From the Guidelines
I strongly recommend a cervical spine CT scan to further evaluate the slight lateral offset of the right lateral mass of C1 with respect to the C2 lateral mass seen on the odontoid view, as it provides superior visualization of bony structures and can help assess potential fractures or subluxations that may not be apparent on the initial X-ray. While this finding could be due to positional rotation (as evidenced by compensatory medialization of the left C1 lateral mass), a CT scan would provide definitive assessment if there is clinical concern for traumatic injury 1. For an 11-year-old patient with suspected cervical spine injury, a non-contrast CT would typically be sufficient unless there's concern for vascular injury. The radiation dose should be minimized using pediatric protocols. This recommendation is particularly important if the patient has neck pain, neurological symptoms, or a history of significant trauma, as proper diagnosis and management of cervical spine injuries is critical to prevent potential neurological complications.
Some key points to consider in this scenario include:
- The sensitivity of CT for the detection of cervical spine abnormalities compared with spine injuries ranges from 81% to 100% 1.
- CT is considered the gold standard for identification of cervical spine fractures, outperforming radiographs in identification of cervical spine fractures in high-, moderate-, and low-risk stratifications 1.
- CT with IV contrast does not aid in detection of cervical spine injury 1.
- MRI may be warranted in some patients, particularly those with neurological symptoms or concern for soft-tissue injuries, but CT is often sufficient for initial evaluation 1.
Overall, a cervical spine CT scan is the most appropriate next step in evaluating the patient's condition, given the potential for traumatic injury and the need for definitive assessment of bony structures.
From the Research
Cervical Spine Injury Evaluation
- The evaluation of cervical spine injuries often begins with computed tomography (CT) for initial osseous and basic soft tissue evaluation, followed by magnetic resonance imaging (MRI) for complementary evaluation of the neural structures and soft tissues 2.
- In cases of suspected acute traumatic osseous injury due to trauma, a cervical spine CT could be performed to provide information to help direct patient care, including diagnosis, next steps in treatment plan, and prognosis 2, 3.
Imaging Modalities for Cervical Spine Trauma
- CT and MRI both have roles to play in the evaluation of cervical spine trauma, with CT offering high sensitivity for detecting traumatic c-spine injury and MRI holding clinical significance in revealing injuries not recognized by CT in symptomatic patients 4.
- The sensitivity of CT was 88.6% (specificity 99%), and 89.8% (specificity 99.2%) with orthopedic surgeon consultation, while MRI had a sensitivity of 88.5% (specificity of 96.9%) 4.
Specific Considerations for Cervical Spine Fractures
- C2 was the most commonly fractured vertebra, followed by C7, and 48.7% of studies had upper cervical spine (C1 and/or C2) fractures 5.
- Multi-level traumatic cervical spine fractures constituted 40% of the cohort, most commonly at C6/C7 and C1/C2, and although the conditional probability of concurrent fracture in studies with multi-level fractures was greatest in contiguous levels, nearly one-third of multi-level fractures involved non-contiguous fractures 5.
Role of MRI in Trauma Patients with Ankylosing Spinal Disorders
- Routine MRI of the spine may not be necessary in trauma patients with ankylosing spinal disorders, and a CT scan may be sufficient, unless there are nonankylosed levels in which a disco-ligamentous injury may have occurred, or in patients with neurological deficits that require investigation of the spinal canal to assess for causes of neurological injury 6.