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Study Type
Study Objective(Purpose of Study)
Study Objective(Purpose of Study)
Study Results
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Study Quality
1. American College of Radiology. ACR Appropriateness Criteria®: Suspected Physical Abuse — Child. Available at: Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for initial radiologic examinations for children suspected of being physically abused. No abstract available. 4
2. American College of Radiology. ACR Appropriateness Criteria®: Suspected Spine Trauma. Available at: Review/Other-Dx N/A To provide evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No abstract available. 4
3. Dogan S, Safavi-Abbasi S, Theodore N, et al. Thoracolumbar and sacral spinal injuries in children and adolescents: a review of 89 cases. J Neurosurg. 2007;106(6 Suppl):426-433. Review/Other-Dx 89 patients To evaluate the mechanisms and patterns of thoracic, lumbar, and sacral spinal injuries in a pediatric population as well as factors affecting the management and outcome of these injuries. Patient injuries included fracture (91%), fracture and dislocation (6.7%), dislocation (1.1%), and ligamentous injury (1.1%). The L2-5 region was the most common injury site (29.8%) and the sacrum the least common injury site (5%). At the time of presentation 85.4% of the patients were neurologically intact, 4.5% had incomplete injuries, and 10.1% had complete injuries. Twenty-six percent of patients underwent surgery for their injuries whereas 76% received nonsurgical treatment. In patients treated surgically, an anterior approach was used in six patients (6.7%), a posterior approach in 16 (18%), and a combined approach in one (1.1%). Postoperatively, six patients (26.1%) with neurological deficits improved, one of whom recovered fully from an initially complete injury. 4
4. Katz JS, Oluigbo CO, Wilkinson CC, McNatt S, Handler MH. Prevalence of cervical spine injury in infants with head trauma. J Neurosurg Pediatr. 2010;5(5):470-473. Review/Other-Dx 905 patients To determine when less aggresive investigation is appropriate for cervical spine injuries (CSIs) in children less than 1 years of age. Nine hundred five infants with head trauma and without a major mechanism/cause were identified. Their mean age was 4.3 months. Of the 905 patients, only 2 cases of CSI were detected, giving a prevalence of 0.2%. The mechanism of injury in these 2 patients was nonaccidental trauma (NAT). 4
5. Ryan ME, Palasis S, Saigal G, et al. ACR Appropriateness Criteria head trauma--child. J. Am. Coll. Radiol.. 11(10):939-47, 2014 Oct. Review/Other-Dx N/A To evaluate the appropriateness of initial radiologic examinations for children with head trauma CT is considered the first line of study for suspected intracranial injury because of its wide availability and rapid detection of acute hemorrhage. However, the majority of childhood head injuries occur without neurologic complications, and particular consideration should be given to the greater risks of ionizing radiation in young patients in the decision to use CT for those with mild head trauma. MRI can detect traumatic complications without radiation, but often requires sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment and exposes the patient to potential anesthesia risks. MRI may be helpful in patients with suspected nonaccidental trauma, with which axonal shear injury and ischemia are more common and documentation is critical, as well as in those whose clinical status is discordant with CT findings. Advanced techniques, such as diffusion tensor imaging, may identify changes occult by standard imaging, but data are currently insufficient to support routine clinical use. 4
6. Madura CJ, Johnston JM, Jr. Classification and Management of Pediatric Subaxial Cervical Spine Injuries. Neurosurg Clin N Am. 2017;28(1):91-102. Review/Other-Dx N/A To review the classification and management of pediatric subaxial cervical spine injuries. Appropriate management of subaxial spine injury in children requires an appreciation for the differences in anatomy, biomechanics, injury patterns, and treatment options compared with adult patients. Increased flexibility, weak neck muscles, and cranial disproportion predispose younger children to upper cervical injuries and spinal cord injury without radiographic abnormality. A majority of subaxial cervical spine injuries can be treated nonoperatively. Surgical instrumentation options for children have significantly increased in recent years. Future studies of outcomes for children with subaxial cervical spine injury should focus on injury classification and standardized outcome measures to ensure continued improvement in quality of care for this patient population. 4
7. Adams JM, Cockburn MI, Difazio LT, Garcia FA, Siegel BK, Bilaniuk JW. Spinal clearance in the difficult trauma patient: a role for screening MRI of the spine. Am Surg. 2006;72(1):101-105. Observational-Dx 97 patietns To evaluate the sensitivity of CT scanning for spinal injuries compared with our MRI protocol Ninety-seven patients underwent MRI cervical spine trauma protocol during 2004. Twenty-nine patients were obtunded, 29 had neurologic symptoms, and 39 had spine pain. MRI confirmed the initial CT findings without new injuries in 83 cases. MRI reclassified fractures as degenerative changes in 12 cases. In 2 cases, the MRI identified new injuries: one a stable partial ligament tear, the second a T7 Chance fracture with ligamental disruption requiring operative fixation. There was no morbidity or mortality documented in obtaining the MRI studies. Overall negative predictive value of CT scanning of the spine was 98 per cent, the positive predictive value was 78 per cent, and the sensitivity and specificity was 94 per cent and 91 per cent, respectively. CT scanning of the cervical and axial spine is sensitive for spinal trauma but not specific. 3
8. Halpern CH, Milby AH, Guo W, Schuster JM, Gracias VH, Stein SC. Clearance of the cervical spine in clinically unevaluable trauma patients. [Review]. Spine. 35(18):1721-8, 2010 Aug 15. Meta-analysis N/A To compare the results of different management strategies for trauma patients in whom the cervical spine was not clinically evaluable due to impaired consciousness, endotracheal intubation, or painful distracting injuries. Slightly more than 7.5% of patients who are clinically unevaluable have cervical spine injuries, and 42% of these injuries are associated with spinal instability. Sensitivity of plain radiography or fluoroscopy for spinal clearance was 57% (95% CI: 57%-60%). Sensitivities for CT and MRI alone were 83% (82%-84%) and 87% (84%-89%), respectively. Complications associated with collar use ranged from 1.3% (2 days) to 7.1% (10 days) but were usually minor and short-lived. Quadriplegia resulting from spinal instability missed by a clearance test had enormous impacts on longevity, quality of life, and costs. These impacts overshadowed the effects of prolonged collar application, even when the incidence of quadriplegia was extremely low. M
9. Egloff AM, Kadom N, Vezina G, Bulas D. Pediatric cervical spine trauma imaging: a practical approach. Pediatr Radiol. 2009;39(5):447-456. Review/Other-Dx N/A To review suggested imaging protocols and the general characteristics, types of injuries, and measurements used to diagnose cervical spine injuries in children. No results stated in abstract. 4
10. Pang D, Wilberger JE, Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982;57:114-29. Review/Other-Dx 24 patients To address the pediatric syndrome of spinal cord injury without radiographic abnormality (SCIWORA) No results stated in abstract. 4
11. Babcock L, Olsen CS, Jaffe DM, Leonard JC, Cervical Spine Study Group for the Pediatric Emergency Care Applied Research N. Cervical Spine Injuries in Children Associated With Sports and Recreational Activities. Pediatr Emerg Care 2016. Observational-Dx 540 children with cervical spine injuries cases and 1060 as non–cervical spine injury controls To ascertain potential factors associated with cervical spine injuries in children injured during sports and recreational activities. For children with sport and recreational activity–related cervical spine injuries, common injury patterns were subaxial (49%) and fractures (56%). These children were at increased odds of spinal cord injury without radiographic abnormalities compared with children with cervical spine injuries from other mechanisms (25% vs 6%). Children with sport and recreational activity–related trauma had increased odds of cervical spine injury if they had focal neurologic findings (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.5–9.4), had complaints of neck pain (OR, 3.1; 95% CI, 1.9–5.0), were injured diving (OR, 43.5; 95% CI, 5.9–321.3), orsustained axial loading impacts (OR, 2.2; 95% CI, 1.3–3.5). Football (22%), diving (20%), and bicycle crashes (11%) were the leading activities associated with cervical spine injury. 3
12. Adelgais KM, Browne L, Holsti M, Metzger RR, Murphy SC, Dudley N. Cervical spine computed tomography utilization in pediatric trauma patients. J Pediatr Surg. 2014;49(2):333-337. Observational-Dx 5148 patients To compare usage of cervical spine CT (CSCT) and plain radiography between a pediatric trauma center (PTC) and referral general emergency departments (GEDs) in a pediatric population. 5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p<0.05) and more frequent ICU admissions (44.3% vs. 26.1% p<0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI=8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI=25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT. 3
13. Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med. 1992;21(12):1454-1460. Observational-Dx 974 cases to test the hypothesis that clinical low-risk criteria, determined prospectively at the bedside, could be used to identify patients without meaningful risk of cervical-spine fracture. Twenty-seven patients with cervical-spine fracture were among the 974 patients for whom data forms were completed. A number of findings were statistically more common in the group of patients with fracture than without, but no single or paired findings identified all patients with fracture. All 27 patients with fracture had at least one of the following four characteristics: midline neck tenderness, evidence of intoxication, altered level of alertness, or a severely painful injury elsewhere. Three hundred fifty-three of 947 (37.3%) patients without cervical-spine fracture had none of these findings. 3
14. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003; 349(26):2510-2518. Observational-Dx 8,283 patients; 394 physicians Multicenter study. Prospective cohort study to compare Canadian C-spine Rule with NEXUS low-risk criteria as decision rules for guiding use of radiography in trauma patients. First analysis (excluded indeterminate cases): Canadian C-spine Rule more sensitive than NEXUS low-risk criteria (99.4% vs 90.7%, P<0.001) and more specific (45.1% vs 36.8%, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9% vs 66.6%, P<0.001). Second analysis (included all patients): Assuming indeterminate cases were positive, sensitivity and specificity of Canadian C-spine Rule, were 99.4% and 40.4%, respectively (P<0.001 for both comparisons with the NEXUS low-risk criteria). Assuming Canadian C-spine Rule was negative for all indeterminate cases, these rates were 95.3% (P=0.09 for the comparison with the NEXUS low-risk criteria) and 50.7% (P=0.001). Study concludes Canadian C-spine Rule is better than NEXUS low-risk criteria with regards to sensitivity and specificity for cervical-spine injury. 3
15. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.[Erratum appears in N Engl J Med 2001 Feb 8;344(6):464]. N Engl J Med. 343(2):94-9, 2000 Jul 13. Observational-Dx 34,069 patients; 818 patients had CSI Multicenter study. Prospective observational study to determine validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study. (NEXUS). Decision instrument had sensitivity of 99% [95% CI, 98.0%-99.6%]), NPV of 99.8% (95% CI, 99.6%-100%), specificity 12.9%, and PPV 2.7%. Decision instrument based on clinical criteria can help physicians identify patients who need radiography of the cervical spine after blunt trauma. Application of this instrument could reduce the use of imaging in such patients. 3
16. Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001; 108(2):E20. Observational-Dx 3,065 patients Prospective multicenter study to examine patterns of spine injury in children (<18 years of age) and to evaluate the efficacy of the NEXUS decision instrument for obtaining cervical spine radiography in pediatric trauma victims. 88 children were <2 years of age, 817 were between 2 and 8, and 2,160 were between 8 to 17 years of age. 30 patients had CSI with C5-C7 being most common site of injury. Decision rule had sensitivity of 100%; 95% CI: 99.4%-100.0% and correctly identified 603 patients as low risk for CSI (NPV: 100.0%; 95% CI: 99.4%-100.0%). NEXUS decision rule performed well in children and could reduce cervical spine imaging by 20 %. Results should not be applied to children <2 years of age because of small number of infants and toddlers in the study. 3
17. Garton HJ, Hammer MR. Detection of pediatric cervical spine injury. Neurosurgery. 2008;62(3):700-708; discussion 700-708. Observational-Dx 190 patients To assess pediatric cervical spine records for injury location and means detection to better inform pediatric specific guideline development. Of 239 patients, 190 had true injuries and adequate medical records; of these, 187 had adequate radiology records. Patients without radiographic abnormality were excluded. In 34 children younger than 8 years, National Emergency X-Radiography Utilization Study criteria missed two injuries (sensitivity, 94%), with 76% of injuries occurring from occiput-C2. In 158 children older than 8 years, National Emergency X-Radiography Utilization Study criteria identified all injured patients (sensitivity, 100%), with 25% of injuries occurring from occiput-C2. For children younger than 8 years, plain-film sensitivity was 75% and combination plain-film/occiput-C3 computed tomographic scan had a sensitivity of 94%, whereas combination plain-film and flexion-extension views had 81% sensitivity. In patients older than 8 years, the sensitivities were 93%, 97%, and 94%, respectively. 4
18. Leonard JC, Kuppermann N, Olsen C, et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med. 2011;58(2):145-155. Observational-Dx 3314 records To identify risk factors associated with cervical spine injury in children after blunt trauma. We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses. 3
19. Pieretti-Vanmarcke R, Velmahos GC, Nance ML, et al. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma. J Trauma. 2009; 67(3):543-549; discussion 549-550. Observational-Dx 12,537 patients <3 years of age; 83 with cervical spine injuries Multicenter retrospective study to determine whether simple clinical criteria can be used to safely rule out cervical spine injuries in patients younger than 3 years. Of 12,537 patients younger than 3 years, cervical spine injuries were identified in 83 patients (0.66%), 8 had spinal cord injury. Four independent predictors of cervical spine injuries were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a NPV of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed cervical spine injuries in this study. Cervical spine injuries in patients younger than 3 years are uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population. 4
20. Jagannathan J, Dumont AS, Prevedello DM, Shaffrey CI, Jane JA, Jr. Cervical spine injuries in pediatric athletes: mechanisms and management. Neurosurg Focus. 2006;21(4):E6. Review/Other-Dx N/A To detail the characteristics and management of pediatric cervical spine injury Sports-related injuries to the spine, although relatively rare compared with head injuries, contribute to significant morbidity and mortality in children. The reported incidence of traumatic cervical spine injury in pediatric athletes varies, and most studies are limited because of the low prevalence of injury. The anatomical and biomechanical differences between the immature spine of pediatric patients and the mature spine of adults that make pediatric patients more susceptible to injury include a greater mobility of the spine due to ligamentous laxity, shallow angulations of facet joints, immature development of neck musculature, and incomplete ossification of the vertebrae. As a result of these differences, 60 to 80% of all pediatric vertebral injuries occur in the cervical region. Understanding pediatric injury biomechanics in the cervical spine is important to the neurosurgeon, because coaches, parents, and athletes who place themselves in positions known to be associated with spinal cord injury (SCI) run a higher risk of such injury and paralysis. The mechanisms of SCI can be broadly subclassified into five types: axial loading, dislocation, lateral bending, rotation, and hyperflexion/hyperextension, although severe injuries often result from a combination of more than one of these subtypes. 4
21. Huber AM, Gaboury I, Cabral DA, et al. Prevalent vertebral fractures among children initiating glucocorticoid therapy for the treatment of rheumatic disorders. Arthritis Care Res (Hoboken). 2010;62(4):516-526. Observational-Dx 134 children To study spine health among 134 children (87 girls) with rheumatic conditions (median age 10 years) within 30 days of initiating glucocorticoid therapy. Thirteen vertebral fractures were noted in 9 children (7%). Of these, 6 patients had a single vertebral fracture and 3 had 2-3 fractures. Fractures were clustered in the mid-thoracic region (69%). Three vertebral fractures (23%) were moderate (grade 2); the others were mild (grade 1). For the entire cohort, mean +/- SD L-spine BMD Z score was significantly different from zero (-0.55 +/- 1.2, P < 0.001) despite a mean height Z score that was similar to the healthy average (0.02 +/- 1.0, P = 0.825). Back pain was highly associated with increased odds for fracture (odds ratio 10.6 [95% confidence interval 2.1-53.8], P = 0.004). 3
22. Rodd C, Lang B, Ramsay T, et al. Incident vertebral fractures among children with rheumatic disorders 12 months after glucocorticoid initiation: a national observational study. Arthritis Care Res (Hoboken). 2012;64(1):122-131. Observational-Dx 118 children To determine the frequency of incident vertebral fractures (IVF) 12 months after glucocorticoid (GC) initiation in children with rheumatic diseases and to identify children at higher risk. Seven (6%) of 118 children (95% confidence interval 2.9-11.7%) had IVF. Their diagnoses were: juvenile dermatomyositis (n = 2), systemic lupus erythematosus (n = 3), systemic vasculitis (n = 1), and mixed connective tissue disease (n = 1). One child was omitted from the analyses after 4 months because of osteoporosis treatment for symptomatic IVF. Children with IVF received on average 50% more GC than those without (P = 0.030), had a greater increase in body mass index (BMI) at 6 months (P = 0.010), and had greater decrements in spine aBMD Z scores in the first 6 months (P = 0.048). Four (67%) of 6 children with IVF and data to 12 months had spine aBMD Z scores less than -2.0 at 12 months compared to 16% of children without IVF (P = 0.011). 2
23. Inaba K, Nosanov L, Menaker J, et al. Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma Multi-Institutional Trials Group Study. J Trauma Acute Care Surg. 78(3):459-65; discussion 465-7, 2015 Mar. Observational-Dx 3,065 adults To develop a clinical decision rule for evaluating the TL-spine after injury. Of 12,479 patients screened, 3,065 (24.6%) met inclusion criteria (mean [SD] age, 43.5 [19.8] years [range, 15-103 years]; male sex, 66.3%; mean [SD] Injury Severity Score [ISS], 8.8 [7.5]). The majority underwent computed tomography (93.3%), 6.3% only plain films, and 0.2% magnetic resonance imaging exclusively. TL-spine injury was identified in 499 patients (16.3%), of which 264 (8.6%) were clinically significant (29.2% surgery, 70.8% TL-spine orthosis). The majority was AO Type A1 282 (56.5%), followed by 67 (13.4%) A3, 43 (8.6%) B2, and 32 (6.4%) A4 injuries. The predictive ability of clinical examination (pain, midline tenderness, deformity, neurologic deficit), age, and mechanism was examined; positive clinical examination finding resulted in a sensitivity of 78.4% and a specificity of 72.9%. Addition of age of 60 years or older and high-risk mechanism (fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian) increased sensitivity to 98.9% with specificity of 29.0% for clinically significant injuries and 100.0% sensitivity and 27.3% specificity for injuries requiring surgery. 3
24. Leroux J, Vivier PH, Ould Slimane M, et al. Early diagnosis of thoracolumbar spine fractures in children. A prospective study. Orthop Traumatol Surg Res. 99(1):60-5, 2013 Feb. Observational-Dx 50 children To study the correlations between the ‘‘breath arrest’’ sensation at the time of trauma and the presence of thoracolumbar spine fractures in children to determine whether this clinical sign, as yet never described in the literature, could improve the early diagnosis of thoracolumbar spine fractures in children. Fifty children were included with a mean age of 11.4 years. Trauma occurred during games or sports in 94% of the cases. They fell on the back in 72% cases. Twenty-three children (46%) had fractures on the MRI, with a mean number of four fractured vertebrae (range, 1-10). Twenty-one of them (91%) had a "breath arrest" sensation. Fractures were not visualized on X-rays in five cases (22%). Twenty-seven children had no fracture; 19 of them (70%) did not feel a "breath arrest". Fractures were suspected on X-rays in 15 cases (56%). 3
25. Diaz JJ Jr, Cullinane DC, Altman DT, et al. Practice management guidelines for the screening of thoracolumbar spine fracture. J Trauma. 63(3):709-18, 2007 Sep. Review/Other-Dx 27 articles To develop an EBM guideline for the diagnosis of thoracolumbar spine (TLS) fractures. Sixty-nine articles were identified after the initial screening process, all of which dealt with blunt injury to the TLS, along with clinical, radiographic, fluoroscopic, and magnetic resonance imaging evaluation. From this group, 32 articles were selected. The reviewers identified 27 articles that dealt with the initial evaluation of TLS injury after trauma. 4
26. Joaquim AF, Ghizoni E, Tedeschi H, Batista UC, Patel AA. Clinical results of patients with thoracolumbar spine trauma treated according to the Thoracolumbar Injury Classification and Severity Score. J Neurosurg Spine. 20(5):562-7, 2014 May. Review/Other-Dx 65 patients To evaluate the neurological outcome of patients with thoracolumbar spine trauma (TLST) treated according to the Thoracolumbar Injury Classification and Severity Score (TLICS). A total of 65 patients were treated. In 37 patients, the TLICS was 3 points or fewer and the patients were treated nonsurgically (Group 1). The remaining 28 patients with a TLICS of 4 or more points underwent surgical treatment (Group 2). In Group 1, 28 patients underwent some follow-up at the authors' institution; all of these patients were neurologically intact with compression or burst fractures (TLICS of 1 or 2 points; median 2). The average age in this group was 44.5 years, and follow-up ranged from 1 to 36 months (mean 6.7 months, median 3 months). Two patients (both with a TLICS of 2 points) underwent late surgery for axial back pain and mild focal kyphosis, without significant clinical improvement. In Group 2, follow-up ranged from 1 to 18 months (mean 4.4 months, median 3 months) and the TLICS ranged from 4 to 10 points (median 7 points). In this group, preoperatively, 9 (32%) patients had AIS Grade E injuries, 6 (21%) had AIS Grade C, 1 (4%) had AIS Grade B, and 12 (43%) had AIS Grade A injuries. At the final follow-up, the AIS grade was E in 11 patients (39%), D in 5 (18%), and A in 12 (43%). No patient had neurological worsening during the follow-up. 4
27. de Gauzy JS, Jouve JL, Violas P, et al. Classification of chance fracture in children using magnetic resonance imaging. Spine (Phila Pa 1976). 2007;32(2):E89-92. Observational-Dx 18 children To evaluate bone and soft tissue lesions in pediatric Chance fracture. On MRI, in all cases, no abnormal signs were noted on the intervertebral disc. Six patients had a bone fracture going through the pedicle and the vertebral body. Twelve patients had a physeal injury located on the superior or on the inferior vertebral endplate. Three types of lesions could be identified according to the location of the lesion in relation to the pedicle. 3
28. Salgado A, Pizones J, Sanchez-Mariscal F, Alvarez P, Zuniga L, Izquierdo E. MRI reliability in classifying thoracolumbar fractures according to AO classification. Orthopedics. 2013;36(1):e75-78. Observational-Dx 11 observers To determine AO classification reproducibility for vertebral fractures among a variety of observers using radiographs and MRI as diagnostic tools. Mean interobserver agreement was kappa=0.53 and 0.47 for the first and second sessions, respectively, for all evaluators. Greater interobserver agreement was observed between the senior doctors (kappa=0.59 and 0.54 for the first and second sessions, respectively) vs residents (kappa=0.45 and 0.31 for the first and second sessions, respectively) (P=.02) and between orthopedic surgeons vs radiologists (kappa=0.71 vs 0.48, respectively) (P=.008). Mean intraobserver agreement was kappa=0.58 (range, 0.38-0.76). Evaluators more familiar with the classification obtained higher kappas. 2
29. White JH, Hague C, Nicolaou S, Gee R, Marchinkow LO, Munk PL. Imaging of sacral fractures. Clin Radiol. 2003;58(12):914-921. Review/Other-Dx N/A To discuss traumatic, insufficiency and pathological sacral fractures. No results stated in abstract. 4
30. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. [Review] [21 refs]. J Trauma. 58(5):902-5, 2005 May. Meta-analysis 712 articles To compare test performance of radiographs and CT in the detection of CSI in trauma patients. Radiographs were 52% sensitive (95% CI: 47%-56%); CT was 98% (95%, CI: 96%-99%). CT outperforms radiography as a screening tool for cervical injury in high risk patients. There is insufficient evidence that CT should replace radiography for low risk patients. M
31. Corcoran B, Linscott LL, Leach JL, Vadivelu S. Application of Normative Occipital Condyle-C1 Interval Measurements to Detect Atlanto-Occipital Injury in Children. AJNR Am J Neuroradiol 2016;37:958-62. Observational-Dx 14 patients To assess the utility of applying age-specific normative occipital condyle-C1 interval ranges to documented cases of atlantooccipital injury compared with previously reported abnormal cutoff values. An occipital condyle-C1 interval 2 SDs above the age-specific mean has a sensitivity of 50% and specificity of 89%–100%, depending on the age group. An occipital condyle-C1 interval 3 SDs above the age-specific mean has a sensitivity of 50% and a specificity of 95%–100%. A 4.0-mm occipital condyle-C1 interval has a sensitivity of 36% and a specificity of 100% in all age groups. A 2.5-mm occipital condyle-C1 interval has a sensitivity of 93% and a specificity of 18%–100%. 3
32. Smith P, Linscott LL, Vadivelu S, Zhang B, Leach JL. Normal Development and Measurements of the Occipital Condyle-C1 Interval in Children and Young Adults. AJNR Am J Neuroradiol 2016;37:952-7. Observational-Dx 124 patients To test the null hypothesis that condyle-C1 interval morphology and joint measurements do not change as a function of age. Two hundred forty-eight joints were measured in 124 subjects with an age range of 2 days to 22 years. The condyle-C1 intervalvaries substantially by age. Average coronal measurements are larger and more variable than sagittal measurements. The medial occipitalcondyle notch is most prevalent from 1 to 12 years and is uncommon in older adolescents and young adults. 3
33. Avellino AM, Mann FA, Grady MS, et al. The misdiagnosis of acute cervical spine injuries and fractures in infants and children: the 12-year experience of a level I pediatric and adult trauma center. Childs Nerv Syst. 2005;21(2):122-127. Observational-Dx 37 patients To determine the frequency of acute cervical spine injuries and fractures that were misdiagnosed in infants and children (< or =14 years) initially evaluated at a pediatric and adult urban level I trauma center. This was a retrospective, single-institution, case series of pediatric cervical spine injuries and fractures that were misdiagnosed during initial emergency room imaging evaluation. "Misdiagnosed" cases were those cases whose imaging studies initially obtained in the emergency room were misinterpreted based on reevaluation by a senior trauma radiologist blinded to the initial results. Nineteen percent (7 out of 37) were misdiagnosed on initial emergency room imaging evaluation. Five percent were true "missed" fractures, and 14% were "normal and/or developmental variants" read as fractures or dislocation. 3
34. Sundgren PC, Philipp M, Maly PV. Spinal trauma. Neuroimaging Clin N Am. 2007;17(1):73-85. Review/Other-Dx N/A To discuss and review spinal trauma and differing imaging modalities. No results stated in abstract. 4
35. Nigrovic LE, Rogers AJ, Adelgais KM, et al. Utility of plain radiographs in detecting traumatic injuries of the cervical spine in children. Pediatr Emerg Care. 28(5):426-32, 2012 May. Observational-Dx 206 children To estimate the sensitivity of plain radiographs in identifying bony or ligamentous cervical spine injury in children. 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). 2
36. Silva CT, Doria AS, Traubici J, Moineddin R, Davila J, Shroff M. Do additional views improve the diagnostic performance of cervical spine radiography in pediatric trauma? AJR. 2010; 194(2):500-508. Observational-Dx 234 patients Retrospective analysis of cervical spine radiographs of pediatric patients to measure the diagnostic performances of lateral views alone and multiple radiographic views of the cervical spine in comparison with MDCT scans in pediatric trauma and to determine whether evaluation of additional views, in relation to lateral views alone, improves the performance of radiography. 22 patients had positive findings on CT: Atlantooccipital subluxation/dislocation was seen in one patient; C1 ring fracture, in three patients; C1-C2 rotatory subluxation, in one; C1-C2 subluxation/dislocation, in one; odontoid fracture, in two; vertebral body wedge fracture, in six; posterior arch fracture dislocation, in 10; and spinous process fracture, in none. The lateral view radiograph alone had 73% sensitivity (95% CI, 50%-89%) and 92% specificity (95% CI, 87%-95%) for cervical spine abnormalities compared with MDCT. The addition of other views did not change the sensitivity of radiography but rather marginally decreased its specificity to 91% (95% CI, 86%-94%). Lateral view radiographs had a borderline acceptable sensitivity to cervical spine abnormalities in pediatric patients compared with MDCT. The addition of other radiographic views did not seem to improve the diagnostic performance of radiography. 2
37. Kulaylat AN, Tice JG, Levin M, Kunselman AR, Methratta ST, Cilley RE. Reduction of radiation exposure in pediatric patients with trauma: cephalic stabilization improves adequacy of lateral cervical spine radiographs. J Pediatr Surg. 2012;47(5):984-990. Observational-Dx 46 patients To test the hypothesis that CS improves visualization of the cervicothoracic junction during lateral cervical spine radiographs. The proportion of adequate visualization of the cervicothoracic junction was 0.85 for cases with stabilization and 0.60 for controls. Odds of obtaining adequate visualization with stabilization are 3.8 times those without stabilization (P = .001) and were even greater for patients younger than 13 years. 2
38. Nasir S, Hussain M, Mahmud R. Flexion/extension cervical spine views in blunt cervical trauma. Chin J Traumatol. 15(3):166-9, 2012. Review/Other-Dx 200 cases To examine the contribution of flexion and extension radiographs in the evaluation of ligamentous injury in awake adults with acute blunt cervical spine trauma, who show loss of cervical lordosis and neck pain. A total of 200 cases were reviewed, of whom 90 (45%) underwent repeat X-rays because of either inadequate exposure or limited motion. None of the patients with loss of lordosis on cross-table view had positive flexion and extension views of cervical spine for instability. 4
39. Pollack CV Jr, Hendey GW, Martin DR, Hoffman JR, Mower WR, NEXUS Group. Use of flexion-extension radiographs of the cervical spine in blunt trauma. Ann Emerg Med. 38(1):8-11, 2001 Jul. Observational-Dx 818 patients To determine the clinical factors associated with ordering flexion-extension (F/E) views and the incidence of diagnostic F/E films in patients with a normal 3-view cervical spine series. Of 818 patients ultimately found to have cervical spine injury, 86 (10.5%) underwent F/E testing. Two patients sustained stable bony injuries detected only on F/E views. Four other patients had a subluxation detected only on F/E views, but all had other injuries apparent on routine cervical spine imaging. 4
40. Rana AR, Drongowski R, Breckner G, Ehrlich PF. Traumatic cervical spine injuries: characteristics of missed injuries. J Pediatr Surg. 2009;44(1):151-155; discussion 155. Observational-Dx 318 patients To characterize missed cervical spine injuries (CSIs). There were 1307 pediatric trauma patients admitted with 318 imaged for potential CSI. Computed tomography was the sole imaging study in 200, x-rays in 64, and both in 54. Time to C-spine clearance was similar for all modalities (P > .05). For CT, 34 (10.7%) were initially positive for CSI with 7 false-positives (FPs) and no false-negative (FN). There were 18 patients with CSI identified by x-ray, with 5 FPs and 5 FNs (missed injuries). The 5 FNs missed by x-ray were all positive by CT scan and required no intervention. None of the flexion/extension views revealed an additional injury. Sex, intubated patients, ISS, age, type, and injury location were not predictive of a missed injury (P > .05).The sensitivity of CT scan was 1.0, specificity was 0.976, and the positive predictive value was 79.4%. The sensitivity of plain x-ray was 61.5%, the specificity was 1.6%, and the positive predictive value was 61.5%. 3
41. Sierink JC, van Lieshout WA, Beenen LF, Schep NW, Vandertop WP, Goslings JC. Systematic review of flexion/extension radiography of the cervical spine in trauma patients. [Review]. Eur J Radiol. 82(6):974-81, 2013 Jun. Review/Other-Dx 6 studies To investigate whether Flexion/Extension (F/E) radiography adds diagnostic value to CT or MRI in the detection of cervical spine ligamentous injury and/or clinically significant cervical spine instability of blunt trauma patients. F/E radiography was overall regarded to be inferior to CT or MRI in the detection of ligamentous injury. This was reflected by the high specificity and NPV for CT with F/E as reference test (ranging from 97 to 100% and 99 to 100% respectively) and the ambiguous results for F/E radiography with MRI as its reference test (0-98% and 0-83% for specificity and NPV respectively). Image quality of F/E radiography was reported to have 31 to 70% adequacy, except in two studies which reported an adequacy of respectively 4 and 97%. 4
42. Anderson RC, Kan P, Vanaman M, et al. Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age. J Neurosurg Pediatr. 2010;5(3):292-296. Review/Other-Dx 575 children To determine whether a safe and effective protocol-driven system could be developed for clearance of the cervical spine in noncommunicative children between 0 and 3 years of age. A total of 2828 pediatric trauma activations required cervical spine clearance during the study period. Of these, 575 (20%) were children <or= 3 years of age who were admitted to the hospital. To facilitate clearing the cervical spine in these children, plain radiographs (100%), CT studies (14%), and MR images (10%) were obtained. Nineteen ligamentous injuries (3.3%) and 9 fractures/dislocations (1.5%) were detected, with 4 patients requiring operative stabilization (0.7%). No late injuries have been detected. 4
43. Brohi K, Healy M, Fotheringham T, et al. Helical computed tomographic scanning for the evaluation of the cervical spine in the unconscious, intubated trauma patient. J Trauma. 2005; 58(5):897-901. Observational-Dx 437 patients To determine whether CT is useful for the evaluation of the cervical spine as part of a spinal assessment and clearance protocol in unconscious patients. CT identified 61 patients with cervical injuries, of whom 31 were deemed unstable. CT had sensitivity 98.1%, specificity 98.8%, and NPV 99.7%. There were no missed unstable injuries. Rapid and safe evaluation of the cervical spine was realized with CT. 3
44. Brockmeyer DL, Ragel BT, Kestle JR. The pediatric cervical spine instability study. A pilot study assessing the prognostic value of four imaging modalities in clearing the cervical spine for children with severe traumatic injuries. Childs Nerv Syst 2012;28:699-705. Observational-Dx 24 patients To prospectively assess the utility of four radiographic modalities to clear the cervical spine in children after severe trauma. Plain cervical spine radiographs demonstrated sensitivity of 100% and specificity of 95%; flexion–extension radiographs had “indeterminate” sensitivity and specificity of 100%. For CT, sensitivity was 100% and specificity was 95%, and for MR imaging, sensitivity was 100% and specificity was 74%. 3
45. Zhuge W, Ben-Galim P, Hipp JA, Reitman CA. Efficacy of MRI for assessment of spinal trauma: correlation with intraoperative findings. J Spinal Disord Tech. 28(4):147-51, 2015 May. Observational-Dx 35 patients To assess the efficacy of magnetic resonance imaging (MRI) for detecting spinal soft tissue injury after acute trauma using intraoperative findings as a reference standard. MRI was 100% sensitive and specific in detecting injury to the anterior longitudinal ligament. MRI was moderately sensitive (80%) but highly specific (100%) for injury to the posterior longitudinal ligament. In contrast, MRI was highly sensitive but less specific in detecting injury to paraspinal muscles (100%, 77%), intervertebral disk (100%, 71%), and interspinous ligament (100%, 64%). MRI was moderately sensitive and specific in detecting ligamentum flavum injury (80% and 86.7%) but poorly sensitive for facet capsule injury (62.5%). 2
46. Brown CV, Antevil JL, Sise MJ, Sack DI. Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come. J Trauma. 2005; 58(5):890-895; discussion 895-896. Observational-Dx 3,537 patients Retrospective review to determine whether spiral CT could be used as the primary imaging modality for the diagnosis of cervical, thoracic, and lumbar spine fractures. Of 236 fractures sustained, CT identified all but two: one cervical and one thoracic. Study concludes CT is sensitive for the identification of spine fractures and that radiographs of the spine are not needed for the evaluation of the spine in blunt trauma patients. 3
47. Sixta S, Moore FO, Ditillo MF, et al. Screening for thoracolumbar spinal injuries in blunt trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 73(5 Suppl 4):S326-32, 2012 Nov. Review/Other-Dx 21 articles To determine the answer to the following: (1) What is the appropriate imaging modality to screen patients for TLS injuries? (2) Which trauma patients require radiographic screening for TLS injuries? (3)Does a patient who is awake and alert without distracting injuries require radiologic workup to rule out TLS injuries? Practice patterns have changed regarding screening blunt trauma patients for TLS injuries. Software reformatted multidetector computed tomographic scans are more sensitive and accurate than plain films. Multidetector computed tomographic scans have become the screening modality of choice and the criterion standard in screening for TLS injuries. The literature supports a Level 1 recommendation to validate this based on a preponderance of Class II data. Patients without altered mentation or significant mechanism may be excluded by clinical examination without imaging. Patients with gross neurologic deficits or concerning clinical examination findings with negative imaging should receive a magnetic resonance imaging expediently, and the spine service should be consulted. 4
48. Henry M, Riesenburger RI, Kryzanski J, Jea A, Hwang SW. A retrospective comparison of CT and MRI in detecting pediatric cervical spine injury. Childs Nerv Syst. 2013;29(8):1333-1338. Observational-Dx 84 patients To evaluate magnetic resonance imaging (MRI) and CT in detecting pediatric cervical spine injuries. Eighty-four patients were identified with a mean age of 9.0 +/- 5.8 years (56% male). Sixteen patients were identified with injury, 12 with soft tissue abnormalities on MRI (nine edema and six ligamentous), and 6 with osseous abnormalities on CTs (six osseous fractures and one discogenic injury). Of the six patients who presented with CT-identified osseous injuries, MRI detected all six fractures as well as an additional compression fracture. Using CT as the standard for osseous injury, MRI had a sensitivity of 100%, specificity of 97%, negative predictive value (NPV) of 75%, and positive predictive value (PPV) of 100%. Using MRI as the standard for soft tissue injury, CT had a sensitivity of 23%, specificity of 100%, NPV of 88%, and PPV of 100%. 3
49. Diaz JJ, Jr., Aulino JM, Collier B, et al. The early work-up for isolated ligamentous injury of the cervical spine: does computed tomography scan have a role? J Trauma. 2005; 59(4):897-903; discussion 903-894. Observational-Dx 1,577 patients; 3 observers Prospective blinded study to assess whether helical CT can be used as a screening tool for isolated ligamentous injury in blunt trauma. Patients also had radiographs and MRI. 278 had 416 cervical spine fractures. Radiographs failed to identify 299/416 (72%) cervical spine fractures in 208/278 (74.8%). Of 1,299 (82%) with no fracture, 85 (6.5%) required an MRI. Sensitivity for radiographs and helical CT for ligamentous injury were 16% and 32%, respectively. NPV for radiographs and helical CT were 74% and 78%, respectively. While helical CT is best modality for screening the cervical spine bony injuries, it is not an effective modality for screening for cervical ligamentous injury where MRI is clearly superior. The indications for MRI include abnormalities on helical CT, neurologic deficits, cervical pain or tenderness on examination, or the inability to clear the cervical spine in the obtunded patient. 2
50. Mascarenhas D, Dreizin D, Bodanapally UK, Stein DM. Parsing the Utility of CT and MRI in the Subaxial Cervical Spine Injury Classification (SLIC) System: Is CT SLIC Enough?. AJR Am J Roentgenol. 206(6):1292-7, 2016 Jun. Observational-Dx 202 patients To evaluate the diagnostic performance of the Subaxial Cervical Spine Injury Classification (SLIC) System in predicting the need for surgical intervention after subaxial cervical spine injury. Using a SLIC score of 4 as the cutoff value for surgical intervention, we found that SLIC scoring based on CT and MRI had a sensitivity of 94.6%, specificity of 71.0%, and AUC of 0.87 with a kappa value of 0.28. SLIC scoring based on CT alone had a sensitivity of 86.2%, specificity of 77.3%, and AUC of 0.88 with a kappa value of 0.52. 2
51. Junewick JJ, Meesa IR, Luttenton CR, Hinman JM. Occult injury of the pediatric craniocervical junction. Emerg Radiol. 2009;16(6):483-488. Observational-Dx 45 patients To review the occurrence of occult craniocervical junction injury in children Of the forty-five patients with negative CT of the craniocervical junction, 30 had positive MRI findings at the craniocervical junction. Seventeen of the 30 patients fulfilled criteria for significant craniocervical junction injury by MRI. Eleven of 17 patients with significant craniocervical junction injury were less than 8 years old and 13 of 17 were involved in motor vehicle accidents. Six of 12 patients with injury below C2 had significant craniocervical injury. 3
52. 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. 74(4):1102-7, 2013 Apr. Observational-Dx 173 patients To describe findings on c-spine magnetic resonance imaging (MRI) after previously normal c-spine computed tomographic (CT) scan findings at a Level 1 trauma center. A total of 173 patients met inclusion criteria. With 100% of patients demonstrating normal c-spine CT scan findings, 83% of c-spine MRI findings were also negative (p < 0.001). Thirty patients (17%) demonstrated significant abnormalities on MRI. Of the 30, 5 (2.9%) required operative c-spine stabilization. Eighty-five patients underwent CT scan in the early group, and 88 in the late group. All 5 patients with unstable injuries not discovered on CT scan were from the early group, compared with none in the late group (p = 0.027). 3
53. Beenen LF, Sierink JC, Kolkman S, et al. Split bolus technique in polytrauma: a prospective study on scan protocols for trauma analysis. Acta Radiol. 56(7):873-80, 2015 Jul. Observational-Dx 30 patients To evaluate three protocols for single pass total body scanning in 64-slice multidetector CT (MDCT) on optimal image quality. Overall image quality was good (4.10) in Group A, more than satisfactory (3.38) in Group B, and nearly excellent (4.75) in Group C (P < 0.001). Interfering artifacts were mostly reported in Group B in the liver and spleen. 2
54. Kreykes NS, Letton RW, Jr. Current issues in the diagnosis of pediatric cervical spine injury. Semin Pediatr Surg. 2010;19(4):257-264. Review/Other-Dx N/A To look at the differences in adult and pediatric cervical spine anatomy and traumatic mechanisms, as well as the differences between cervical spine injury in infants/children and adolescents/teens. To examine the literature currently available in each population and derive consensuses on the issues that are important in managing the pediatric cervical spine. And to provide a framework that trauma centers can use to develop safe and effective cervical spine clearance protocols. No results stated in abstract. 4
55. Yaniv G, Portnoy O, Simon D, Bader S, Konen E, Guranda L. Revised protocol for whole-body CT for multi-trauma patients applying triphasic injection followed by a single-pass scan on a 64-MDCT. Clin Radiol. 68(7):668-75, 2013 Jul. Observational-Dx 82 patients To evaluate a revised protocol for whole-body computed tomography (CT) for multi-trauma patients in an emergency department and compare it to conventional protocols. Mean enhancement values in the ascending and descending aorta were significantly greater with the conventional protocol. Enhancement of the abdominal aorta, iliac arteries, IVC, liver, spleen, and kidneys was significantly greater with the revised protocol. Mediastinal streak artefacts were present in all conventional protocol images and absent in all revised protocol images. Image quality using the revised protocol was significantly better (p < 0.002). The mean effective radiation dose was significantly lower (p = 0.005), and image number reduced (p < 0.001). 3
56. Morais DF, de Melo Neto JS, Meguins LC, Mussi SE, Filho JR, Tognola WA. Clinical applicability of magnetic resonance imaging in acute spinal cord trauma. Eur Spine J. 2014;23(7):1457-1463. Observational-Dx 98 patients To assess the clinical application of magnetic resonance imaging (MRI) in patients with acute spinal cord trauma (SCT) according to the type, extension, and severity of injury and the clinical-radiological correlation. The radiological findings were better visualized using MRI, except for the posterior elements (p = 0.001), which were better identified with CT. A total of 271 lesions were diagnosed as follows: 217 using MRI, 154 using CT, and 100 (36.9 %) using both MRI and CT. MRI detected 117 more lesions than CT. 3
57. Bagley LJ. Imaging of spinal trauma. Radiol Clin North Am. 2006;44(1):1-12, vii. Review/Other-Dx N/A To discuss clinical criteria for screening for spinal injury and the increasing roles of multidetector CT and MR imaging in the evaluation of spinal trauma. No results stated in abstract. 4
58. Easter JS, Barkin R, Rosen CL, Ban K. Cervical spine injuries in children, part II: management and special considerations. J Emerg Med. 2011;41(3):252-256. Review/Other-Dx N/A To discuss the role of magnetic resonance imaging (MRI) as well as the management of pediatric cervical spine injuries in the emergency department. Children have several common variations in their anatomy, such as pseudosubluxation of C2-C3, widening of the atlantodens interval, and ossification centers, that can appear concerning on imaging but are normal. Physicians should be alert for signs or symptoms of atlantorotary subluxation and spinal cord injury without radiologic abnormality when treating children with spinal cord injury, as these conditions have significant morbidity. MRI can identify injuries to the spinal cord that are not apparent with other modalities, and should be used when a child presents with a neurologic deficit but normal X-ray study or CT scan. 4
59. Liao CC, Lui TN, Chen LR, Chuang CC, Huang YC. Spinal cord injury without radiological abnormality in preschool-aged children: correlation of magnetic resonance imaging findings with neurological outcomes. J Neurosurg. 2005;103(1 Suppl):17-23. Observational-Tx 58 patients To study the correlation between MR imaging findings and the outcomes of neurological deficits, with an elimination of the bias for age. Among the patients with SCIWORA younger than 8 years old, the different patterns of the injured spinal cords could be identified using MR imaging as transection, contusive hemorrhage, traumatic edema, and concussion. The MR imaging patterns of SCIWORA had significant prognostic correlations with the neurological outcomes of these patients; that is, a normal spinal cord appearance was prognostic of a complete recovery of neurological deficits, and intramedullary lesions correlated with permanent deficits with functional disability. 3
60. Khanna P, Chau C, Dublin A, Kim K, Wisner D. The value of cervical magnetic resonance imaging in the evaluation of the obtunded or comatose patient with cervical trauma, no other abnormal neurological findings, and a normal cervical computed tomography. J Trauma Acute Care Surg. 72(3):699-702, 2012 Mar. Observational-Dx 150 patients To evaluate the utility of MRI in the evaluation of obtunded and comatose patients in the acute setting, and to confirm the usefulness of multidetector CT for the identification of patients in need of operative management. Among the 150 obtunded or comatose patients with a negative CT, the majority (51%) had a normal MRI. Among the patients with a positive MRI, the most common MRI-positive findings were ligamentous and soft tissue injury (81%). However, no MRI findings were deemed unstable, and no surgical intervention or change in the clinical management aside from collar immobilization of these individuals occurred after MRI. 3
61. Qualls D, Leonard JR, Keller M, Pineda J, Leonard JC. Utility of magnetic resonance imaging in diagnosing cervical spine injury in children with severe traumatic brain injury. J Trauma Acute Care Surg. 78(6):1122-8, 2015 Jun. Observational-Dx 1196 children To determine the added benefit of MRI as an adjunct to CT in the clearance of children with severe head trauma. A total of 1,196 head-injured children were admitted to the pediatric intensive care unit between January 2002 and December 2012. Sixty-three children underwent CT and MRI and met Glasgow Coma Scale criteria. Seven children were identified with negative CT and positive MRI findings, but none of these injuries were considered unstable by our criteria. Five children were determined to have unstable injuries, and all were detected on CT. 3
62. Satahoo SS, Davis JS, Garcia GD, et al. Sticking our neck out: is magnetic resonance imaging needed to clear an obtunded patient's cervical spine? J Surg Res. 2014;187(1):225-229. Observational-Dx 309 patients To examine the data in an urban, county trauma center to determine if a negative cervical spine CT scan is sufficient to clear the obtunded trauma patient. A total of 309 patients had both CT and MRI, 107 (35%) of whom had negative CTs. Mean time between CT and MRI was 16 d. Of those patients, seven (7%) had positive acute traumatic findings on MRI. Findings included ligamentous injury, subluxation, and fracture. However, only two of these patients required surgical intervention. None had unstable injuries. 3
63. Steigelman M, Lopez P, Dent D, et al. Screening cervical spine MRI after normal cervical spine CT scans in patients in whom cervical spine injury cannot be excluded by physical examination. Am J Surg. 2008;196(6):857-862; discussion 862-853. Observational-Dx 120 patients To determine if the addition of cervical spine MRI to the evaluation of trauma patients is unnecessary after normal results on cervical spine CT One hundred twenty patients underwent MRI to examine their cervical spines. Seven patients had abnormal MRI findings suggestive of acute traumatic injury. No MRI studies led to operative intervention. Screening MRI increased from 1% of comatose patients in 2002 to 18% in 2006. 3
64. Tomycz ND, Chew BG, Chang YF, et al. MRI is unnecessary to clear the cervical spine in obtunded/comatose trauma patients: the four-year experience of a level I trauma center. J Trauma. 2008; 64(5):1258-1263. Observational-Dx 690 patients Retrospective study to demonstrate that CT is adequate in clearing the spine in obtunded patients. Patients also had MRI. 180 patients (26%) had normal CT and normal neurologic examinations. MRI identified 38 patients with acute traumatic findings. None had an unstable injury, required surgery, or developed delayed instability. CT using modern imaging protocols, in patients without neurologic deficit is adequate for clearing the spine in obtunded patients. 3
65. Menaker J, Philp A, Boswell S, Scalea TM. Computed tomography alone for cervical spine clearance in the unreliable patient--are we there yet? J Trauma. 2008; 64(4):898-903; discussion 903-894. Review/Other-Dx 734 patients Retrospective study to demonstrate that an admission cervical spine CT with no acute injury is not sufficient for clearance in an unreliable patient. Patients had MRI. 203 patients had “no acute injury” on CT; 184 had a negative MRI and collars were removed. 18 patients had an abnormal MRI, 2 of whom required operative repair and 14 required extended collar use; 1 patient had a suboptimal MRI and was discharged in a collar. Study recommends MRI for clearance in unreliable patients. 4
66. Russin JJ, Attenello FJ, Amar AP, Liu CY, Apuzzo ML, Hsieh PC. Computed tomography for clearance of cervical spine injury in the unevaluable patient. World Neurosurg. 80(3-4):405-13, 2013 Sep-Oct. Meta-analysis 13 articles To review computed tomography (CT) as a stand-alone test for the clearance of cervical spine injury in the unevaluable patient population. Our analysis of 13 articles revealed that a total of 1322 unevaluable patients with a negative CT C-spine who also underwent MRI; 137 of these patients (10%) had positive findings on MRI. Among nine studies with patient management data, a total of 115 patients had positive MRI findings in the setting of a negative CT. Of those 115 patients, 52%, or 60 patients, had changes to their management based on MRI findings. Surgical stabilization was required in three patients, representing 2.5% of the 115 patients with positive MRI findings. The total number of patients in these nine studies who had a negative CT was 855. Therefore, the negative predictive value of a negative CT in this patient population was 92.9% for clinically significant cervical spine injury and 99.6% for cervical spine injury requiring operative intervention. M
67. Malhotra A, Wu X, Kalra VB, et al. Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis. [Review]. Eur Radiol. 27(3):1148-1160, 2017 Mar. Review/Other-Dx 23 articles To quantify the rate of unstable injuries detected by MRI missed on CT in blunt cervical spine (CS) trauma patients and assess the utility of MRI in CS clearance. Of 428 unique citations, 23 proved eligible, with 5,286 patients found, and 16 unstable injuries reported in five studies. The overall pooled incidence is 0.0029 %. Among studies reporting only obtunded patients, the pooled incidence is 0.017 %. In alert patients, the incidence is 0.011 %. All reported positive findings were critically reviewed, and only 11 could be considered truly unstable. 4
68. Tolhurst SR, Vanderhave KL, Caird MS, et al. Cervical arterial injury after blunt trauma in children: characterization and advanced imaging. J Pediatr Orthop. 33(1):37-42, 2013 Jan. Review/Other-Dx 61 patients To characterize cervical vascular injury (CVI) in children and adolescents and evaluate the utility of advanced imaging in CVI screening in this patient population. Sixty-one patients were identified. Nineteen underwent screening to evaluate for CVI, including 12 males and 7 females, mean age 13.5 years. The most common mechanism of injury was motor vehicle collision (n=11). Seven patients underwent MRA, 7 CTA, 3 had both studies, and 2 had traditional angiography. Seven patients had CVI, with an overall incidence of 11.5%. High-risk criteria (fracture extension to transverse foramina, fracture/dislocations or severe subluxations, or C1-C3 injury) were associated with increased rates of CVI. Neurological injury was found in 12/19 patients screened and 6/7 patients with CVI. Two of 7 patients underwent anticoagulation due to documented CVI. No delayed-onset ischemic neurological events occurred. 4
69. Fisher BM, Cowles S, Matulich JR, Evanson BG, Vega D, Dissanaike S. Is magnetic resonance imaging in addition to a computed tomographic scan necessary to identify clinically significant cervical spine injuries in obtunded blunt trauma patients?. Am J Surg. 206(6):987-93; discussion 993-4, 2013 Dec. Observational-Dx 227 patients To determine if magnetic resonance imaging (MRI) detects clinically significant injuries not seen on computed tomographic (CT) scans. The study cohort consisted of 277 patients. In 13 (5%) patients, MRI detected clinically significant cervical spine injuries that were missed by CT scans, and in 7 (3%) these injuries required intervention. The number needed to screen with MRI to prevent 1 missed injury was 21. 3
70. Muchow RD, Resnick DK, Abdel MP, Munoz A, Anderson PA. Magnetic resonance imaging (MRI) in the clearance of the cervical spine in blunt trauma: a meta-analysis. J Trauma. 64(1):179-89, 2008 Jan. Meta-analysis 464 patients 5 level I protocols Meta-analysis of both prospective and retrospective studies to determine the efficacy of clearing the cervical spine in symptomatic patients with negative radiographic or CT studies. 5 studies had zero false negatives with NPV of 100%. Log odds meta-analysis produced a 94.2% PPV (95% CI, 75.0, 989), 97.2% sensitivity (95% CI, 89.5, 99.3), and 98.5% specificity (95% CI, 91.8, 99.7). 97 patients (21%) had abnormalities identified by MRI that were not found with radiographs with or without CT. MRI study that is normal can conclusively exclude a spinal injury and should be considered the gold standard. M
71. Flynn JM, Closkey RF, Mahboubi S, Dormans JP. Role of magnetic resonance imaging in the assessment of pediatric cervical spine injuries. J Pediatr Orthop 2002;22:573-7. Observational-Dx 74 children To determine the role of magnetic resonance imaging (MRI) in the evaluation of children with suspected cervical spine injury (CSI) The average age of the evaluated children was 8 years. MRI confirmed the plain radiography diagnosis in 66% of children and altered the diagnosis in 34%. 3
72. Hutchings L, Atijosan O, Burgess C, Willett K. Developing a spinal clearance protocol for unconscious pediatric trauma patients. J Trauma. 2009;67(4):681-686. Review/Other-Dx 115 patients The purpose of this study was to retrospectively assess the means of spinal imaging and clearance in a pediatric trauma population with significant associated injuries, including head injury, at a United Kingdom level I trauma centre. This dataset was then studied to recommend a protocol for cervical spinal clearance in this population. In the cohort of 115 patients, there was a male predominance (63%) with motor vehicle accidents as the major mechanism of injury (63.5%). Ten patients (8.7%) were identified with spinal injuries, all of whom had sustained closed head injuries. Two of these patients had spinal cord injuries; one subsequently died. Spinal injury resulted in longer intubation times and intensive care stays, but no difference in new injury severity score or outcome. Clearance methods ranged from clinical examination to imaging with radiographs, computed tomography (CT), and dynamic screening. Magnetic resonance imaging was used as a secondary modality in two cases only, and in neither case was it used for clearance. CT demonstrated 100% specificity and sensitivity with positive and negative predictive values of 1 for all spinal regions. There were no cases of Spinal Cord Injury WithOut Radiologic Abnormality and no evidence of missed injuries. 4
73. Panczykowski DM, Tomycz ND, Okonkwo DO. Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma. [Review]. J Neurosurg. 115(3):541-9, 2011 Sep. Meta-analysis 17 studies with 14,327 patients Meta-analysis was performed to determine the comparative effectiveness of multislice helical CT alone to diagnose acute unstable CSI following blunt trauma. The overall sensitivity and specificity for modern CT were both >99.9% (95% CI, 0.99-1.00 and 0.99-1.00, respectively). The negative likelihood ratio of an unstable cervical injury after a CT scan negative for acute injury was <0.001 (95% CI, 0.00-0.01), while the NPV of a normal CT scan was 100% (95% CI, 0.96-1.00). Global severity of injury, CT slice thickness, and study quality did not significantly affect accuracy estimates. Modern CT alone is sufficient to detect unstable cervical spine injuries in trauma patients. Adjuvant imaging is unnecessary when the CT scan is negative for acute injury. Results of this meta-analysis strongly show that the cervical collar may be removed from obtunded or intubated trauma patients if a modern CT scan is negative for acute injury. M
74. Raza M, Elkhodair S, Zaheer A, Yousaf S. Safe cervical spine clearance in adult obtunded blunt trauma patients on the basis of a normal multidetector CT scan--a meta-analysis and cohort study. [Review]. Injury. 44(11):1589-95, 2013 Nov. Meta-analysis 10 studies To determine whether in obtunded adult patients with blunt trauma, a clinically significant injury to the cervical spine be ruled out on the basis of a normal multidetector cervical spine computed tomography. A total of 10 studies involving 1850 obtunded blunt trauma patients with initial cervical spine CT scan reported as normal were included in the final meta-analysis. The cumulative negative predictive value and specificity of cervical spine CT of the ten studies was 99.7% (99.4-99.9%, 95% confidence interval). The positive predictive value and sensitivity was 93.7% (84.0-97.7%, 95% confidence interval). In the retrospective review of our obtunded blunt trauma patients, none was later diagnosed to have significant cervical spine injury that required a change in clinical management. M
75. Schoenwaelder M, Maclaurin W, Varma D. Assessing potential spinal injury in the intubated multitrauma patient: does MRI add value? Emerg Radiol. 2009;16(2):129-132. Observational-Dx 55 patients To determine the role of magnetic resonance imaging (MRI) in intubated multitrauma patients with normal computed tomography (CT) in excluding unstable ligamentous injury to the cervical spine. Fifty-five patients met the inclusion criteria. Ten of these patients had a discoligamentous injury identified on MRI; however, all these patients had injuries limited to only one of the three columns of the cervical spine. Single-slice helical CT with sagittal reformats had a negative predictive value of 82% for discoligamentous injury and 100% for unstable injury. A normal single-slice helical CT with sagittal reformats of the cervical spine in intubated trauma patients excluded unstable injuries at follow-up cervical spine MR imaging. 3
76. National Institute for Health and Care Excellence. Spinal injury: assessment and initial management. NICE guideline [NG41].  Available at: Review/Other-Dx N/A Guidance document for the assessment and early management of spinal column and spinal cord injury in pre-hospital settings (including ambulance services), emergency departments and major trauma centres. No results stated in the abstract. 4
77. Ghasemi A, Haddadi K, Shad AA. Comparison of Diagnostic Accuracy of MRI with and Without Contrast in Diagnosis of Traumatic Spinal Cord Injuries. Medicine (Baltimore). 2015;94(43):e1942. Observational-Dx 40 patients To compare the efficacy of MRI with and without contrast in diagnosis and prognosis evaluation of SCIs. In these patients, 3 different types of MRI signal patterns were detected and compared.The most common cases of spinal injuries were accident (72.5%) and the after fall (27.5%). The prevalence of lesions detected includes spine fracture (70%), spinal stenosis (32.5%), soft tissue injuries (30%), and tearing of the spinal cord (2.5%). A classification was developed using 3 patterns of SCIs. Type I, seen in 2 (5.0%) of the patients, demonstrated a decreased signal intensity consistent with acute intraspinal hemorrhage. Type II, seen in 8 (20.0%) of the patients, demonstrated a bright signal intensity consistent with acute cord edema. Type III, seen in 1 (2.5%) of the patients, demonstrated a mixed signal of hypointensity centrally and hyperintensity peripherally consistent with contusion. In the diagnosis of all injuries, MRI with contrast efficacy comparable to noncontrast MRI, except in the diagnosis of soft tissue, which was significantly higher sensitivity (P < 0.05). 2
78. Eastman AL, Chason DP, Perez CL, McAnulty AL, Minei JP. Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma. 2006;60(5):925-929; discussion 929. Observational-Dx 162 patients To determine the sensitivity of CTA for the diagnosis of BCVI. The authors hypothesized that advances in CT technology have improved the diagnostic sensitivity of CTA at least to that of invasive catheter angiography. Over 11 months, 162 patients were at risk for BCVI. In all, 146 patients received both CTA and CA. 46 BCVIs were identified among 43 patients. In 45/46 cases (98%), the results of CTA and catheter angiography were concordant. There was a single false-negative CTA in a patient with a grade I vertebral artery injury. The remaining 103 patients had normal CTAs confirmed by a normal catheter angiography. The overall sensitivity, specificity, PPV, NPV, and accuracy of CTA for the diagnosis of BCVI were 97.7%, 100%, 100%, 99.3%, and 99.3%, respectively. 3
79. Fleck SK, Langner S, Baldauf J, Kirsch M, Rosenstengel C, Schroeder HW. Blunt craniocervical artery injury in cervical spine lesions: the value of CT angiography. Acta Neurochir (Wien). 2010;152(10):1679-1686. Review/Other-Dx 53 patients To determine the frequency and injury characteristics of blunt traumatic cervical artery injuries in patients suffering from cervical spine injuries by using a standardized CT angiography (CTA) protocol of the craniocervical vessels. CTA was considered adequate for diagnosis in all but one case due to reduced CTA imaging quality. In one patient, DUS instead of CTA was performed with respect to pregnancy. We detected isolated osseous cervical spine injury in 53 consecutive patients. Of these patients, 18.9% suffered from vertebral artery injuries (VAI) (14 VAI in 10 patients). Carotid artery injuries were not detected in these patients. In five (50%) patients, we observed cerebral infarction due to VAI. 4
80. Payabvash S, McKinney AM, McKinney ZJ, Palmer CS, Truwit CL. Screening and detection of blunt vertebral artery injury in patients with upper cervical fractures: the role of cervical CT and CT angiography. Eur J Radiol. 83(3):571-7, 2014 Mar. Observational-Dx 210 patients To evaluate the clinical utility of nonenhanced CT (NECT)-based screening criteria and CTA in detection of blunt vertebral artery injury (BVAI) in trauma patients with C1 and/or C2 fractures. 210 patients were included; of these, 124 underwent CTA (21/124 with digital subtraction angiography, DSA), and 2 underwent DSA only. Overall, 30/126 suffered BVAI. Among 21 patients who underwent both CTA and DSA, there was 1 false negative and 1 false positive (both grade 1). There was strong interobserver agreement regarding CTA-based BVAI detection (kappa=0.93, p<0.001) and grading (kappa=0.90, p<0001). Only 3/30 BVAI patients suffered a posterior circulation stroke; none of the patients who had a negative CTA or were not selected for CTA, based on NECT screening criteria, suffered symptomatic stroke. While C1/C2 comminuted fracture was more common in patients with high grade BVAI (p=0.039), simultaneous C3-C7 comminuted fracture increased the overall BVAI risk (p=0.011). 3
81. Chung D, Sung JK, Cho DC, Kang DH. Vertebral artery injury in destabilized midcervical spine trauma; predisposing factors and proposed mechanism. Acta Neurochir (Wien). 154(11):2091-8; discussion 2098, 2012 Nov. Observational-Dx 91 patients To evaluate, by logistic regression analysis, the data from patients with traumatically destabilized blunt cervical spine injuries that required surgery who were potential candidates for VAI management. Eighteen patients (19.8 % of 91 patients) had a VAI associated with midcervical spine trauma (C2-C6). In univariate statistical analysis, transverse foramen fracture (P = 0.002), facet dislocation (P = 0.014), and facet fracture (P = 0.001) were significant risk factors. However, only facet fracture was determined to be significant risk factor after multivariate analysis (P = 0.006, odds ratio 20.98). It is hypothesized that a VAI occurs in a midcervical spine injury when a facet fracture allows the bony compartment to impinge on the relatively narrow free space of the intervertebral foramen, which is also occupied by the cervical root. 3
82. Kopelman TR, Leeds S, Berardoni NE, et al. Incidence of blunt cerebrovascular injury in low-risk cervical spine fractures. Am J Surg. 202(6):684-8; discussion 688-9, 2011 Dec. Review/Other-Dx 260 patients To determine the incidence of BCVI with CSfx in the absence of high-risk injury patterns. A total of 260 patients had CSfx. When screened for high-risk pattern of injury for BCVI, 168 patients were identified and 13 had a BCVI (8%). The remaining 92 patients had isolated low CSfx (C4-C7) without other risk factors for BCVI. In this group, 2 patients were diagnosed with BCVI (2%). Failure to screen all patients with CSfx would have missed 2 of 15 BCVIs (13%). 4
83. Durand D, Wu X, Kalra VB, Abbed KM, Malhotra A. Predictors of Vertebral Artery Injury in Isolated C2 Fractures Based on Fracture Morphology Using CT Angiography. Spine (Phila Pa 1976). 2015;40(12):E713-718. Observational-Dx 67 patients To classify isolated axis fracture morphology on the basis of established orthopedic and neurosurgical criteria to determine predictors of VAI based on CTA. Sixty-seven patients met inclusion criteria. Fracture pattern analysis revealed that the majority were dens fractures (50.8%) and traumatic spondylolisthesis (41.8%); 29.9% had miscellaneous coronal/sagittal fractures and 22.4% were a combination.VAI was identified in 37.3% of patients with isolated C2 fractures, and 88% of patients had transverse foramen involvement. Fracture patterns significantly associated with VAI were type III dens and transverse foramen fractures with intraforaminal fragments, with or without comminution. 3
84. Desai NK, Kang J, Chokshi FH. Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical "seatbelt sign". AJNR Am J Neuroradiol. 2014;35(9):1836-1840. Observational-Dx 137 patients To understand the clinical and radiologic risk factors associated with pediatric blunt cerebrovascular injury on CTA of the neck with primary attention to the cervical "seatbelt sign." Four hundred sixty-three patients underwent CTA of the neck; 137 had blunt trauma. Forty-two of 85 patients involved in a motor vehicle collision had a cervical seatbelt sign; none had blunt cerebrovascular injury. Nine vessels (4 vertebral arteries, 4 ICAs, 1 common carotid artery) in 8 patients ultimately were diagnosed with various grades (I-IV) of blunt cerebrovascular injury, representing 5.8% (8/137) of the population screened for blunt neck trauma. The mean Glasgow Coma Scale score was significantly lower (P=.02) in the blunt cerebrovascular injury group versus the non-blunt cerebrovascular injury group. Although not statistically significant, patients with blunt cerebrovascular injury had a higher tendency to have additional traumatic injuries, primarily basilar skull fractures (P=.05) and intracranial hemorrhage (P=.13). 3
85. Delgado Almandoz JE, Schaefer PW, Kelly HR, Lev MH, Gonzalez RG, Romero JM. Multidetector CT angiography in the evaluation of acute blunt head and neck trauma: a proposed acute craniocervical trauma scoring system. Radiology. 2010;254(1):236-244. Observational-Dx 830 consecutive patients Retrospective study to determine the diagnostic yield of MDCT angiography in the evaluation of patients presenting to the emergency department with acute blunt head and neck trauma to assess for arterial injury and to propose a practical scoring system for the identification of patients at highest risk of arterial injury. MDCT angiographic results showed injury to 118 arterial structures in 106 (12.8%) patients. Multivariate logistic regression analysis showed that the presence of cervical interfacetal subluxation/dislocations (44.4%; OR, 6.3; P<.0001), fracture lines reaching an arterial structure (22.1%; OR, 4.4; P < .0001), and high-impact mechanism of injury (16.5%; OR, 3.1; P<.0001) were independent predictors of an increased risk of arterial injury and were used to construct a scoring system. Patients with scores of 2 and 3 (21.9% and 52.2%, respectively) were at highest risk of arterial injury. The proposed acute craniocervical trauma scoring system could be used as a guide to select blunt trauma patients for MDCT angiographic evaluation. Future validation of this scoring system is necessary. 3
86. Bromberg WJ, Collier BC, Diebel LN, et al. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J Trauma. 68(2):471-7, 2010 Feb. Review/Other-Dx 68 articles EBM guideline for the screening, diagnosis, and treatment of BCVI by the Eastern Association for the Surgery of Trauma organization Practice Management Guidelines committee. The East Practice Management Guidelines Committee suggests guidelines that should be safe and efficacious for the screening, diagnosis, and treatment of BCVI. Risk factors for screening are identified, screening modalities are reviewed indicating that although angiography remains the gold standard, multi-planar (=8 slice) CTA may be equivalent, and treatment algorithms are evaluated. It is noted that change in the diagnosis and management of this injury constellation is rapid due to technological advancement and the difficulties inherent in performing randomized prospective trials in this patient population. 4
87. Agrawal D, Sinha TP, Bhoi S. Assessment of ultrasound as a diagnostic modality for detecting potentially unstable cervical spine fractures in pediatric severe traumatic brain injury: A feasibility study. J Pediatr Neurosci. 2015;10(2):119-122. Review/Other-Dx 10 patients To assess the feasibility of standard portable ultrasound in detecting potentially unstable cervical spine injuries in severe traumatic brain injured (TBI) patients during initial resuscitation. The best window for the cervical spine was through the anterior triangle using the linear array probe (6-13 MHz). In the ten patients with documented cervical spine injury, bilateral facet dislocation at C5-C6 was seen in 4 patients and at C6-C7 was seen in 3 patients. C5 burst fracture was present in one and cervical vertebra (C2) anterolisthesis was seen in one patient. Cervical ultrasound could easily detect fracture lines, canal compromise and ligamental injury in all cases. Ultrasound examination of the cervical spine was possible in the emergency setting, even in unstable patients and could be done without moving the neck. 4
88. Machino M, Yukawa Y, Ito K, Kanbara S, Morita D, Kato F. Posterior ligamentous complex injuries are related to fracture severity and neurological damage in patients with acute thoracic and lumbar burst fractures. Yonsei Med J. 2013;54(4):1020-1025. Observational-Dx 100 patients To accurately assess the severity of damage in thoracic and lumbar burst fractures with the PLC injuries Fourth-one of 100 cases showed PLC injuries in MRI study. The load sharing classification score was significantly higher in the P group [7.8+/-0.2 points for the P group and 6.9+/-1.1 points for the C group (p<0.001)]. The TLICS (excluded PLC score) score was also significantly higher in the P group [6.2+/-1.1 points for the P group and 4.0+/-1.4 points for the C group (p<0.001)]. 3
89. Vaccaro AR, Rihn JA, Saravanja D, et al. Injury of the posterior ligamentous complex of the thoracolumbar spine: a prospective evaluation of the diagnostic accuracy of magnetic resonance imaging. Spine (Phila Pa 1976). 2009;34(23):E841-847. Observational-Dx 42 patients To determine the accuracy of magnetic resonance imaging (MRI) in diagnosing injury of the posterior ligamentous complex (PLC) in patients with thoracolumbar trauma. Forty-two patients with 62 levels of injury were studied. There were 33 males (78.6%) and 9 females (21.4%), and the average age was 35.7 years. According to the kappa score, there was a moderate level of agreement between the radiologist's interpretation and the intraoperative findings for all PLC components except the thoracolumbar fascia, for which there was slight agreement. The sensitivity for the various PLC components ranged from 79% (left facet capsule) to 90% (interspinous ligament). The specificity ranged from 53% (thoracolumbar fascia) to 65% (ligamentum flavum). There was less agreement between the radiologist and surgeon for the patients with less severe neurologic compromise, i.e., those patients with an AIS grade of either D or E. 2
90. Heinemann U, Freund M. Diagnostic strategies in spinal trauma. Eur J Radiol. 2006;58(1):76-88. Review/Other-Dx N/A To discuss diagnostic strategies in spinal trauma Spinal injuries may result in severe neurological deficits, especially if nerve roots or even the spinal cord are affected. Besides presenting the important anatomical and technical basis underlying the imaging findings of spinal injuries, the trauma mechanisms and the resulting injuries are discussed. Based on the current literature and recommendations of scientific organizations, an approach is provided to the radiologic work up of spinal trauma. The different imaging modalities are presented. Advantages and disadvantages of the methods are discussed. 4
91. Jones TM, Anderson PA, Noonan KJ. Pediatric cervical spine trauma. J Am Acad Orthop Surg. 2011;19(10):600-611. Review/Other-Dx N/A To review pediatric cervical spine trauma Pediatric anatomy and physiology predispose to upper cervical spine injury and spinal cord injury without radiologic abnormality in contrast to lower cervical spine injury seen in adults. Care of pediatric patients is difficult because they have a greater head-to-body ratio than adults and may have difficulty cooperating with a history and physical examination. In evaluating a child with a suspected cervical spine injury, radiography may be supplemented with CT or MRI. Definitive management of pediatric cervical spine trauma must be adapted to the distinctive anatomy and growth potential of the patient. As with all injuries, prevention is necessary to reduce the incidence of trauma to the pediatric spine. 4
92. Brand MC. Part 1: recognizing neonatal spinal cord injury. Adv Neonatal Care. 2006;6(1):15-24. Review/Other-Dx N/A To review the embryological development of the spinal column highlighting mechanisms of injury and identifying underlying factors that increase the risk of spinal cord injury in newborns No results listed in abstract. 4
93. Srinivasan V, Jea A. Pediatric Thoracolumbar Spine Trauma. Neurosurg Clin N Am. 2017;28(1):103-114. Review/Other-Dx N/A To review thoracolumbar injury patterns that may be seen in children. No results stated in abstract. 4
94. Kim S, Yoon CS, Ryu JA, et al. A comparison of the diagnostic performances of visceral organ-targeted versus spine-targeted protocols for the evaluation of spinal fractures using sixteen-channel multidetector row computed tomography: is additional spine-targeted computed tomography necessary to evaluate thoracolumbar spinal fractures in blunt trauma victims? J Trauma. 2010;69(2):437-446. Observational-Dx 72 patients To assess retrospectively whether the visceral organ-targeted images obtained from “AP-CT protocol” are comparable with spine-targeted images obtained from “TL spine CT protocol” when accompanied with MPR images obtained from the AP-CT protocol in the evaluation of TL spinal fractures. The overall areas under the curves for sets S and A for fracture detection were 0.996 and 0.995, respectively; no significant difference was found between the two sets. Concordance rates for typing performance also showed no statistical significance between the two sets for any of the three observers. 3
95. Lucey BC, Stuhlfaut JW, Hochberg AR, Varghese JC, Soto JA. Evaluation of blunt abdominal trauma using PACS-based 2D and 3D MDCT reformations of the lumbar spine and pelvis. AJR. 2005; 185(6):1435-1440. Observational-Dx 156 consecutive patients To show the value of 2D and 3D reformations from CT data from abdominal and pelvic CT in finding lumbar and pelvic fractures. CT was compared with radiographic findings and findings of dedicated repeat CT. CT detected 80 lumbar and 178 pelvic fractures; radiography showed 40 and 138 fractures respectively. No additional fractures were detected on repeat CT exam. Radiographs are no longer needed when data from abdominopelvic CT is available in trauma patients. 2
96. Roos JE, Hilfiker P, Platz A, et al. MDCT in emergency radiology: is a standardized chest or abdominal protocol sufficient for evaluation of thoracic and lumbar spine trauma? AJR Am J Roentgenol. 2004;183(4):959-968. Observational-Dx 82 patients To assess the diagnostic performance of a standardized 4-MDCT trauma protocol for the evaluation of the thoracic and lumbar spine in patients with multiple injuries. Image quality for axial images was excellent in 80% and in 68% using 4 x 1 mm and 4 x 2.5 mm collimation, respectively. Image quality of the multiplanar reformations was excellent in 75% and good in 65% using 4 x 1 mm and 4 x 2.5 mm collimation, respectively. Spinal fractures were detected by observer 1 and observer 2 with a sensitivity and specificity of 98% and 97% and of 97% and 97%, respectively. Interobserver agreement regarding the confidence scale for fracture detection was substantial (kappa = 0.80), and agreement between the different imaging protocols for fracture classification was excellent for observer 1 (kappa = 0.95) and observer 2 (kappa = 0.97). 1
97. Barcelos AC, Joaquim AF, Botelho RV. Reliability of the evaluation of posterior ligamentous complex injury in thoracolumbar spine trauma with the use of computed tomography scan. Eur Spine J. 25(4):1135-43, 2016 Apr. Observational-Dx 43 patients To evaluate the reliability of CT scan in the diagnosis of posterior ligamentous complex (PLC) injury in thoracolumbar spine trauma (TLST). On average, PLC injury was identified in 91.4% of type B or C injuries. Tension band injury and dislocation were found in 90.5% of type B and 93.2% of type C injuries. The intraobserver reliability for the PLC injury parameters ranged from 0.518 to 1.000, except for increased interspinous distance (IID). Interobserver reliability ranged from 0.303 to 0.688. When the patients were evaluated as a whole, dislocation showed the highest kappa (0.656 and 0.688). When type A or B injuries were assessed, the highest kappa were found for IID (0.533 and 0.511) and tension band injury (0.486 and 0.452). The kappa for AOSpine classification was 0.526 and 0.645 in both assessments. 2
98. Boese CK, Nerlich M, Klein SM, Wirries A, Ruchholtz S, Lechler P. Early magnetic resonance imaging in spinal cord injury without radiological abnormality in adults: a retrospective study. J Trauma Acute Care Surg. 74(3):845-8, 2013 Mar. Observational-Dx 21 patients To describe the clinical and imaging characteristics of patients experiencing blunt spinal trauma without radiological abnormalities but transient or persistent neurological deficits. Of 1,604 patients experiencing blunt spinal trauma, 21 (12 men and 9 women) with a mean age of 35.5 years (range, 16.2-70.9 years) presented with a clinicoradiographic mismatch. Magnetic resonance imaging (MRI) was available in 15 patients. In seven patients (46.6%), MRI revealed either neural (n = 2, 13.3%) or extraneural (n = 5, 33.3%) spinal abnormalities. Importantly, in eight patients (53.3%), no spinal abnormalities were visible on MRI. Furthermore, subgroup analysis revealed no prognostic value regarding the presence or absence of detectable spinal injuries. 4
99. Vordemvenne T, Hartensuer R, Lohrer L, Vieth V, Fuchs T, Raschke MJ. Is there a way to diagnose spinal instability in acute burst fractures by performing ultrasound? Eur Spine J. 2009;18(7):964-971. Observational-Dx 18 patients To examine the predictive value of ultrasound diagnostics for the assessment of traumatic lesions of the posterior ligament complex (PLC) in burst fractures of the thoracolumbar spine. A total of 18 patients, 14 males and 4 females, with acute burst fractures have been qualified for inclusion in the study. The patients' mean age was 43.4 years. Comparing intraoperative findings with preoperatively performed investigations, ultrasound archived a sensitivity of 0.99 and a specificity of 0.75 (P < 0.05) to detect traumatic lesions to the PLC. As hypothesized the obtained predictive value using ultrasound correlates closely with intraoperative findings. 2
100. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4