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Suspected Spine Trauma-Child

Variant: 1   Child, 3 to 16 years of age, acute cervical spine trauma, meets low risk criteria (based on PECARN or NEXUS). Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
US cervical spine Usually Not Appropriate O
Radiography cervical spine Usually Not Appropriate ☢☢
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢☢
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI cervical spine without and with IV contrast Usually Not Appropriate O
MRI cervical spine without IV contrast Usually Not Appropriate O
CT cervical spine with IV contrast Usually Not Appropriate ☢☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT cervical spine without IV contrast Usually Not Appropriate ☢☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CT myelography cervical spine Usually Not Appropriate ☢☢☢

Variant: 2   Child, 3 to 16 years of age, acute cervical spine trauma, at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography cervical spine Usually Appropriate ☢☢
MRI cervical spine without IV contrast May Be Appropriate (Disagreement) O
CT cervical spine without IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
US cervical spine Usually Not Appropriate O
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢☢
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI cervical spine without and with IV contrast Usually Not Appropriate O
CT cervical spine with IV contrast Usually Not Appropriate ☢☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CT myelography cervical spine Usually Not Appropriate ☢☢☢

Variant: 3   Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography cervical spine Usually Appropriate ☢☢
MRI cervical spine without IV contrast May Be Appropriate (Disagreement) O
US cervical spine Usually Not Appropriate O
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢☢
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI cervical spine without and with IV contrast Usually Not Appropriate O
CT cervical spine with IV contrast Usually Not Appropriate ☢☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT cervical spine without IV contrast Usually Not Appropriate ☢☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CT myelography cervical spine Usually Not Appropriate ☢☢☢

Variant: 4   Child, younger than 16 years of age, suspected thoracolumbar spine trauma. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography thoracic and lumbar spine Usually Appropriate ☢☢☢
MRI thoracic and lumbar spine without IV contrast May Be Appropriate (Disagreement) O
CT thoracic and lumbar spine without IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
Arteriography thoracic and lumbar spine Usually Not Appropriate ☢☢☢☢
MRA thoracic and lumbar spine without and with IV contrast Usually Not Appropriate O
MRA thoracic and lumbar spine without IV contrast Usually Not Appropriate O
MRI thoracic and lumbar spine without and with IV contrast Usually Not Appropriate O
CT thoracic and lumbar spine with IV contrast Usually Not Appropriate ☢☢☢☢
CT myelography thoracic and lumbar spine Usually Not Appropriate ☢☢☢☢
CT thoracic and lumbar spine without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTA thoracic and lumbar spine with IV contrast Usually Not Appropriate ☢☢☢☢☢

Panel Members
Nadja Kadom, MDa; Susan Palasis, MDb; Sumit Pruthi, MD, MBBSc; Walter L. Biffl, MDd; Timothy N. Booth, MDe; Nilesh K. Desai, MDf; Richard A. Falcone Jr., MD, MPHg; Jeremy Y. Jones, MDh; Madeline M. Joseph, MDi; Abhaya V. Kulkarni, MDj; Jennifer R. Marin, MD, MSck; Sarah S. Milla, MDl; David M. Mirsky, MDm; John S. Myseros, MDn; Charles Reitman, MDo; Richard L. Robertson, MDp; Maura E. Ryan, MDq; Gaurav Saigal, MDr; Jacob Schulz, MDs; Bruno P. Soares, MDt; Aylin Tekes, MDu; Andrew T. Trout, MDv; Matthew T. Whitehead, MDw; Boaz Karmazyn, MDx.
Summary of Literature Review
Introduction/Background
Discussion of Procedures by Variant
Variant 1: Child, 3 to 16 years of age, acute cervical spine trauma, meets low risk criteria (based on PECARN or NEXUS). Initial imaging.
Variant 1: Child, 3 to 16 years of age, acute cervical spine trauma, meets low risk criteria (based on PECARN or NEXUS). Initial imaging.
A. Radiography Cervical Spine
Variant 1: Child, 3 to 16 years of age, acute cervical spine trauma, meets low risk criteria (based on PECARN or NEXUS). Initial imaging.
B. CT Cervical Spine
Variant 1: Child, 3 to 16 years of age, acute cervical spine trauma, meets low risk criteria (based on PECARN or NEXUS). Initial imaging.
C. MRI Cervical Spine
Variant 1: Child, 3 to 16 years of age, acute cervical spine trauma, meets low risk criteria (based on PECARN or NEXUS). Initial imaging.
D. Arteriography Cervicocerebral
Variant 1: Child, 3 to 16 years of age, acute cervical spine trauma, meets low risk criteria (based on PECARN or NEXUS). Initial imaging.
E. US Cervical Spine
Variant 1: Child, 3 to 16 years of age, acute cervical spine trauma, meets low risk criteria (based on PECARN or NEXUS). Initial imaging.
F. CT Myelography Cervical Spine
Variant 2: Child, 3 to 16 years of age, acute cervical spine trauma, at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). Initial imaging.
Variant 2: Child, 3 to 16 years of age, acute cervical spine trauma, at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). Initial imaging.
A. Radiography Cervical Spine
Variant 2: Child, 3 to 16 years of age, acute cervical spine trauma, at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). Initial imaging.
B. CT Cervical Spine
Variant 2: Child, 3 to 16 years of age, acute cervical spine trauma, at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). Initial imaging.
C. MRI Cervical Spine
Variant 2: Child, 3 to 16 years of age, acute cervical spine trauma, at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). Initial imaging.
D. CTA Neck
Variant 2: Child, 3 to 16 years of age, acute cervical spine trauma, at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). Initial imaging.
E. MRA Neck
Variant 2: Child, 3 to 16 years of age, acute cervical spine trauma, at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). Initial imaging.
F. Arteriography Cervicocerebral
Variant 2: Child, 3 to 16 years of age, acute cervical spine trauma, at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). Initial imaging.
G. US Cervical Spine
Variant 2: Child, 3 to 16 years of age, acute cervical spine trauma, at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). Initial imaging.
H. CT Myelography Cervical Spine
Variant 3: Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. Initial imaging.
Variant 3: Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. Initial imaging.
A. Radiography Cervical Spine
Variant 3: Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. Initial imaging.
B. CT Cervical Spine
Variant 3: Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. Initial imaging.
C. MRI Cervical Spine
Variant 3: Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. Initial imaging.
D. CTA Neck
Variant 3: Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. Initial imaging.
E. MRA Neck
Variant 3: Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. Initial imaging.
F. Arteriography Cervicocerebral
Variant 3: Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. Initial imaging.
G. US Cervical Spine
Variant 3: Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. Initial imaging.
H. CT Myelography Cervical Spine
Variant 4: Child, younger than 16 years of age, suspected thoracolumbar spine trauma. Initial imaging.
Variant 4: Child, younger than 16 years of age, suspected thoracolumbar spine trauma. Initial imaging.
A. Radiography Thoracic and Lumbar Spine
Variant 4: Child, younger than 16 years of age, suspected thoracolumbar spine trauma. Initial imaging.
B. CT Thoracic and Lumbar Spine
Variant 4: Child, younger than 16 years of age, suspected thoracolumbar spine trauma. Initial imaging.
C. MRI Thoracic and Lumbar Spine
Variant 4: Child, younger than 16 years of age, suspected thoracolumbar spine trauma. Initial imaging.
D. CTA Thoracic and Lumbar Spine
Variant 4: Child, younger than 16 years of age, suspected thoracolumbar spine trauma. Initial imaging.
E. MRA Thoracic and Lumbar Spine
Variant 4: Child, younger than 16 years of age, suspected thoracolumbar spine trauma. Initial imaging.
F. Arteriography Thoracic and Lumbar Spine
Variant 4: Child, younger than 16 years of age, suspected thoracolumbar spine trauma. Initial imaging.
G. US Thoracic and Lumbar Spine
Variant 4: Child, younger than 16 years of age, suspected thoracolumbar spine trauma. Initial imaging.
H. CT Myelography Thoracic and Lumbar Spine
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
References
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2. American College of Radiology. ACR Appropriateness Criteria®: Suspected Spine Trauma. Available at: https://acsearch.acr.org/docs/69359/Narrative/.
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.