Pediatric Spine Imaging¶

Key Differences from Adult Spine Imaging¶

The pediatric spine differs from the adult spine in several important ways that affect imaging interpretation:

Normal Variants That Can Mimic Pathology¶

Synchondroses — Growth plates between the vertebral body and neural arch (posterior synchondrosis closes by age 3–6, anterior by age 3). Can mimic fractures on CT.
Physiological anterior wedging — Normal in the thoracolumbar spine in young children (can mimic compression fracture)
Pseudosubluxation of C2 on C3 — Physiological anterior translation up to 3–4 mm is normal in children up to age 8 due to ligamentous laxity and horizontal facet orientation
Os terminale — Secondary ossification center at the tip of the odontoid (fuses by age 12). Can mimic a fracture.
Subdental synchondrosis — Growth plate between the odontoid and C2 body (fuses by age 6). Can mimic a fracture.

Imaging Considerations¶

MRI — Preferred over CT whenever possible to minimize radiation
Ultrasound — Useful for screening the neonatal spine (before ossification) for dysraphism and tethered cord
CT — Reserved for trauma evaluation when radiographs are inadequate; use low-dose protocols
Radiation sensitivity — Children are more radiosensitive; minimize CT and fluoroscopy

Common Pediatric Spine Conditions¶

Scoliosis (idiopathic, congenital, neuromuscular)
Spinal dysraphism and tethered cord
Discitis (childhood — see Discitis in Children)
SCIWORA (spinal cord injury without radiographic abnormality)
Atlantoaxial rotatory subluxation (torticollis)
Os odontoideum

Clinical Pearl

Pseudosubluxation of C2 on C3 is a normal variant in children that can mimic traumatic subluxation on lateral radiograph. The Swischuk line (posterior cervical line drawn from C1 to C3 spinous processes) helps distinguish: if C2 spinous process falls within 1.5 mm of this line, pseudosubluxation is likely. True subluxation displaces C2 significantly anterior to this line.

Key Points¶

Normal synchondroses and growth plates can mimic fractures on CT
Pseudosubluxation of C2 on C3 is normal in young children
MRI is preferred over CT to minimize radiation
Neonatal spinal ultrasound can screen for dysraphism
Many pediatric spine conditions (SCIWORA, discitis, atlantoaxial rotatory fixation) are unique to children

References¶

Lustrin ES, Karakas SP, Ortiz AO, Cinnamon J, Castillo M, Vaheesan K, et al. Pediatric cervical spine: normal anatomy, variants, and trauma. Radiographics. 2003;23(3):539-60.
McAllister AS, Nagaraj U, Radhakrishnan R. Emergent imaging of pediatric cervical spine trauma. Radiographics. 2019;39(4):1126-1142.
Adib O, Berthier E, Loisel D, Aubé C. Pediatric cervical spine in emergency: radiographic features of normal anatomy, variants and pitfalls. Skeletal Radiol. 2016;45(12):1607-1617.
Expert Panel on Pediatric Imaging; Dahmoush H, Gaddam DS, Ho ML, Bauer DF, Bosemani T, et al. ACR Appropriateness Criteria® Back Pain-Child: 2024 Update. J Am Coll Radiol. 2025;22(5S):S79-S107.
Szwedowski D, Walecki J. Spinal cord injury without radiographic abnormality (SCIWORA) — clinical and radiological aspects. Pol J Radiol. 2014;79:461-464.
Mandadi AR, Koutsogiannis P, Das JM, Waseem M. Pediatric spine trauma. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; updated 2024 Mar 10. Available from: https://www.ncbi.nlm.nih.gov/books/NBK442027/
Pseudosubluxation of the cervical spine. Radiopaedia.org. Available from: https://radiopaedia.org/articles/pseudosubluxation-of-the-cervical-spine