X-rays Effectively Clear Most Pediatric Cervical Spine Injuries, 10-Year Trauma Center Study Finds

Lead author Dr. William Starr and colleagues reviewed 10 years of pediatric trauma cases at their Level 1 pediatric trauma center, following nationally recommended protocols. The process involved using X-rays as the initial screening method for children with Glasgow Coma Scale (GCS) scores between 14 and 15, while those with more severe impairment (lower GCS) underwent CT scans first.

Key Findings:

• A total of 2,081 children had negative C-spine X-rays during the study period.
• Of these, 1,974 (95%) had their spines cleared without requiring further imaging.
• The remaining 108 underwent additional CT or MRI scans, most often due to persistent neck pain, lower GCS scores, or neurological symptoms such as tingling.
• None of these patients required surgery for a clinically significant injury.

The authors noted that despite recommendations from organizations such as the Pediatric Trauma Society, some hospitals have shifted away from X-rays toward CT scans as the default initial imaging method—a trend more common in adult trauma care. They cautioned that this shift may unnecessarily increase radiation exposure for children, as X-rays carry a much lower dose compared to CT.

Beyond its diagnostic accuracy, the researchers highlighted several benefits of X-ray use: it is more cost-effective, reduces radiation exposure, and can speed up the safe removal of cervical collars, improving comfort and quality of life for young patients.

Statistical analysis revealed that lower GCS scores were the strongest predictor for ordering additional imaging after a negative X-ray. Patients needing further scans were also more likely to have severe injuries elsewhere, require intubation, or be involved in cases of suspected non-accidental trauma.

While the study reinforces the reliability of X-rays in this context, the authors acknowledged several limitations. These include the retrospective design, potential selection biases, and the fact that their institution benefits from pediatric-specific expertise and resources that may not be available everywhere. Additionally, long-term follow-up data were limited, though most hospitals in their region share electronic health records, making it unlikely that missed injuries went undetected.

The researchers concluded that for evaluable pediatric trauma patients—those who can cooperate with examination—a normal X-ray combined with a normal clinical assessment offers a safe and effective method for clearing the cervical spine. They called for larger multicenter studies and prospective research to validate these findings across varied healthcare settings.

“As pediatric specialists, we should continue to advocate for the use of X-ray as an essential tool in trauma care,” Dr. Starr’s team wrote. “It remains a dependable, efficient, and safer option for our youngest patients.”

Reference:

William Starr, Stephanie Iantorno, Jing Wang, Richard Eldredge, Rajiv Iyer, Karch Smith, Natalya McNamara, Kezlyn Larsen, Stephen Fenton, Robert Swendiman, Katie Russell - Pediatric cervical spine clearance: a 10-year evaluation of X-ray in evaluable patients at a level 1 pediatric trauma center: Trauma Surgery & Acute Care Open 2025;10:e001539.