II. Epidemiology

  1. Pediatric Cervical Spine Injury is a rare event, but requires vigilance in all potential cases (see pitfalls)
    1. Percentage of Pediatric Trauma patients with a Cervical Spine Injury: <1%
    2. Percentage that children under age 8 represent of all Cervical Spine injuries: <4%
  2. Most common Cervical Spine injuries in children
    1. Ligamentous Injury (Cervical Spine instability risk)
    2. Spinal cord Hemorrhage or edema

III. Pitfalls

  1. Missing a Cervical Spine Injury can have devastating effects
    1. Have a high index of suspicion in high mechanism injury
  2. Young children cannot verbalize focal pain and associated neurologic symptoms
    1. Younger children have the most serious injuries missed (often with delays up to 3-5 days)
  3. Upper Cervical Spine is difficult to xray in children (esp. odontoid view)
    1. This region represents 75% of pediatric Cervical Spine injuries
  4. CT Imaging related radiation exposure carries a greater malignancy risk in children
  5. Clinical Decision Rules (e.g. NEXUS Criteria) are unreliable in under age 2 (and questionable in under age 8 years old)
  6. Red Flag: New radiculopathy or myelopathy (hyperreflexia, Clonus, babinski, weakness), esp. if bilateral
    1. Obtain MRI prior to discharge (even with negative CT or other imaging)
    2. MRI for ligamentous instability with subluxation, Central Cord Syndrome, Vertebral Fracture
    3. Claudius and Gruen in Herbert (2018) EM:Rap 18(4): 16-7

IV. Physiology: Unique aspects of the pediatric Cervical Spine (under age 8 years old)

  1. Disproportionately large head
  2. Small caliber neck with weak muscles and ligaments
  3. Vertebral Anatomy allows for greater slippage
    1. Vertebrae slope anteriorly to allow forward slippage
    2. Facet joints are shallow and more horizontal in children
  4. Discrepancy between spine flexibility and neurovacular flexibility
    1. Bony skeleton can stretch 2 inches without serious injury
    2. Neurovascular structures can withstand Stretching to only 0.25 inches

V. Mechanism

  1. Highest risk events or activities related to Cervical Spine Injury in children
    1. High speed Motor Vehicle Accidents (50-60% of all Cervical Spine injuries)
    2. Falls in younger children (20-30% of all Cervical Spine injuries)
    3. High impact sports (football, diving)
  2. C-Spine Levels most commonly involved
    1. Infants and Toddlers (or Marfan Syndrome, Down Syndrome)
      1. Atlanto-occipital joints (C1)
      2. Atlantoaxial joints (C1-C2)
    2. School Age Children
      1. Lower Cervical Spine (C5-C7)


  1. Definition: Spinal Cord Injury without Radiographic Abnormality (SCIWORA)
    1. Normal CT and Cervical Spine XRay
    2. MRI Cervical Spine typically identifies significant injuries and predicts prognosis
  2. Background
    1. Increased elasticity of Cervical Spine ligaments
    2. Important cause of pediatric spinal cord injury
    3. May be responsible for pre-hospital Trauma-related deaths
  3. Timing of neurologic deficit
    1. Most have onset in the first 24 hours
    2. Some presentations may be delayed weeks (or until future minor neck injury)
  4. MRI Cervical Spine
    1. Emergent indications
      1. Neurologic symptoms (Paresthesias, weakness or sensory deficits)
      2. Children under age 2 years with limited head movement
      3. Child Abuse
    2. Interpretation
      1. Best prognosis: Normal MRI or mild cord edema
      2. Worst prognosis: Major Hemorrhage

VII. Types: Atlanto-occipital and atlanto-axial dislocations

  1. Age
    1. Age <3 years most commonly affected
  2. Mechanism
    1. High Cervical Spine Injury secondary to vertical distraction
    2. Typically seen in high speed Motor Vehicle Accidents
  3. Presentation
    1. Most commonly fatal at the accident scene
    2. Cervical Collars may provoke the distraction
  4. Findings on CT
    1. Joint widening between occiput-C1 or C1-C2 (unilateral or bilateral)
    2. Retropharyngeal space widening on C2

VIII. Types: Dens Fracture

  1. Age
    1. Age <7 years old
  2. Findings on Cervical Spine XRay
    1. Peg of the dens is displaced anteriorly
    2. Fracture occurs at the synchondrosis (weak bony Growth Plate)

IX. Imaging: Cervical Spine XRay

  1. Precautions
    1. Cervical Spine XRay can not rule out high suspicion Pediatric C-Spine Injury
    2. CT Cervical Spine or MRI Cervical Spine is indicated where suspicion is high
  2. Odontoid view
    1. Unreliable in children under age 5 years old (due to compliance)
    2. When Pediatric Cervical Spine Injury occurs, it affects the upper Cervical Spine in 75% of cases
    3. If CT Head is done, ask radiology to extend CT to include C3
  3. Predental space
    1. Normal up to 5 mm in children
  4. Pseudo-subluxation of C2-C3
    1. Normal pediatric variant in 20% of children
    2. Line of Swischuk
      1. Line drawn between each anterior spinous process cortex
      2. Expect up to a 2mm displacement posteriorly of the C2 spinous process
      3. A difference >2mm is abnormal

X. Management: Approach

  1. Assume Cervical Spine Injury present
    1. All children with multiple injuries or significant mechanism (e.g. MVA)
    2. Maintain C-Spine immobilzation until full clinical evaluation
    3. Clinical Decision Rules (e.g. NEXUS Criteria) may be unreliable in children
      1. Avoid in under age 2 years old
      2. Use only with caution in under age 8 years old (Test Sensitivity: 94%)
      3. Garton (2008) Neurosurgery 62(3): 700-8 [PubMed]
    4. Children under age 2 years (pre-verbal) warrant the closest of observation
      1. Most difficult to clear the Cervical Spine
  2. Falls less than 5 feet rarely cause C-Spine Injury
    1. XRay not needed if C-Spine ROM normal and no pain
    2. Schwartz (1997) Ann Emerg Med 30:249-52 [PubMed]
  3. Children under age 5 years old have significantly different injuries than older children and adults
    1. Spinal injuries in under age 5 years are typically ligamentous and higher level
    2. Those who have spinal injuries appear significantly ill or injured
      1. Brain injury (GCS <14 or GCS-eye:1)
      2. Intubated
    3. Children under age 5 years need spine imaging only if the following criteria are not met
      1. Not intubated and not comatose
      2. No motor or sensory neurologic findings
      3. No neck symptoms (no pain or Torticollis and freely moves neck)
    4. Clearing the c-spine
      1. Indicated if above criteria met (asymptomatic, normal Neurologic Exam)
      2. Remove Cervical Collar and palpate the neck for midline tenderness or deformity
      3. Observe for normal range of motion (direct neck movement if child can follow commands)
    5. References
      1. Arora and Menchine in Herbert (2015) EM:Rap 15(10): 10
      2. Hale (2015) J Trauma Acute Care Surg 78(5): 943-8 +PMID:25909413 [PubMed]
      3. Pieretti-Vanmarcke (2009) J Trauma 67(3): 543-9 [PubMed]

XI. Management: Canadian Pediatric Trauma Consensus Guidelines (2011)

  1. Unreliable patient (<2 years old, comatose)
    1. Abnormal Neurologic Exam
      1. Leave the Cervical Collar in place
      2. Cervical Spine MRI (or Cervical Spine CT)
      3. Spine Consult
    2. Normal Neurologic Exam
      1. Leave the Cervical Collar in place
      2. Imaging (Cervical Spine XRays and consider Cervical Spine CT)
        1. Spine imaging abnormal: Spine Consult
        2. Spine imaging normal
          1. Frequently reassess
          2. Spine consult if no improvement in Level of Consciousness within 24 to 72 hours
  2. Reliable patient
    1. Clear patient if able via Clinical Decision Rules (e.g. NEXUS Criteria)
      1. Discontinue Cervical Collar
    2. Obtain Cervical Spine XRay if unable to clear patient via decision rules
      1. Obtain AP and Lateral views (and odontoid if cooperative)
      2. Abnormal Neurologic Exam or abnormal or non-diagnostic XRay
        1. Leave the Cervical Collar in place
        2. Cervical Spine MRI (or Cervical Spine CT)
      3. Normal Neurologic Exam
        1. Age >8 years old: Clear based on repeat exam and history
        2. Age <8 years old
          1. If obtaining Head CT, extend down to include C3 (if radiology able to perform)
          2. Consider clearing patient based on serial exams and history
          3. If in doubt
            1. Obtain MRI Cervical Spine
            2. Consider Consultation with spine surgery
            3. Consider inpatient observation with serial exams
  3. References
    1. Chung (2011) J Trauma 70(4): 873-84 [PubMed]

XII. References

  1. Claudius and Behar in Herbert (2012) EM:Rap 12(6): 6-8
  2. Gharahbaghian in Herbert (2017) EM:Rap 12(6): 7-9
  3. Spangler and Inaba in Herbert (2015) EM:Rap 15(12): 7-8

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