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I read with interest Smart et al's letter  regarding the
assessment of paediatric cervical spine injuries.
It would certainly appear that many children in their cohort were Xrayed unnecessarily according to current guidelines. However, I would hope
that the practice in their institution has changed dramatically in the 6
years since the group attended.
Current guidelines on sel...
Current guidelines on selction of patients for imaging are based
primarily on adults. In the NEXUS group, only 30 children had a cervical
spine injury, and in the Canadian c-spine group, there were no
children at all. Extrapolating these results to children who may be
distressed or uncooperative should be performed with caution. The low
prevalence of cervicla spine injuries in children makes guidelines
difficult to create. In an 11 year analysis of the Trauma Audit Network
Database, only 239 children (out of 19,538 with major trauma) were
identified as having a cervical spine fracture and 21 with SCIWORA
(personal data, as yet unpublished).
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 series  or questionnaires, 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.
(1) Smart PJE, Hardy PJ, Buckley DMG, Somers JM, Broderick NJ,
Halliday KE, Williams L. Cervical spine injuries to children under 11:
should we use radiography more selectively in their initial assessment?
Emerg Med J 2003;20:225-227.
(2) Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR.
A prospective multicenter study of cervical spine injury in children.
(3) Stiell IG, Wells GA, Vandemheem KL, Clement CM, Lesiuk H, De Maio
VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer
J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardin M,
Worthington J. The Canadian C-Spine Rule for Radiography in Alert and
Stable Trauma Patients. JAMA 2001;286:1841-1848.
(4) Buhs C, Cullen M, Klein M, Farmer D. The pediatric trauma c-spine:
is the 'odointoid' view necessary? J Pediatr Surg 2000;35:994-997.
(5) Swischuk LE, John SD, Hendrick EP. Is the open-mouth odointoid
view necessary in children under 5 years? Pediatr Radiol 2000;30:186-189.