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Defining pediatric cervical spine clearance with computed tomography: A prospective observational study by the
Katie W Russell1, Anastasia M Kahan, Richard S Eldredge
1Division of Pediatric Surgery (K.W.R., A.M.K., K.E.L., R.A.S., Z.J.K., H.-Y.W.), Primary Children's Hospital, University of Utah, Salt Lake City, UT; Department of Surgery (K.W.R., A.M.K., R.A.S., J.W.R., Z.J.K., H.-Y.W.), Mayo Clinic, Rochester, MN; Department of Surgery (R.S.E.), Phoenix Children's Hospital, Phoenix, AZ; Department of Surgery (B.E.P., D.M.N.), Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH; Department of Surgery (D.J.O., M.K.), University of California, San Francisco, San Francisco, CA; Department of Surgery (A.R.J.), University of California, San Diego, San Diego, CA; Division of Pediatric Surgery (R.C.I.), Stanford University, Stanford, CA; Department of Surgery (S.D.C.), Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA; Department of Surgery (L.I.K.-Q., K.I.), University of Texas Southwestern, Dallas, TX; Department of Surgery (L.A.G.), University of Colorado, Aurora, CO; Mary Bridge Children's Hospital (T.J.S.), Tacoma, WA; Ascension Sacred Heart (M.A.E.), Pensacola, FL; Division of Pediatric Surgery (K.J.L.), Le Bonheur Children's Hospital, Memphis, TN; Department of Surgery (R.F.W.), Indiana University School of Medicine, Indianapolis, IN; Department of Neurosurgery (B.K.Y.), University of Utah, Salt Lake City, UT; Department of Surgery (R.R.I., D.L.B., V.M.R.), Keck School of Medicine, University of Southern California, Los Angeles, CA.
Introduction:
The optimal imaging strategy for pediatric cervical spine clearance remains controversial. The primary objective of this study was to determine the sensitivity of computed tomography (CT) in detecting clinically significant cervical spine injury in children. We hypothesized that CT is sufficiently sensitive to allow for definitive clearance of the pediatric cervical spine after blunt trauma.
Methods:
We conducted a prospective, multicenter, observational study from March 1, 2022, to July 31, 2025, at 72 diverse adult, mixed, and pediatric trauma centers across the United States. All children <18 years who underwent cervical spine imaging after blunt trauma were included. The primary outcome was the ability of CT to identify a clinically significant cervical spine injury requiring operative intervention or halo placement. We performed a post hoc panel review of all cases with normal imaging that required surgery. The diagnostic test characteristics and 95% CI of CT were calculated.
Results:
We prospectively enrolled 19,651 pediatric patients, of whom 12,693 (65%) underwent cervical spine CT and comprise the analytic cohort. The median age was 12 (interquartile range, 6-15), 37% (n=4,673) were female, and 19% (n=2,389) were obtunded, defined as GCS ≤13. The sensitivity of CT at the treating hospitals to identify a clinically significant injury was 94.7% [CI: 89.4%-97.5%], with a negative predictive value of 99.9% [CI: 99.9%-100%]. Error analysis identified eight patients with false-negative CT interpretations, of which six injuries were identifiable on retrospective review. Accounting for retrospectively identifiable injuries, CT sensitivity for detecting clinically significant injury was 98.7% [CI: 94.8%-99.8%], with a negative predictive value of 100% [CI: 99.9%-100%].
Conclusions:
In pediatric blunt trauma patients evaluated for cervical spine injury, CT is highly sensitive for detecting clinically significant injuries. These findings support pediatric cervical spine clearance based on a normal cervical spine CT. (J Trauma Acute Care Surg. 2026;00: 000-000. © 2026 The Author(s). Published by Wolters Kluwer Health, LLC. on behalf of the American Association for the Surgery of Trauma.).
Level Of Evidence:
Prospective Cohort Study; Level II.
