Original Research Article|Articles in Press

Can you see with CT? Is cervical spine computed tomographic imaging sufficient in pediatric trauma?


      • Cervical spine CT is sufficient to detect clinically significant injury in children.
      • RetroClival hematoma is often overlooked and associated with ligamentous injury.
      • Protocols encompassing adequate view acquisition should be developed.



      Traumatic cervical spine injury (CSI) is fundamentally different in children, and imaging recommendations vary; however, prompt diagnosis is necessary.


      We conducted a retrospective cohort study, evaluating children who presented after traumatic injury from 7/1/2012 to 12/31/2019 receiving a cervical spine CT. Evaluation of the incidence and clinical significance of CSI undetected on CT subsequently diagnosed on MRI was conducted. Additionally, all with CSI underwent image review to evaluate for potential overlooked, but visible pathology.


      1487 children underwent a cervical spine CT, revealing 52 with CSI. 237 underwent MRI due to an abnormal CT or continued clinical concern. Ultimately, three were discovered to have clinically significant CSI missed on CT. In all cases, retrospective review demonstrated a retroclival hematoma when soft tissue windows were formatted in sagittal and coronal views.


      A normal CT may be sufficient to rule-out clinically significant CSI. However, the presence of a retroclival hematoma must be evaluated.



      CSI (cervical spine injury), CT (computed tomography), MRI (magnetic resonance imaging), CVJ (craniocervical junction), IQR (interquartile range), NPV (negative predictive value), PPV (positive predictive value), MVC (motor vehicle collision), PECARN (Pediatric Emergency Care Applied Research Network), NEXUS (National Emergency X-Radiology Utilization Study), CCR (Canadian C-spine Rule)
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        • Copley P.C.
        • Tilliridou V.
        • Kirby A.
        • Jones J.
        • Kandasamy J.
        Management of cervical spine trauma in children.
        Eur J Trauma Emerg Surg. 2019 Oct; 45: 777-789
        • Kokoska E.R.
        • Keller M.S.
        • Rallo M.C.
        • Weber T.R.
        Characteristics of pediatric cervical spine injuries.
        J Pediatr Surg. 2001 Jan; 36: 100-105
        • Phillips N.
        • Rasmussen K.
        • McGuire S.
        • et al.
        Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort.
        Emerg Med J. 2021 May; 38: 330-337
        • Luehmann N.C.
        • Pastewski J.M.
        • Cirino J.A.
        • et al.
        Implementation of a pediatric trauma cervical spine clearance pathway.
        Pediatr Surg Int. 2020 Jan; 36: 93-101
        • Platzer P.
        • Jaindl M.
        • Thalhammer G.
        • et al.
        Cervical spine injuries in pediatric patients.
        J Trauma. 2007 Feb; 62: 389-396
        • Hoffman J.R.
        • Wolfson A.B.
        • Todd K.
        • Mower W.R.
        Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS).
        Ann Emerg Med. 1998 Oct; 32: 461-469
        • Stiell I.G.
        • Clement C.M.
        • McKnight R.D.
        • et al.
        The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.
        N Engl J Med. 2003 Dec 25; 349: 2510-2518
        • Burns E.C.
        • Yanchar N.L.
        Using cervical spine clearance guidelines in a pediatric population: a survey of physician practices and opinions.
        CJEM. 2011 Jan; 13: 1-6
        • Ehrlich P.F.
        • Wee C.
        • Drongowski R.
        • Rana A.R.
        Canadian C-spine rule and the national emergency X-radiography utilization low-risk criteria for C-spine radiography in young trauma patients.
        J Pediatr Surg. 2009 May; 44: 987-991
        • Garton H.J.
        • Hammer M.R.
        Detection of pediatric cervical spine injury.
        Neurosurgery. 2008 Mar; 62: 700-708
        • Hale A.T.
        • Alvarado A.
        • Bey A.K.
        • et al.
        X-ray vs. CT in identifying significant C-spine injuries in the pediatric population.
        Childs Nerv. Syst. 2017 Nov; 33: 1977-1983
        • Slaar A.
        • Fockens M.M.
        • Wang J.
        • et al.
        Triage tools for detecting cervical spine injury in pediatric trauma patients.
        Cochrane Database Syst Rev. 2017 Dec; 12: CD011686
        • Viccellio P.
        • Simon H.
        • Pressman B.D.
        • et al.
        A prospective multicenter study of cervical spine injury in children.
        Pediatrics. 2001 Aug; 108: E20
        • Chung S.
        • Mikrogianakis A.
        • Wales P.W.
        • et al.
        Trauma association of Canada pediatric subcommittee national pediatric cervical spine evaluation pathway: consensus guidelines.
        J Trauma. 2011 Apr; 70: 873-884
        • Rozzelle C.J.
        • Aarabi B.
        • Dhall S.S.
        • et al.
        Management of pediatric cervical spine and spinal cord injuries.
        Neurosurgery. 2013 Mar; 72: 205-226
        • Rana A.R.
        • Drongowski R.
        • Breckner G.
        • Ehrlich P.F.
        Traumatic cervical spine injuries: characteristics of missed injuries.
        J Pediatr Surg. 2009 Jan; 44: 151-155
        • Gargas J.
        • Yaszay B.
        • Kruk P.
        • Bastrom T.
        • Shellington D.
        • Khanna S.
        An analysis of cervical spine magnetic resonance imaging findings after normal computed tomographic imaging findings in pediatric trauma patients: ten-year experience of a level I pediatric trauma center.
        J Trauma Acute Care Surg. 2013 Apr; 74: 1102-1107
        • Bailey D.K.
        The normal cervical spine in infants and children.
        Radiology. 1952 Nov; 59: 712-719
        • Gore P.A.
        • Chang S.
        • Theodore N.
        Cervical spine injuries in children: attention to radiographic differences and stability compared to those in the adult patient.
        Semin Pediatr Neurol. 2009 Mar; 16: 42-58
        • Mortazavi M.
        • Gore P.A.
        • Chang S.
        • Tubbs R.S.
        • Theodore N.
        Pediatric cervical spine injuries: a comprehensive review.
        Childs Nerv. Syst. 2011 May; 27: 705-717
        • Gutierrez X.
        • April M.
        • Maddry J.
        • Hill G.
        • Becker T.
        • Schauer S.
        Incidence of pediatric cervical spine injuries in Iraq and Afghanistan.
        South Med J. 2019 May; 112: 271-275
        • Leonard J.C.
        • Browne L.R.
        • Ahmad F.A.
        • et al.
        Cervical spine injury risk factors in children with blunt trauma.
        Pediatrics. 2019 Jul; 144e20183221
        • Kim W.
        • Ahn N.
        • Ata A.
        • Adamo M.A.
        • Entezami P.
        • Edwards M.
        Pediatric cervical spine injury in the United States: defining the burden of injury, need for operative intervention, and disparities in imaging across trauma centers.
        J Pediatr Surg. 2021 Feb; 56: 293-296
        • Pannu G.S.
        • Shah M.P.
        • Herman M.J.
        Cervical spine clearance in pediatric trauma centers: the need for standardization and an evidence-based protocol.
        J Pediatr Orthop. 2017 Apr/May; 37: e145-e149
        • Tominaga Y.
        • Ndu A.B.
        • Coe M.P.
        • et al.
        Neck ligament strength is decreased following whiplash trauma.
        BMC Muscoskel Disord. 2006 Dec; 7: 103
        • Al-Sarheed S.
        • Alwatban J.
        • Alkhaibary A.
        • et al.
        Cervical spine clearance in unconscious pediatric trauma patients: a level l trauma center experience.
        Childs Nerv. Syst. 2020 Apr; 36: 811-817
        • Maung A.A.
        • Johnson D.C.
        • Barre K.
        • et al.
        Cervical spine MRI in patients with negative CT: a prospective, multicenter study of the research consortium of new england centers for trauma (ReCONECT).
        J Trauma Acute Care Surg. 2017 Feb; 82: 263-269
        • Offiah C.E.
        • Day E.
        The craniocervical junction: embryology, anatomy, biomechanics and imaging in blunt trauma.
        Insights Imag. 2017 Feb; 8: 29-47
        • Tubbs R.S.
        • Grabb P.
        • Spooner A.
        • Wilson W.
        • Oakes W.J.
        The apical ligament: anatomy and functional significance.
        J Neurosurg. 2000 Apr; 92: 197-200
        • Radcliff K.
        • Kepler C.
        • Reitman C.
        • Harrop J.
        • Vaccaro A.
        CT and MRI-based diagnosis of craniocervical dislocations: the role of the occipitoatlantal ligament.
        Clin Orthop Relat Res. 2012 Jun; 470: 1602-1613
        • Hunt K.
        • Hallworth S.
        • Smith M.
        The effects of rigid collar placement on intracranial and cerebral perfusion pressures.
        Anaesthesia. 2001 Jun; 56: 511-513
        • Jimenez R.R.
        • Deguzman M.A.
        • Shiran S.
        • Karrellas A.
        • Lorenzo R.L.
        CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks?.
        Pediatr Radiol. 2008 Jun; 38: 635-644