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

Abstract

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.

Weighing the Risk Profile of Cervical Spine MRI in Evaluating Pediatric Cervical Spine Injuries

“…Several recent reports have demonstrated excellent sensitivity of X-ray for CSI [20, 21]. Lindholm et al [22] showed that even a single lateral-view X-ray was equivalent to multiple views and had 100% sensitivity for bony injuries. Another concern of MRI is that of “false positives,” where minor injuries on imaging may prompt maintenance of a cervical collar for prolonged periods while inpatient or on discharge.…”

The Fate of the Cervical Collar

“…Pediatric patients have been shown previously to have low rates of CSI. [5][6][7][8][9]13 Those without a diving/axial load mechanism, along with a normal mental status and intact neurologic examination, have even lower risk. 1,6 However, posterior cervical midline tenderness often prompts concern for CSI.…”

“…B lunt traumatic injury is the reason for many urgent pediatric visits to an emergency department (ED). [1][2][3][4] Although cervical spine injury (CSI) after blunt trauma is rare in the pediatric population, [5][6][7][8][9] the consequences of CSI can be devastating. Thus, timely and accurate cervical spine assessment is critical.…”

“…10 If the cervical spine cannot be clinically cleared, 2-view cervical spine radiographs are obtained as an initial screening tool. 1,5,[7][8][9][10][11] Despite these efforts, many children with mild CSI cannot be cleared because of persistent midline cervical spine tenderness and/or neck pain. Because of the low frequency of significant CSI in the face of normal x-rays and physical examination, further advanced imaging with computed tomography or magnetic resonance imaging is usually not performed at our institution.…”

“…Guidelines have been established for posttraumatic cervical spine clearance that emphasize a patient's history and physical examination 10 . If the cervical spine cannot be clinically cleared, 2-view cervical spine radiographs are obtained as an initial screening tool 1,5,7–11 …”