Zhang Jeff F, Umenta Janet, Ali Adil, Reynolds Renee, Ham Phillip Benson, Thomas Richard D, Piryani Ravi, Izhar Muhammad, Wrotniak Brian, Swayampakula Anil K
Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA.
Department of Neurosurgery, State University of New York at Buffalo, Buffalo, New York, USA.
Trauma Surg Acute Care Open. 2023 Feb 6;8(1):e001016. doi: 10.1136/tsaco-2022-001016. eCollection 2023.
In pediatric trauma patients, 60-80% of spinal cord injuries involve the cervical vertebrae. While the American College of Radiology offers guidelines for best imaging practices in the setting of acute pediatric trauma, there is a lack of uniformity in imaging-decision protocols across institutions. MRI has been shown to demonstrate high sensitivity for both bony and ligamentous injuries while also avoiding unnecessary radiation exposure in the pediatric patient population. However, the efficacy of flexion-extension (FE) radiography following initial MRI has not been evaluated in children. Our hypothesis is that FE radiography conducted following an initial MRI does not contribute significant diagnostic information or reduce time to cervical collar removal and thus can be removed from institutional protocols in order to avoid unnecessary testing and reduce pediatric radiation exposure.
Trauma data were collected for pediatric patients presenting with suspected acute cervical spine injury from 2014 to 2021. A total of 108 patients were subdivided into 41 patients who received "MRI Only" and 67 patients who received both "MRI and FE" diagnostic cervical spine imaging. Chi-square testing and t-tests were performed to determine differences between MRI and FE radiographic detection rates of bony and ligamentous injuries in the subgroups.
In patients for whom FE did not find any injury, MRI detected bony and ligamentous injuries in 9/63 and 12/65 cases, respectively. In 3/21 (14.3%) cases in which MRI detected a bony and/or ligamentous injury and FE did not, patients eventually required surgical intervention for c-spine stabilization. No patients required surgical fixation when FE radiography showed an abnormality and MRI was normal. Addition of follow-up FE radiography after initial MRI did not have a significant effect on overall hospital length of stay (MRI Only vs MRI+FE: 9.2±12.0 days vs 8.6±13.5 days, p=0.816) or on rates of collar removal at discharge or greater than 48 hours after imaging (MRI Only vs MRI+FE: 41.5% vs 56.7%, p=0.124).
FE radiography following initial MRI did not have a significant effect on reducing time to cervical collar removal or overall hospital length of stay. In addition, in 3 of 6 cases (50.0%) in which surgical fixation was required, MRI detected ligamentous and/or bony injury while FE radiography was normal.
This study contributes Level 2b scientific evidence consistent with a well-designed cohort or case-control analytic study.
在小儿创伤患者中，60%-80%的脊髓损伤累及颈椎。虽然美国放射学会提供了急性小儿创伤情况下最佳影像学检查的指南，但各机构的影像学决策方案缺乏一致性。磁共振成像（MRI）已被证明对骨损伤和韧带损伤均具有高敏感性，同时还可避免小儿患者群体遭受不必要的辐射暴露。然而，初始MRI检查后进行屈伸（FE）X线摄影的有效性尚未在儿童中得到评估。我们的假设是，初始MRI检查后进行的FE X线摄影不会提供显著的诊断信息，也不会缩短去除颈托的时间，因此可以从机构方案中删除，以避免不必要的检查并减少小儿辐射暴露。
收集2014年至2021年疑似急性颈椎损伤的小儿患者的创伤数据。总共108例患者被分为41例仅接受“MRI检查”的患者和67例接受“MRI检查和FE X线摄影”两种颈椎诊断影像学检查的患者。进行卡方检验和t检验，以确定亚组中MRI和FE X线摄影对骨损伤和韧带损伤的检出率差异。
在FE X线摄影未发现任何损伤的患者中，MRI分别在9/63例和12/65例中检测到骨损伤和韧带损伤。在3/21例（14.3%）患者中，MRI检测到骨和/或韧带损伤而FE X线摄影未检测到，这些患者最终需要进行手术干预以稳定颈椎。当FE X线摄影显示异常而MRI正常时，没有患者需要手术固定。初始MRI检查后增加随访FE X线摄影对总体住院时间（仅MRI检查组与MRI+FE检查组：9.2±12.0天 vs 8.6±13.5天，p=0.816）或出院时或成像后超过48小时去除颈托的比率（仅MRI检查组与MRI+FE检查组：41.5% vs 56.7%，p=0.124）没有显著影响。
初始MRI检查后进行的FE X线摄影对缩短去除颈托的时间或总体住院时间没有显著影响。此外，在6例（50.0%）需要手术固定的患者中，有3例MRI检测到韧带和/或骨损伤，而FE X线摄影正常。
本研究提供了与精心设计的队列研究或病例对照分析研究一致的2b级科学证据。
