Detection of pediatric cervical spine injury

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OBJECTIVE: In evaluating the pediatric cervical spine for injury, the use of adult protocols
without sufficient sensitivity to pediatric injury patterns may lead to excessive
radiation doses. Data on injury location and means of detection can inform pediatricspecific
guideline development.
METHODS: We retrospectively identified pediatric patients with codes from the
International Classification of Diseases, 9th Revision, for cervical spine injury treated
between 1980 and 2000. Collected data included physical findings, radiographic means
of detection, and location of injury. Sensitivity of plain x-rays and diagnostic yield from
additional radiographic studies were calculated.
RESULTS: Of 239 patients, 190 had true injuries and adequate medical records; of
these, 187 had adequate radiology records. Patients without radiographic abnormality
were excluded. In 34 children younger than 8 years, National Emergency X-Radiography
Utilization Study criteria missed two injuries (sensitivity, 94%), with 76% of injuries
occurring from occiput–C2. In 158 children older than 8 years, National Emergency
X-Radiography Utilization Study criteria identified all injured patients (sensitivity, 100%),
with 25% of injuries occurring from occiput–C2. For children younger than 8 years,
plain-film sensitivity was 75% and combination plain-film/occiput–C3 computed tomographic
scan had a sensitivity of 94%, whereas combination plain-film and flexionextension
views had 81% sensitivity. In patients older than 8 years, the sensitivities
were 93%, 97%, and 94%, respectively.
CONCLUSION:Younger children tend to have more rostral (occiput–C2) injuries compared
with older children. The National Emergency X-Radiography Utilization Study
protocol may have lower sensitivity in young children than in adults. Limited computed
tomography from occiput–C3 may increase diagnostic yield appreciably in young children
compared with flexion-extension views. Further prospective studies, especially
of young children, are needed to develop reliable pediatric protocols.

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