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Cervical spine imaging in children under 9 after trauma

Three Part Question

In [children under 9 years old with suspected cervical spine injury] is [the odontoid peg view needed in addition to lateral and antero-posterior views] to [radiologically clear the cervical spine]?

Clinical Scenario

You have just read a recent important publication by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons who recommend that in the under 9 age group, children requiring radiological assessment of their Cervical Spine need only undergo an AP or lateral cervical spine view. It is your current practice to perform three view radiography but you realise that getting the odontoid peg view can be very difficult in non-compliant children. You wonder on what evidence this specific guideline was based.

Search Strategy

Medline 1966-12/02 using the OVID interface.
[exp Spinal Cord Injuries OR spinal cord injur$.mp OR cervical spine injur$.mp OR spinal fractur$.mp OR exp x-rays OR OR radiograph$.mp] AND [exp odontoid process OR] AND [Best Bets Paediatric filter]. LIMIT to Human AND English.

Search Outcome

Altogether 156 papers were identified of which two were relevant. The reference list of the guidelines were also searched but these were the only 2 papers of direct relevence. The 2 papers and the guidelines are summarised in the table below.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Swischuck L et al,
984 questionnaires submitted to paediatric radiologists (432 respondents) to determine whether odontoid views were included in the imaging protocols and how often odontoid fractures were missed on lateral views and detected on odontoid views in children under 5 yearsSurveyConcept that the odontoid view might not be necessary in children under 5Of the 432 respondents, 161 (37%) indicated that an open-mouth odontoid view was not routinely included in their imaging protocol

Of the 271 respondents who routinely use the open mouth odontoid view, 122 (45%) would request a CT if this view was too difficult to obtain

28 of the 432 respondents (7%) reported missing a total of 46 fractures on the lateral view that were detected on the odontoid view
Only 44% of radiologists responded Recollection of a missed fracture is not a reliable method of data collection Emergency physicians, not radiologists are the cohort of doctors who are actually most likely to recollect missed fractures such as these
Buhs C et al,
Multi-institutional review of all paediatric patients in the 0-16 age group with a documented cervical spine injury during a 10 year period from 1987-1997 at 4 hospitals 51 children with cervical spine injury were identified from the medical recordsRetrospective cohort studyIdentification of a cervical fracture on odontoid peg view aloneIn no child in the 0-8 year old group was the odontoid peg useful to make a diagnosis of fracture. Also in 63% of these children, the film was of such poor quality that the dens could not be evaluated

In the 9-16 year old group only 1/36 children (3%) was the open mouth view the diagnostic view (a Type III odontoid injury)
Total number of children with cervical injury was only 51 This study looks retrospectively at positive fractures only, no cohort of odontoid views was analysed, thus limiting greatly the utility of this study
American Association of Neurological Surgeons and the Congress of Neurological Surgeons,
Search of Medline (1966-2001) in the following subject headings: “spinal injuries” and “child” were reviewed with “cervical vertebrae”, “spinal injuries” and “child”. Altogether, 58 relevant articles were identifiedSystematic reviewGuidelines for the management of acute cervical spine and spinal cord injuriesInsufficient evidence to support diagnostic standards however the following are recommended:

In children <9 years of age who have experienced trauma and are non-conversant, or have neurological deficit, an altered mental status, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension it is recommended that anteroposterior and lateral cervical spine radiographs be obtained
Search strategy is not fully described in this paper Note authors came to their recommendations largely on the 2 other studies summarised above


The comprehensive review of the literature by the American Association of Neurological surgeons in 2002 come to the conclusion that odontoid peg views in the under 9 age group are unnecessary. However Swischuk et al in their survey of 432 paediatric radiologists report that they have identified 46 fractures, seen on the odontoid peg view that could not be seen on the lateral view. The American Association have set the current best evidence guidelines in this area but it should be remembered that they warn that these do not represent diagnostic standards and caution should be used in their application.

Clinical Bottom Line

Guidelines on cessation of the odontoid peg views in the under 9 age group should be viewed with great caution.


  1. Swischuk LE, John SD, Hendrick EP. Is the open-mouth odontoid view necessary in children under 5 years? Pediatric Radiology 2000:30(3),186-189.
  2. Buhs C, Cullen M, Klein M et al. The pediatric trauma c-spine: Is the “odontoid” view necessary? Journal of Pediatric Surgery 2000;35(6), 994-997.
  3. American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery 2002;50 (Suppl 3), S85-S99.