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Utility of Plain Radiographs in Detecting Traumatic Injuries of the Cervical Spine in Children

Nigrovic, Lise E. MD, MPH*; Rogers, Alexander J. MD; Adelgais, Kathleen M. MD, MPH‡§; Olsen, Cody S. MS; Leonard, Jeffrey R. MD¶#; Jaffe, David M. MD#; Leonard, Julie C. MD, MPH#

doi: 10.1097/PEC.0b013e3182531911
Original Articles

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.

From the *Division of Emergency Medicine, Children’s Hospital Boston and Harvard Medical School, Boston, MA; †Departments of Emergency Medicine and Pediatrics, University of Michigan Medical Center and University of Michigan School of Medicine, Ann Arbor, MI; ‡Department of Emergency Medicine, Primary Children’s Medical Center and University of Utah, Salt Lake City, UT; §Division of Emergency Medicine, Children’s Hospital of Denver and University of Colorado, Aurora, CO; ∥Central Data Management and Coordinating Center and University of Utah School of Medicine, Salt Lake City, UT; and Departments of ¶Neurosurgery and #Pediatrics, St Louis Children’s Hospital and Washington University in St Louis School of Medicine, St Louis, MO.

Disclosure: The authors declare no conflict of interest.

Reprints: Lise E. Nigrovic, MD, MPH, Division of Emergency Medicine, Children’s Hospital, Boston, 300 Longwood Ave, Boston, MA 02115 (e-mail:

This work was supported by a grant from the Health Resources and Services Administration/Maternal and Child Health Bureau (MCHB), Emergency Medical Services of Children (EMSC) Program (H34 MC04372).

PECARN is supported by cooperative agreements U03MC00001, U03MC00003, U03MC00006, U03MC00007, and U03MC00008 from the EMSC program of the Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services.

This study was presented at the American Academy of Pediatrics National Conference & Exhibition (October 16, 2009) in Washington, DC.

© 2012 Lippincott Williams & Wilkins, Inc.