CT Topped X-Ray for C-Spine Injuries in Risky Ped Trauma
CT detected 71 of 74 C-spine injuries.
By Jane Salodof MacNeil
Elsevier Global Medical News
ALBUQUERQUE - Computed tomography imaging with coronal and sagittal reconstructions is superior to conventional x-rays when diagnosing possible cervical spine injuries in high-risk pediatric trauma patients, according to a study at a level I trauma center.
Dr. Gregory A. Mencio and his colleagues at Vanderbilt University in Nashville, Tenn., reviewed 413 consecutive charts of high-risk patients younger than 18 years at a level I trauma center from 2000 through 2004. All were evaluated by CT and conventional 5-view radiography of the cervical spine.
CT scanning detected 71 of 74 cervical spine injuries in the pediatric patients, who had an average age of 10.7 years. Only 50 injuries were detected by x-ray.
Combining the two modalities brought the detection rate to 72 cases - just 1 more case than was diagnosed by CT, Dr. Mencio reported at the annual meeting of the Pediatric Orthopaedic Society of North America.
"When all things were considered, the sensitivity, specificity, and negative predictive value were better with CT than conventional x-ray, and combining the two studies resulted in only a small improvement over CT alone," said Dr. Mencio, a professor of orthopedics and rehabilitation and director of the orthopedic rehabilitation section at Monroe Carell Jr. Children's Hospital at Vanderbilt.
Before embarking on the review, the investigators considered it intuitive that CT investigation of cervical spine injuries would be as accurate in children as in adults. No studies had previously compared the two modalities in children, however, and Dr Mencio said no consensus had been reached on a diagnostic standard for children who had been risk stratified as being in need of x-rays.
Typically, the patients are children who present in the emergency department with traumatic injuries from car accidents, falls, and sports, he explained in an interview at the meeting.
At Vanderbilt, determination of risk is based on National Emergency X-Radiography Utilization Study (NEXUS) criteria; those include tenderness at the posterior midline of the cervical spine, loss of consciousness, intoxication, neurologic deficit, and pain from another distracting injury.
"A lot of these kids have multiple systems injury," Dr. Mencio said. "Basically, you can do a CT of the head and neck and torso and total spine. It takes about 10 minutes to scan them from top to bottom, and you have all the information that you need."
Along with being more cumbersome than CT, conventional x-ray was even less effective in younger children.
It failed to diagnose 32% of all cervical spine injuries in the study--and 42% of those in 18 children younger than 14 years, Dr. Mencio said.
In adult studies, he added, x-rays perform similarly, missing 35%-48% of cervical spine injuries.
The researchers also estimated that the radiation dose was lower with CT, but the costs were higher: $1,800 for CT, vs. $500 for x-rays. In both cases, Dr. Mencio noted, conflicting data appear in the medical literature.
He offered the following recommendations, as adopted by the investigators at their own institution:
CT of the cervical spine with sagittal and coronal reconstructions is the initial imaging modality of choice for high-risk pediatric trauma patients.
Conventional x-ray may be used to elucidate dynamic instability and follow alignment over time.
Magnetic resonance imaging is used to evaluate patients with neurologic injuries and in obtunded patients who risk prolonged immobilization.