ORIGINAL PAPER X-ray vs. CT in identifying significant C-spine injuries in the pediatric population Andrew T. Hale 1 & Abraham Alvarado 1 & Amita K. Bey 1 & Sumit Pruthi 2 & Gregory A. Mencio 3 & Christopher M. Bonfield 4 & Jeffrey E. Martus 3 & Robert P. Naftel 1,4 Received: 28 December 2016 /Accepted: 1 May 2017 # Springer-Verlag Berlin Heidelberg 2017 Abstract Purpose Evaluation of cervical spine injury (CSI) in children requires rapid, yet accurate assessment of damage. Given con- cerns of radiation exposure, expert consensus advises that computed tomography (CT) should be used sparingly. However, CT can provide superior image resolution and de- tection of pathology. Herein, we evaluate if X-ray offers equal diagnostic accuracy compared to CT imaging in identifying CSI in children. Methods We conducted a retrospective study between October 2000 and March 2012 of pediatric patients evaluated for cervical spine injury at a level 1 trauma center. All patients included in this study were imaged with cervical spine X-rays and CT at the time of injury. Demographic information, mech- anism of injury, significant versus non-significant injury (as defined by the NEXUS criteria), radiographic findings, level of the injury, presence of spinal cord injury, treatment, clinical outcome, and length of follow-up were collected. Chi-squared (χ 2 ) and Fisher’ s exact tests were used as appropriate and means and standard deviations were reported. Results We identified 1296 patients who were screened for CSI. Of those, 164 patients were diagnosed with spinal cord/ column injuries (CSI). Eighty-nine patients were excluded for only having a CT or X-ray imaging without the other modal- ity. Thus, a total of 75 patients with CSI were included in the final cohort. Using the NEXUS definitions, 78% of patients had clinically significant injuries while 22% had non- significant injuries. There were no injuries detected on X-ray that were not also detected on CT. For all injuries, X-ray sen- sitivity was 50.7%. X-rays were more sensitive to significant injuries (62.3%) compared in non-significant injuries, which were missed on all X-rays (0%). Therefore, X-rays did not identify 24 significant cervical spine injuries (32%) as defined by NEXUS. Conclusions CT is superior to X-rays in detecting both clini- cally significant and insignificant cervical spine injuries. These results were not dependent on patient age or location of the injury. We recommend CT imaging in the evaluation of suspected cervical spine injuries in children. Level of evidence: III Keywords Pediatrics . Cervical spine . Trauma . Computed tomography . X-ray Background Cervical spine injury (CSI) is uncommon, occurring in approxi- mately 1.5% of children evaluated for traumatic injuries [1]. However, cervical spine trauma evaluation requires expeditious diagnostic evaluation. Patients who are not promptly diagnosed are at risk of severe neurologic outcomes [2–4]. An accurate and timely diagnosis requires appropriate imaging studies in addition to a high level of clinical suspicion. The National Emergency X- Radiography Utilization Study (NEXUS) evaluated a clinical decision instrument to determine the need for cervical spine im- aging in blunt trauma patients with specific signs or symptoms * Andrew T. Hale Andrew.hale@vanderbilt.edu 1 Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’ s Hospital of Vanderbilt University, Nashville, TN, USA 2 Department of Radiology, Monroe Carell Jr. Children’ s Hospital of Vanderbilt University, Nashville, TN, USA 3 Division of Orthopedic Surgery, Monroe Carell Jr. Children’ s Hospital of Vanderbilt University, Nashville, TN, USA 4 Division of Neurological Surgery, Monroe Carell Jr. Children’ s Hospital of Vanderbilt University, Nashville, TN, USA Childs Nerv Syst DOI 10.1007/s00381-017-3448-4