independent normal CT measurements of the upper cervical spine will help to differentiate physiological and pathological states in children. The BDI appears to change significantly with age but not sex; on the other hand, the LMI and ADI appear to be age-independent measures. This preliminary study suggests acceptable levels of interrater reliability, and further expanded study will aim to validate these measurements to produce a profile of normal upper cervical spine measurements in children.

US emergency department use by children, 2001-2010

OBJECTIVE

Children commonly use emergency departments (EDs) for a variety of health care needs. We describe recent trends in US ED use by children.

METHODS

This is a cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of ED visits, and US Census data between 2001 and 2010. We examined demographic trends, visit characteristics, insurance status, disposition, hospital variables, diagnoses, reason for visit, and resource use among patients younger than 19 years. Linear regression was used to evaluate significance of trends.

RESULTS

Approximately one quarter of all ED visits was made by patients younger than 19 years. Emergency department visits by children increased 14.4% between 2001 and 2010 (P = 0.04); the rate of visits increased from 36.4 to 40.6 per 100 population. Trauma is the most common reason for pediatric ED visits. Black children had the highest rate of ED use (61.9 per 100 in 2010). Visit rates by Hispanic children were relatively low but increased by 82.7% since 2001 (P = 0.00). The proportion of ED visits by Medicaid beneficiaries rose from 32.0% to 51.9% (P = 0.00). The volume and frequency of diagnostic testing, administration of intravenous fluids, medication administration, and discharge prescriptions increased. Visits with computed tomography or magnetic resonance imaging almost doubled from 3.1% of the visits in 2001 to 6.6% of the visits in 2010 (P = 0.00).

CONCLUSIONS

The use of ED by children is growing faster than population growth, and the intensity of ED care has risen sharply. Hispanic children and Medicaid beneficiaries represent the fastest growing populations of children using the ED.

Cervical spine computed tomography utilization in pediatric trauma patients

BACKGROUND

Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs).

METHODS

Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression.

RESULTS

5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p<0.05) and more frequent ICU admissions (44.3% vs. 26.1% p<0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI=8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI=25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT.

CONCLUSIONS

Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED.

A pediatric cervical spine clearance protocol to reduce radiation exposure in children

BACKGROUND

To minimize radiation exposure in children and reduce resource use, we implemented an age-specific algorithm to evaluate cervical spine injuries at a Level 1 trauma center. The effects of protocol implementation on computed tomography (CT) use in children (≤ 10 y) were determined.

METHODS

With institutional review board approval, we conducted a retrospective review using the institutional trauma registry. All pediatric patients (≤ 10 y) (n = 324) between January 2007 and present were reviewed. We excluded cases in which no imaging or outside imaging was performed. Patients were evaluated by physical exam alone, with the aid of plain radiograms or with cervical spine CT. All patients who required head CT also had CT of cervical spine to C3. We analyzed demographic, injury, and outcome data using STATA to perform chi-square and t-test, and to determine P value. P < 0.05 was defined as significant. We used the WinDose program to calculate the radiation-effective dose used in cervical spine CT.

RESULTS

There were 123 and 124 patients in the pre-protocol and post-protocol groups, respectively. Demographics, GCS, and injury analysis, specifically head-neck and face Injury Severity Scores showed no significant difference between groups. There was a 60% (P < 0.001) decrease in the use of full CTs after protocol implementation. We estimated that the protocol reduced the exposed area by 50% and decreased the radiation dose to the thyroid by > 80%. We extrapolated the combined effect results in a threefold reduction in radiation exposure.

CONCLUSIONS

Implementation of a cervical spine protocol led to a significant reduction in radiation exposure among children.

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.

Utility of plain radiographs in detecting traumatic injuries of the cervical spine in children

OBJECTIVE

The objective of this study was to estimate the sensitivity of plain radiographs in identifying bony or ligamentous cervical spine injury in children.

METHODS

We identified a retrospective cohort of children younger than 16 years with blunt trauma-related bony or ligamentous cervical spine injury evaluated between 2000 and 2004 at 1 of 17 hospitals participating in the Pediatric Emergency Care Applied Research Network. We excluded children who had a single or undocumented number of radiographic views or one of the following injuries types: isolated spinal cord injury, spinal cord injury without radiographic abnormalities, or atlantoaxial rotary subluxation. Using consensus methods, study investigators reviewed the radiology reports and assigned a classification (definite, possible, or no cervical spine injury) as well as film adequacy. A pediatric neurosurgeon, blinded to the classification of the radiology reports, reviewed complete case histories and assigned final cervical spine injury type.

RESULTS

We identified 206 children who met inclusion criteria, of which 127 had definite and 41 had possible cervical spine injury identified by plain radiograph. Of the 186 children with adequate cervical spine radiographs, 168 had definite or possible cervical spine injury identified by plain radiograph for a sensitivity of 90% (95% confidence interval, 85%-94%). Cervical spine radiographs did not identify the following cervical spine injuries: fracture (15 children) and ligamentous injury alone (3 children). Nine children with normal cervical spine radiographs presented with 1 or more of the following: endotracheal intubation (4 children), altered mental status (5 children), or focal neurologic findings (5 children).

CONCLUSIONS

Plain radiographs had a high sensitivity for cervical spine injury in our pediatric cohort.

The pediatric cervical spine instability study. A pilot study assessing the prognostic value of four imaging modalities in clearing the cervical spine for children with severe traumatic injuries

PURPOSE

Cervical spine clearance in severely injured children after trauma is often difficult because of unique injury patterns, concerns about radiation exposure to growing tissue, and unfamiliarity with unstable cervical injuries. We prospectively assessed the utility of four radiographic modalities to clear the cervical spine in children after severe trauma.

METHODS

Twenty-four comatose, intubated children with severe traumatic injuries underwent radiographic evaluation to clear the cervical spine. Each patient had plain radiographs, flexion-extension radiographs under fluoroscopy, computed tomography (CT), and magnetic resonance (MR) imaging within 10 days of admission. Patients underwent cervical spine flexion-extension radiographs 2-3 months after trauma to detect late instability. Sensitivity and specificity for each radiographic modality was determined.

RESULTS

Plain cervical spine radiographs demonstrated sensitivity of 100% and specificity of 95%; flexion-extension radiographs had “indeterminate” sensitivity and specificity of 100%. For CT, sensitivity was 100% and specificity was 95%, and for MR imaging, sensitivity was 100% and specificity was 74%.

CONCLUSIONS

There was a low prevalence of cervical instability in this high-risk group. Plain radiographs, flexion-extension radiographs, and CT all had high sensitivities and specificities. MR imaging had a high false-positive rate, making it sensitive but not specific. The data support using either CT or plain radiographs as the initial cervical spine screening study, but CT is recommended because of its superior ability to detect critical injuries. To definitively rule out ligamentous instability after a negative screening CT scan or cervical spine X-ray, these data support using flexion-extension X-rays with fluoroscopy and not MR imaging.

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.

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.

Traumatic cervical spine injuries: characteristics of missed injuries

PURPOSE

Computed tomographic (CT) scanning has mostly replaced x-rays as an imaging modality, but concerns exist because of excess radiation, missed injuries, and whether it is the definitive procedure for intubated patients. The purpose of this study was to characterize missed cervical spine injuries (CSIs).

METHODS

All pediatric (<18) trauma patients from 2004 to 2006 were analyzed. Age, sex, Injury Severity Score (ISS), mechanism, time, and missed injuries were reviewed. Flexion/extension views were used in patients with prolonged intubation. Descriptive statistics, chi(2), Student's t test, and bivariate correlation were used.

RESULTS

There were 1307 pediatric trauma patients admitted with 318 imaged for potential CSI. Computed tomography was the sole imaging study in 200, x-rays in 64, and both in 54. Time to C-spine clearance was similar for all modalities (P > .05). For CT, 34 (10.7%) were initially positive for CSI with 7 false-positives (FPs) and no false-negative (FN). There were 18 patients with CSI identified by x-ray, with 5 FPs and 5 FNs (missed injuries). The 5 FNs missed by x-ray were all positive by CT scan and required no intervention. None of the flexion/extension views revealed an additional injury. Sex, intubated patients, ISS, age, type, and injury location were not predictive of a missed injury (P > .05).The sensitivity of CT scan was 1.0, specificity was 0.976, and the positive predictive value was 79.4%. The sensitivity of plain x-ray was 61.5%, the specificity was 1.6%, and the positive predictive value was 61.5%.

CONCLUSIONS

Our data suggest that CT scans should be the primary modality to image a CSI. Flexion/extension views did not add to the decision making for C-spine clearance after CT evaluation.

CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks?

BACKGROUND

Various reports support the use of cervical spine (c-spine) CT over conventional radiography in screening of c-spine injury. Interest now exists in diagnostic radiation-induced morbidity.

OBJECTIVE

To estimate excess relative risk for developing cancer from c-spine high-resolution CT radiation exposure.

MATERIALS AND METHODS

We conducted a retrospective review of children evaluated for c-spine injury using CT. The study population was divided into three age groups, 0-4 years (group 1), 5-8 years (group 2), and older than 8 years (group 3). Anthropomorphic 1-year-old and 5-year-old phantoms were used to measure radiation at the thyroid during radiography and CT. Excess relative risk for thyroid cancer was estimated using these measurements.

RESULTS

A total of 557 patients were evaluated with CT. The radiographic method most commonly used was head CT/c-spine CT in 363 (65%). Only 179 children (32%) had any type of prior radiography. The use of c-spine CT exposes the thyroid to 90-200 times more radiation than multiple conventional radiographs. The mean excess relative risk for thyroid cancer after CT was 2.0 for group 1 and 0.6 for group 2. There were no comparison data for group 3.

CONCLUSION

C-spine CT is associated with a significant exposure to ionizing radiation and increases excess relative risk for thyroid cancer in young children.

Controversies in "clearing" trauma to the cervical spine

Clearance of the traumatic cervical spine is a subject affecting most healthcare professionals dealing with trauma patients. There is a host of often contradictory literature making it hard for an interested reader to come to their own informed opinion based on the current evidence. This review aims to outline the relevant literature for the clearance of the traumatic cervical spine with the particular aim of highlighting the contradictions, controversies and unanswered questions still besetting this important subject. A brief, subjective opinion for a combined clinical and imaging protocol for clearance of the traumatic cervical spine is given.

Pediatric polytrauma management

Appropriate care of pediatric polytrauma patients requires the knowledge and expertise of a variety of subspecialists. Though most of pediatric polytrauma patients survive, long-term sequelae are common. The most common causes of long-term functional deficits after pediatric polytrauma involve injuries to the central nervous and musculoskeletal systems. Orthopaedic care of polytrauma patients is important to facilitate early mobilization and care of these children, as well as to minimize late impairment.

Diagnostic strategies in spinal trauma

Spinal injuries may result in severe neurological deficits, especially if nerve roots or even the spinal cord are affected. Besides presenting the important anatomical and technical basis underlying the imaging findings of spinal injuries, the trauma mechanisms and the resulting injuries are discussed. Based on the current literature and recommendations of scientific organizations, an approach is provided to the radiologic work up of spinal trauma. The different imaging modalities are presented. Advantages and disadvantages of the methods are discussed.

Combined high cervical spine and brain stem injuries: a complex and devastating injury in children

BACKGROUND

In young children, high cervical spine injuries (HCSI) can result in inaugural reversible, cardiac arrest or apnea. We noted in children sustaining such injuries an unusual incidence of associated brain stem injuries and defined a special pattern of combined lesions.

METHODS

Children with HSCI surviving inaugural cardiac arrest/apnea were selected for a retrospective analysis of a trauma data bank. Epidemiologic, clinical, and radiological characteristics, and outcome were reviewed and compared with those of the rest of the trauma population with severe neurologic injuries (defined by a Glasgow Coma Scale < 8).

RESULTS

Thirteen children with HCSI above the C3 spinal level and inaugural cardiac arrest/apnea were identified and compared with 819 severely head injured children without HSCI. Mean age was 4.7 +/- 2.9 years, and median Glasgow Coma Scale was 3 (3-6) after resuscitation. Initial standard x-ray views missed spine injuries in 6 patients. Spiral computed tomographic (CT) scan showed cervical fracture-dislocations associated with diffuse brain lesions and brain stem injury in all patients. Children with combined lesions had more frequent severe facial and skull base fractures compared with the rest of the population. They also were younger and sustained more frequent severe distracting injury to the neck than the rest of the population. Mortality rate (69%) was 2.6-fold higher than that observed in children without HCSI. In survivors, none demonstrated spinal cord injury resulting in persistent peripheral neurologic deficits, but only one achieved a good recovery.

CONCLUSIONS

Combined HCSI and brain stem injuries must be suspected in young children sustaining a severe distracting injury to the craniocervical junction. Early recognition of these catastrophic injuries by systematic spiral cervical spine and brain stem computed tomographic scan evaluation is mandatory.

Pediatric trauma susceptibility to sepsis

OBJECTIVE

The purpose of this review is to review how pediatric trauma may predispose children to sepsis.

DESIGN

The information discussed in this report is derived from a recent literature review of pediatric trauma and related topics and discussion at an international consensus conference on pediatric sepsis.

MEASUREMENTS AND MAIN RESULTS

There is a paucity of evidence on sepsis-related complications in pediatric trauma patients. Severe traumatic brain injury is a leading predisposing factor for sepsis complications. Excluding burn trauma, traumatically injured children without severe head injury rarely succumb to overwhelming sepsis.

CONCLUSIONS

Patients with multiple traumatic injuries are frequently admitted to the intensive care unit, and because head injury is the most common ailment, unconscious patients with a combination of injuries that include head injury will regularly require mechanical ventilation and central venous access and are at risk for life-threatening nosocomial infections. Outside of pulmonary contusions, organ-specific causes of infection are infrequent.

Cervical spine clearance: a review

Ethical concerns have hindered any randomised control blinded studies on the imaging required to assess the cervical spine in an unconscious trauma patient. The issue has been contentious for many years and has resulted in burgeoning but inconclusive guidance. MRI and multislice CT technology have made rapid advances, but the literature is slower to catch up. Never the less there appears to be an emerging consensus for the multiply injured patient. The rapid primary clinical survey should be followed by lateral cervical spine, chest and pelvic radiographs. If a patient is unconscious then CT of the brain and at least down to C3 (and in the USA down to D1) has now become routine. The cranio-cervical scans should be a maximum of 2 mm thickness, and probably less, as undisplaced type II peg fractures, can be invisible even on 1 mm slices with reconstructions. If the lateral cervical radiograph and the CT scan are negative, then MRI is the investigation of choice to exclude instability. Patients with focal neurological signs, evidence of cord or disc injury, and patients whose surgery require pre-operative cord assessment should be imaged by MRI. It is also the investigation of choice for evaluating the complications and late sequela of trauma. If the patient is to have an MRI scan, the MR unit must be able to at least do a sagittal STIR sequence of the entire vertebral column to exclude non-contiguous injuries, which, since the advent of MRI, are now known to be relatively common. Any areas of oedema or collapse then require detailed CT evaluation. It is important that cases are handled by a suitably skilled multidisciplinary team, and avoid repeat imaging due to technical inadequacies. The aim of this review is to re-examine the role of cervical spine imaging in the context of new guidelines and technical advances in imaging techniques.

First experiences with multidetector CT in traumatized children

INTRODUCTION

The aim of this study was to describe and discuss first experiences with multidetector CT (MDCT) in the assessment of traumatized children.

MATERIAL AND METHODS

Since the implementation of a MDCT scanner in April 2002, 85 children (31 girls, 54 boys with a mean age of 9.2 years) consecutively underwent MDCT (Siemens, Erlangen, Germany) with different protocols depending on age, weight, trauma mechanism and clinical presentation. In all patients in whom pathology was suspected, multiplanar reformations (MPR) in coronal and or sagittal orientation was performed. Examinations were evaluated by two radiologists retrospectively and in consensus.

RESULTS

In 55 (65%) children, a MDCT solely of the head was performed, in 46 there was no pathology found. In six (7%), head and facial bones were scanned. Head and abdomen was examined in two (2%), in two (2%) the abdomen only and in one (1%) the pelvis solely. Scans of the spine were obtained in seven (8%) children. A thorax and abdomen examination only was obtained in one (1%) child each. In 11 (13%) children, a polytrauma protocol was performed. In all patients, the time of examination did not exceed 17 min, including setup time. All children survived at the writing of this report.

CONCLUSION

MDCT was promising in the management of traumatized children and seems to shorten the necessary time to reach diagnosis and to initiate life-saving treatment.

Common tasks and problems in paediatric trauma radiology

Scope of this article is to give practical hints for the most common, typical and important topics of trauma radiology in children to those radiologists who are not exclusively occupied with paediatric imaging. Due to the increased radiation sensitivity of children compared with adults balancing radiation protection and necessary image quality is of utmost importance. Outlines for this optimisation process are given. Especially in imaging of the extremities perhaps the greatest difficulties are posed by the dynamically changing face of the immature, growing, only partially ossified skeleton. Lack of experience must be compensated by meticulous comparison with the normal skeletal development as shown in standard textbooks, and by knowledge of the radiological image of the developmental variants. Besides general remarks about paediatric trauma radiology, some important topics are discussed into more detail. Especially the elbow joint poses a challenge for those less experienced with its radiological appearance in children. More than in adults, ultrasound should remain the primary imaging modality of choice especially in the assessment of abdominal trauma, and CT be tailored to radiological and clinical findings. Imaging and diagnosis of non-accidental injury (NAI) may be a less common task for the general radiologist, however, the severe social implications of physical child abuse mandate a basic knowledge about the radiological symptoms and the imaging management of this problem for all physicians occupied with paediatric radiology.