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Cervical spine imaging in children under 9 after trauma
  1. Savvas Omorphos, Medical student,
  2. Andreas Kontos, Medical student,
  3. Joel Desmond, RCS Research Fellow,
  4. K Mackway-Jones
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jones{at}


    A short cut review was carried out to establish whether the odontoid peg view is useful to radiologically exclude cervical spine injury in children under 9 years of age. Altogether 156 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. In addition recent guidelines are noted. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by Savvas Omorphos, Andreas Kontos, Medical students Checked by Joel Desmond, RCS Research Fellow

    Clinical scenario

    You have just read a recent important publication by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons who recommend that in the under 9 age group, children requiring radiological assessment of their cervical spine need only undergo an AP or lateral cervical spine view. It is your current practice to perform three view radiography but you realise that getting the odontoid peg view can be very difficult in non-compliant children. You wonder on what evidence this specific guideline was based.

    Three part question

    In [children under 9 years old with suspected cervical spine injury] is [the odontoid peg view needed in addition to lateral and antero-posterior views] to [radiologically clear the cervical spine]?

    Search strategy

    Medline 1966–12/02 using the OVID interface. [(exp Spinal Cord Injuries) OR (spinal cord injur$.mp) OR (cervical spine injur$.mp) OR (spinal fractur$.mp) OR (exp x-rays) OR ( OR (radiograph$.mp)] AND [(exp odontoid process) OR (] AND [BestBETs Paediatric filter] LIMIT to Human AND English.

    Search outcome

    Altogether 156 papers were identified of which two were relevant. The reference list of the guidelines were also searched but these were the only two papers of direct relevence. The two papers and the guidelines are summarised in table 4.

    Table 4


    The comprehensive review of the literature by the American Association of Neurological surgeons in 2002 come to the conclusion that odontoid peg views in the under 9 age group are unnecessary. However, Swischuk et al in their survey of 432 paediatric radiologists report that they have identified 46 fractures, seen on the odontoid peg view that could not be seen on the lateral view. The American Association have set the current best evidence guidelines in this area but it should be remembered that they warn that these do not represent diagnostic standards and caution should be used in their application.


    Guidelines on cessation of the odontoid peg views in the under 9 age group should be viewed with great caution.

    Report by Savvas Omorphos, Andreas Kontos, Medical students Checked by Joel Desmond, RCS Research Fellow