Plain Radiography Could Reduce CT Use in Low-Risk Pediatric Blunt Trauma

Kahan AM, Wan H, Eldredge RS, Kastenberg ZJ, et al. Plain Radiograph Use in Pediatric Blunt Trauma Patients with Suspicion for Cervical Spine Injury: A Prospective Observational Analysis of the Western Pediatric Cervical Spine Study. J Am Coll Surg. August 2026. 

Despite guideline support for plain radiography (XR) in low-risk pediatric blunt trauma, CT remains the predominant imaging modality for cervical spine evaluation, raising concerns about unnecessary radiation exposure. Kahan and colleagues evaluated contemporary XR utilization and its diagnostic performance in children meeting consensus criteria for XR-first imaging.  

The authors performed a prospective, multicenter observational study of 19,995 children enrolled in the Western Pediatric Cervical Spine Study across 72 US trauma centers from 2022 to 2025. Children appropriate for XR screening (Glasgow Coma Scale score >13, asymptomatic, non-obtunded) were identified using consensus criteria. XR utilization, sensitivity, and negative predictive value (NPV) were assessed, and multivariable logistic regression was used to identify predictors of XR use. 

XR was performed in 39% of patients overall and varied significantly by trauma center type (pediatric 48% versus adult 14% versus mixed 15%; p<0.001), whereas CT was used in 60%. Among XR-appropriate children (n = 12,650), an estimated 7,705 CT examinations potentially could have been replaced with XR. In the overall cohort, XR sensitivity for any cervical spine injury was 30.3% (95% CI 26.2–34.6%) with an NPV of 95.2% (95% CI 94.7–95.7%). In XR-appropriate children, only two clinically significant cervical spine injuries were missed, yielding a sensitivity of 75.0% (95% CI 34.9–96.8%) and an NPV of 99.9% (95% CI 99.9%–100.0%).

Plain radiography was used in fewer than half of children meeting consensus criteria for XR-first imaging. In appropriately selected patients, XR demonstrated an NPV of 99.9% for clinically significant cervical spine injury, supporting broader implementation of XR-first imaging strategies to reduce CT utilization and pediatric radiation exposure.