Cervical Spine Magnetic Resonance Imaging in Pediatric cervical spine injury
In a study, Cervical spine Magnetic Resonance Imaging has greater sensitivity and specificity when compared to CSS radiography in a symptomatic pediatric low-impact trauma population. This data call into question the routine use of CSS radiographs in children 1).
There is a striking variability in the use of personnel, imaging modalities and, most importantly, standardized protocol in the evaluation of the pediatric trauma patient with a potential cervical spine injury. Cervical spine clearance protocols have been shown to decrease the incidence of missed injuries, minimize excessive radiation exposure, decrease the time to collar removal, and lower overall associated costs. It is in opinion of Pannu et al., that development of a task force or multicenter research protocol that incorporates existing evidence-based literature is the next best step in improving the care of children with cervical spine injuries 2).
Multiple mandibular fractures were inversely correlated with CSI. One possibility is that energy dissipation in the mandible with multiple fractures is protective of the C-spine leading to fewer fractures. Children and adults had different associations in the pattern of mandible fractures concomitant with CSI. This has implications in management, imaging, and workup of trauma patients 3).
Pediatric cervical spine injury (CSI) is a rare but potentially devastating sequelae of blunt trauma. Existing protocols to evaluate children at risk for CSI frequently incorporate computerized tomography (CT) and magnetic resonance imaging (MRI); however, the clinical value of performing both remains unclear.
Single center retrospective review of pediatric trauma patients who underwent both CT and MRI of the cervical spine between 2001 and 2015. Based on radiographic findings, CT and MRI results were grouped into one of three categories: no injury, stable injury, or unstable injury. Radiographic instability was defined by disruption of two or more contiguous spinal columns while radiographic stability was defined by any other acute cervical spine abnormality on imaging. Clinical instability was defined by the need for surgical intervention (halo or spinal fusion), with the remaining patients, including children discharged in a cervical collar, considered clinically stable.
In total, 221 children met the inclusion criteria, with a median age of 9 (IQR 3, 14). The Glasgow Coma Scale (GCS) of the cohort was 9 (IQR 4, 15). Thirty-three children (14.9%) had clinically unstable injuries, requiring surgical intervention. Among the 160 children (72.4%) with no injury on CT, MRI identified no injury in 84 cases (52.5%), a stable injury in 76 cases (47.5%), and an unstable injury in none. Among the 21 children with stable injuries on CT, MRI findings were concordant in 17 cases (81.0%). In four cases (19.0%), a spinal column injury was identified on CT and appeared to be stable, but later deemed unstable on MRI. Forty patients (18.1%) had an unstable injury on CT with 100% MRI concordance.In pediatric trauma patients suspected of having a CSI, a normal cervical spine CT is sufficient to rule out a clinically significant CSI as no child with a normal cervical CT was found to be radiographically or clinically unstable 4).