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I read with interest the letter by Smart et al1 regarding the assessment of paediatric cervical spine injuries.
It would certainly appear that many children in their cohort were radiographed unnecessarily according to current guidelines. However, I would hope that the practice in their institution has changed dramatically in the six years since the group attended.
Current guidelines on selection of patients for imaging are based primarily on adults. In the NEXUS group, only 30 children had a cervical spine injury,2 and in the Canadian c-spine group, there were no children at all.3
Extrapolating these results to children who may be distressed or uncooperative should be performed with caution.
The low prevalence of cervical spine injuries in children makes guidelines difficult to create. In an 11 year analysis of the Trauma Audit Network Database, only 239 children (of 19 538 with major trauma) were identified as having a cervical spine fracture and 21 with spinal cord injury without radiological abnormality (unpublished data).
I am concerned that the authors feel that a single lateral projection should be adequate. The evidence for omitting the PEG view is based on small case series4 or questionnaires,5 and certainly the odointoid synchondrosis should be ossified by the age of 7.
Imaging of the paediatric cervical spine remains a difficult problem. As the authors confirm, there is no substitute for adequate clinical assessment, but where this is not possible, every effort should be made to rule out a potentially devastating injury.
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