Pediatric Cervical Spine Clearance Systematic Review and Meta-Analysis: MRI is More Sensitive but Less Specific than CT for Detecting Unstable Injuries

Introduction: There is mixed consensus regarding clinical decision-making models for pediatric cervical spine injury (CSI) clearance. This study provides a comprehensive overview of the most frequently recommended imaging protocols for pediatric CSI assessment and the utility of current c-spine clearance models.

Methods: A systematic literature review was conducted using PRISMA guidelines to investigate CT use in the clearance of suspected pediatric CSI. Primary endpoints included recommendation for or against CT, comparisons with other imaging modalities, and protocol changes. From each study the number of unstable CSIs requiring surgical intervention or halo were recorded along with each documented imaging modality’s raw number of true positives, true negatives, false positives, and false negatives (missed injuries).

Results: 28 publications were included. 12 studies recommended CT in pediatric c-spine clearance whereas increased future malignancy risk from radiation exposure was the most cited factor in the 13 studies recommending against. Of these 28 studies, 22 were statistically analyzed. From the 13 retrospective studies that had findings on institutional CT use, we compiled data from 1110 patients and calculated a pooled sensitivity of 86.67% with a standard error (SE) of 0.08% and pooled specificity of 95.05% and SE of 0.09% for detecting pediatric CSIs after trauma. Of the 8 studies with MRI data, we pooled 487 patients and found sensitivity=94.00% with SE=0.19% and specificity=66.59% with SE=0.12%. Of the 9 studies with X-ray data, we pooled 1025 patients and found sensitivity=75% with SE=0.07% and specificity=81.27% with SE=0.08%. No clinically significant missed injuries were reported in the included studies.

Conclusion : While awaiting a field-tested and validated national protocol, our study evaluated institutional protocol data to determine that MRI is the most sensitive imaging modality in clearing the pediatric c-spine after injury.