Pediatric emergency medicine trisk 3582 3582
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deficit, neck pain, substantial torso injury, high-risk motor vehicle collision, and
diving.
When a child’s cervical spine cannot be reliably evaluated clinically, imaging is
usually the next step. Radiographic options for evaluating the cervical spine
include plain films, CT, and MRI. The plain radiograph remains the preferred
initial test for patients with acute trauma. The American College of Radiology
recommends a three-view series (lateral, anteroposterior [AP], and open-mouth)
for initial screening in children <14 years, regardless of mental status. An
adequate lateral film includes the base of the skull and C1–T1, has a sensitivity of
73% (<8 years) to 93% (age >8 years) for fracture detection but even if no
abnormalities are identified, does not “clear” the cervical spine. The addition of an
AP view of C3–C7 and an AP open-mouth (odontoid) view of C1–C2 increases
the sensitivity of initial radiographic evaluation to more than 95%. However, the
open-mouth view in young children (<8 years) has been shown to be the least
useful of the three images, may not be necessary, and therefore is most strongly
recommended for older children or those who can readily cooperate. In one study
at a combined adult and pediatric trauma center, the most common reasons for a
missed injury on initial radiologic evaluation included unfamiliarity with pediatric
cervical spine anatomy, failure to recognize normal developmental variants, and
suboptimal conventional film techniques. Posterior elements of the cervical spine
may not be well visualized with the initial radiographic series. Therefore, oblique
(pillar) views are an option, but rarely add significant information to the initial
radiographic assessment. Flexion and extension radiographs are accomplished in
an awake patient by having the patient flex and extend the neck as far as possible
without discomfort, but are not appropriate in the acute trauma evaluation and
should not be obtained in a patient with pre-existing neck pain at rest. These films
are best used in follow-up evaluation in children who were previously diagnosed
with ligamentous injuries.
A CT scan is often used as a secondary screen, or primary in some institutions,
to substantiate suspected fractures or when adequate plain radiographs cannot be
obtained. A common scenario is the use of CT to supplement viewing the C1–C3
region in young children with trauma to minimize thyroid radiation exposure.
Several studies have demonstrated the superiority of upper cervical spine CT scan
versus plain radiographs in diagnosing injuries in this region. In certain
circumstances, it may be indicated to obtain CT as a primary screening tool, a
common approach in adult trauma patients. Benefits of primary screening with CT
are most appreciable for patients with high to moderate risk of injury, whereas
patients with low risk of injury do not clearly benefit from this practice. In fact,
