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Iwate Medical University Morioka 020-8505, Japan
I read with interest the article "Using CT of the Cervical Spine for Early Evaluation of Pediatric Patients with Head Trauma" [1]. In spite of the authors' statement, I do not think that their limited CT of the cervical spine effectively screened cervical spine injuries in children with head trauma. In the study population of 63 patients younger than 16 years, only one true-positive finding was identified, and six patients had false-positive findings on CT.
In general, radiologic depiction of injury to cervical vertebrae is rare, particularly in children younger than 8 years [2]. In this age group, radiography is relatively effective in screening bone lesions (except fractures through synchondroses), and spinal cord injury frequently presents no radiologic abnormalities. CT is a suitable screening method for atlantoaxial rotary subluxation, which is frequent in the 6- to 10-year-old age group, but the clinical features are often characteristic. I suspect that CT screening may be useful only in children at least 12 years old who have a mature cervical spine, because they have a high frequency of fractures and dislocations similar in nature to those of adults [2].
I am skeptical about CT screening of cervical spine injuries in infants and young children because of the rarity of injury and because of the resulting higher radiation exposure and the cost. I think that a different approach in a more specified clinical setting may be needed for screening of cervical spine injuries.
References
Martha Jefferson Hospital Charlottesville, VA 22902
University of North Carolina at Chapel Hill Chapel Hill, NC
27599-7200
We thank Dr. Ehara for the letter regarding the limitations of CT screening of cervical spine injuries in a pediatric population. First, we would like to clarify that we did not have six false-positive findings on CT, but rather six false-positive findings and one true-positive finding on radiography [1]. Therefore, the specificity (ability to rule out a fracture when no fracture is present) of radiography was 81% in this series [1], which is somewhat lower than what is seen in adults [2]. This level of specificity may be unacceptable to many clinicians for the evaluation of a high-risk injury.
Studies comparing the relative accuracy of radiography to CT in cervical spine injuries in children are needed. However, as Ehara correctly pointed out, the incidence of cervical spine fractures in children is relatively low. Thus, because the probability of fracture for a child is small, the population necessary to sufficiently power a study to compare the accuracy of CT and radiography for the detection of injury would be great, and that research was not the focus of our project.
The objective of the research presented in our article [1] was to determine whether CT would be an efficient adjunct to radiography in evaluating the cervical spine in children who are at high risk for fracture. In other words, would adjunctive CT be able to rule out fracture of the cervical spine with less delay than radiography alone? We have begun to answer this question by showing that considerably fewer repeated radiographic images are required to clear the cervical spine when CT of the cervical spine is performed at the time of head CT [1]. In addition, the need for numerous repeated radiographs and the equivocal radiographic diagnoses that resulted in diagnostic cervical spine CT being performed later in as many as 33% of children in our series [1] suggests that radiographic diagnosis of pediatric cervical spine fracture is not simple in children. This difficulty in appropriately visualizing all cervical vertebrae is not unique to our institution: Lally et al. [3] found that all seven cervical vertebrae were seen in only 57% of children in their initial cervical spine trauma series.
Our study suggests that the addition of screening cervical spine CT to radiography in a select group of high-risk children increases neither the cost nor the radiation dose to the child and improves the efficiency of cervical spine clearance [1]. Larger prospective studies are warranted to further delineate the usefulness of this modality.
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