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Pediatric cervical spinal motion restriction

Pediatric cervical spinal motion restriction
Literature review current through: Sep 2023.
This topic last updated: Feb 10, 2022.

INTRODUCTION — Techniques for cervical spinal motion restriction (previously called cervical spine precautions or immobilization) are reviewed here. The evaluation and management of cervical spine injuries and field care of children and skeletally immature adolescents with sport-related neck injuries are discussed separately. (See "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Field care and evaluation of the child or adolescent athlete with acute neck injury".)

BACKGROUND — Cervical spine injury is rare in children. It is primarily seen in children who sustain blunt trauma, occurring in 1 to 2 percent of such cases. The injury may involve bones, ligaments, blood vessels, or the spinal cord, and must be rapidly recognized and treated to avoid permanent disability or death. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Epidemiology'.)

DEFINITIONS

Spinal motion restriction versus immobilization — Precautions must be taken to limit the motion of the spine in any child who is suspected of having a cervical spine injury until the injury is excluded [1]. Historically, the process of restricting the motion in the spine during emergency medical management was described as "spinal immobilization." More recently, trauma experts have adopted the term "spinal motion restriction" for this process because true immobilization of the spine is unattainable [2].

Cervical spine injuries in children frequently involve the axial spine and are at higher risk of being associated with spinal cord injury [3]. Spinal motion restriction should be established in the prehospital setting or upon presentation to the health care facility. It should be continued until injury is ruled out clinically or radiographically [1]. Worsening of cervical cord injury may be avoided with proper spinal motion restriction and careful airway management [4].

Neutral spine position — The neutral position of the spine maximizes the spinal canal diameter to minimize further injury to the spinal cord and corresponds to "the normal anatomic position of the head and torso that one assumes when standing and looking straight ahead" [5]. With the child lying supine on a flat surface and looking straight ahead, the neutral position for the cervical spine places the gaze perpendicular to that surface (figure 1) [6]. In morphologically normal children, the neutral position also aligns the external auditory meatus with the shoulder in the coronal plane [7]. Neutral position for the remainder of the spinal column refers to a position lying supine without obvious rotation or bending of the spinal column [8].

Neutral spine positioning in children requires special allowance for their relatively large head size, which varies by age [9,10]. In particular, the prominent occiput in infants and young children forces the cervical spine into flexion when the patient is supine. Rigid longboards used for extricating children may be modified to facilitate the maintenance of neutral position [7,9,10]. Some pediatric rigid longboards have depressed areas for the occiput in order to maintain neutral position (figure 1). Alternatively, the back can be elevated by the placement of padding under the shoulders and extending to the lumbar region. In one prospective study of children younger than eight years, the mean back elevation needed to achieve a neutral position was 2.5 cm (1 inch) [6].

Children older than eight years of age, adolescents, and adults require occipital elevation to maintain the neutral position when in the supine position. No consensus regarding the amount of elevation exists; the range described in the literature varies from 1.3 to 9.5 cm, with most authors favoring approximately 2 cm [5,11]. Correlation with spinal magnetic resonance imaging in a small series of adults suggests that 2 cm of occipital padding provides a favorable ratio of spinal canal to spinal cord cross-sectional area, but this finding is likely not generalizable [12].

INDICATIONS — Spinal motion restriction should be employed whenever there is clinical suspicion of cervical spine injury including any one of the following clinical findings [13,14] (see "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Evaluation'):

High-risk mechanism of injury:

High-risk blunt trauma mechanism (table 1)

Diving injuries or those involving axial load biomechanics

Physical examination findings that suggest cervical spine injury:

Altered mental status (including intoxication or drowsiness)

Neck pain

Tenderness at the posterior midline of the cervical spine

Decreased range of neck motion on exam by patient report or based upon physical examination

Neurologic deficits

Multiple system trauma, particularly when associated with severe injuries to the head or torso

Cervical spine motion restriction is also warranted in those children who have an underlying predisposing factor (eg, developmental anomalies of the cervical spine as seen with Down or Klippel-Feil syndrome, impaired bone and soft tissue integrity such as occurring in osteogenesis imperfecta or Ehlers-Danlos syndrome, cervical arthritis, or cervical spine surgery) even with trivial mechanisms of injury. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Predisposing conditions'.)

The ability to walk away from the scene of the injury does not negate the need for a cervical collar because some patients with cervical spine injuries can ambulate initially.

The patient's cervical spine must remain protected until a cervical spine injury has been excluded clinically and/or radiographically. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Evaluation'.)

CONTRAINDICATIONS — Contraindications to rigid cervical collar placement include:

Presence of fixed neck deformity

Massive cervical swelling for which collar placement may impinge upon the airway

Need to perform cricothyrotomy

Attempts at applying a collar worsen neurologic symptoms or neck pain

Penetrating trauma [15]

Alternative approaches are discussed separately for these patients below. (See 'Alternatives to rigid cervical collars' below.)

TECHNIQUES — Pediatric techniques for spinal motion restriction should be used up until about 16 years of age.

Methods for restricting spine motion in children are influenced by their developmental anatomy. Compared with adults, children younger than eight years have relatively large heads, weak cervical muscles, and short necks which makes them particularly prone to axial cervical spine injury. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Anatomic considerations'.)

As children grow, the cervical spine matures with adult patterns of injury typically present by 16 years of age [3,16]. Protection of the cervical spine to prevent worsening of an existing spinal cord injury requires restricting motion in both the neck and the body. The neck is placed in a cervical collar, and the body is placed in the supine position, preferably on a soft conforming surface. Infants and young children warrant a cut out in the board or padding under the shoulders to maintain neutral position (figure 1). Otherwise, the relatively large head and prominent occiput of the infant and young child pushes the neck into flexion when lying supine. Cervical spinal motion restrictions should be applied while the airway is being assessed.

Spinal motion restriction typically begins in the prehospital environment. Prior to implementing spinal motion restriction, the child should undergo rapid assessment and stabilization of airway, breathing, and circulation. If the patient requires ongoing resuscitation, spinal motion restriction will need to progress during resuscitation. The recommended order of spinal motion restriction in trauma patients is as follows:

Manual in-line stabilization of the cervical spine

Application of a rigid cervical collar

Extrication of the patient from the scene

Use of a rigid longboard should be limited to unconscious patients or patients who cannot assist with movement due to injury. The log-roll procedure should be used to facilitate supine placement on a rigid longboard. If transport times exceed 30 minutes, padding of pressure points or use of a vacuum mattress should be considered to avoid development of decubitus ulcers. The rigid longboard should be secured to the transport stretcher.

Conscious patients without debilitating injuries should be secured directly to the transport stretcher or in an age-appropriate car seat secured to the stretcher.

Upon arrival at the hospital, patients with spinal motion restriction in place undergo rapid assessment of the neck and spine for signs of injury as part of the primary survey (see "Trauma management: Approach to the unstable child", section on 'Airway with cervical spine motion restriction'). Manual in-line stabilization is applied and maintained while the cervical collar is removed to facilitate palpation of the anterior and posterior neck. The cervical collar is reapplied or, if inappropriately sized in the field, replaced. Once the rigid cervical collar is in place, manual in-line stabilization is repeated when the patient is log-rolled for assessment of the back and rest of the spinal column. At this point, if present, the rigid spine board is removed and the patient rolled back to a supine position on the gurney.

For infants and toddlers that arrive within car seats, the head and neck should be supported using manual in-line stabilization when removing them from the car seat, regardless of whether or not a rigid collar is in place.

Manual in-line stabilization of the cervical spine — To perform manual in-line stabilization of the cervical spine, the provider places the hands on both sides of the head with fingertips gently touching the clavicles (stabilization from behind the patient) or with the hand gently resting on the clavicles (stabilization from in front of the patient) and maintains the cervical spine in a neutral position (figure 2). The provider should not apply traction.

Rigid cervical collars — Only rigid cervical collars should be used for motion restriction. Appropriate sizing is imperative to properly support a neutral cervical spine position. Furthermore, inappropriate sizing can promote excessive cervical spine flexion (collar is too short) or extension (collar is too tall). Because proper size depends upon the type of collar, the user should follow the manufacturer's recommendations for sizing.

As a general rule, high-cut collars are optimal because they provide points of support at the chin, angle of the jaw, the mastoid processes, and the occiput. This is of particular importance in the children as they are more likely to injure their axial cervical spine.

Many cervical collars are commercially available that provide sizing from infancy to adulthood:

Stifneck (Laerdal)

Aspen Pediatric Collar (Aspen Medical Products)

Philadelphia (DeRoyal)

Miami J (Ossur Americas)

These collars are expensive and can be difficult for ambulances to stock the full range of sizes. Several companies market extrication collars that are more economical and easier to stock due to adjustable settings:

Perfit ACE Extrication Collar (Ambu/DeRoyal)

Extrication Collar (Matrix)

The chin must fit securely into the chin cup of the collar. This will prevent flexion of the neck, which causes the chin to slide down into the collar. The mandible should not be forced posteriorly. This could compromise the airway. The lower portion of the collar should rest firmly on the chest and clavicles.

Alternatives to rigid cervical collars — Rigid cervical collars are the preferred method for cervical spine motion restriction in almost all trauma patients. Exceptions include:

If there is not a commercially available cervical collar which properly fits the infant, child, or child with dysmorphic features (eg, Pierre Robin or Klippel Feil) a rolled towel can be placed around the neck, crossed in front of the neck over the chest and secured with tape.

In injured athletes, helmets and shoulder pads should be left in place until arrival at the hospital unless they can be removed with the assistance of multiple providers to ensure cervical stabilization. Helmets and shoulder pads should always be removed if they interfere with maintenance of airway, breathing, and circulation. (See "Field care and evaluation of the child or adolescent athlete with acute neck injury", section on 'When to remove helmet and/or shoulder pads'.)

Prehospital providers sometimes keep infants and children within intact and visually undamaged car seats for transport if the child does not appear to be injured or acutely ill [17,18]. For infants and toddlers, cervical spine motion restriction may involve placing towel rolls on either side of the head or rolling a single towel and placing it in a horseshoe around the child's head. With either technique, the towel rolls are secured by taping them to the car seat [19]. For infants and toddlers that arrive within car seats, the head and neck should be supported using manual in-line stabilization when removing them from the car seat, regardless of whether or not a rigid collar is in place.

For patients with contraindications to rigid cervical collar placement (neck swelling, fixed neck deformity, need for cricothyrotomy, or collar placement exacerbates neurologic symptoms), cervical spine movement restriction can be temporarily maintained by manual in-line stabilization (figure 2). For patients with fixed deformities or whose symptoms are worsened by collar application, the patient can be allowed to assume a position of maximum comfort followed by placement of padding (eg, rolled towels or blankets) that are secured with tape to support this position. Care should be taken to ensure that tape does not impair airway management.

Log-roll procedure — Although not always feasible in the prehospital setting, in most patients, a rigid cervical collar should be applied before rolling the patient. The log-roll procedure maintains the spine in a neutral position during rolling and requires four people to properly perform in adults (figure 3) [8]. The Advanced Trauma Life Support (ATLS) Program does not specify the number of people needed for log-rolling a child. However, in log-rolling a child, having one person solely responsible for maintaining the cervical spine in the neutral position is critical. Two to four additional people may be needed, depending upon the size of the child.

The arms are straightened and placed with palms inward next to the body.

The legs are straightened and ankles secured to each other with padding between them.

The patient is rolled with the body as a unit onto the center of the gurney or the rigid longboard.

When patients arrive in the emergency department on a rigid longboard, the log-roll procedure is also used to remove the child from the board. (See 'Rigid longboards' below.)

ADDITIONAL CONSIDERATIONS

Rigid longboards — The routine use of rigid longboards is now discouraged by the American College of Surgeons, the American Academy of Pediatrics, the American College of Emergency Physicians, and the National Association of Emergency Medical Services Physicians [13]. In a retrospective, observational study from Arizona (United States) that evaluated over 100,000 encounters at agencies that adopted protocols limiting use of the rigid longboard, rates of spinal cord injury at hospital discharge pre- and post-implementation were similar (0.20 versus 0.22 percent, respectively) [20]. Patients with known or suspected cervical spine injury should be positioned in the supine or semi-recumbent position on a soft conforming surface to relieve pressure points. In the prehospital setting, it may be necessary to secure a patient to a rigid longboard during field extrication. This is most often the case when the patient has a comorbid condition that limits their mobility such as a severe head injury or extremity deformity. For children there are several rigid longboards that are marketed to accommodate their size and anatomy such as a half-sized rigid longboards or boards with occipital head recess.

The patient should be removed from the rigid longboard, if used, as soon as possible to avoid unnecessary pain and pressure sores. This goal is commonly accomplished during the exposure portion of the primary survey when the patient is log-rolled for evaluation of the flank and back. Patients in whom significant concern for spinal cord injury exists and who may remain on the rigid longboard for longer than 30 minutes, should have padding placed under the occiput, scapulae, sacrum, and heels (figure 4). (See "Evaluation and acute management of cervical spine injuries in children and adolescents".)

Children who do not require placement on a rigid longboard or supine positioning on the gurney for medical treatment should be transported in an age-appropriate car seat secured to the gurney according to the Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances recommendations of National Highway Traffic Safety Administration [18].

Motion restriction during airway management — The cervical spine should be manually stabilized during airway management to prevent exacerbation of a spinal cord injury (figure 2). Initially, the airway can be opened with the jaw-thrust maneuver (figure 5). Orotracheal intubation with in-line manual stabilization provides the best approach to secure the airway in trauma victims without causing further cervical spine injury [8,21-23]. If a rigid collar is in place, then it should be opened to facilitate intubation. (See "Technique of emergency endotracheal intubation in children".)

Surgical airways are indicated in the presence of significant maxillofacial or laryngotracheal trauma. In children less than eight years of age, needle cricothyroidotomy or emergent tracheostomy are preferred [24,25]. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults" and "Needle cricothyroidotomy with percutaneous transtracheal ventilation".)

Obvious cervical spine deformity — Care must be taken when moving an obviously deviated cervical spine. The ATLS program recommends that any patient with an obvious deformity of the neck be kept in a neutral position; however, if there is an obvious fixed deformity, clinicians should not attempt manual reduction in the field. (See 'Contraindications' above.)

Patient transfer — When transferring a patient with spinal motion restrictions in place from the gurney to a radiology table or a hospital bed, a scoop stretcher (figure 6) or slide board (figure 7) can be used to transfer the patient safely between surfaces, but it should not be used for continued spinal motion restriction. During transfer with a scoop stretcher, the stretcher is picked up at each end and supported in the center to prevent sagging and loss of neutral position.

Children who are undergoing ambulance transfer should be further secured for transport (figure 4):

The trunk, pelvis, lower extremities, and feet should be appropriately secured to the gurney or rigid longboard. Straps must fit snugly enough to fix the body to the rigid longboard but should not be so tight as to restrict respiration [26]. Secure the feet first and then move toward the head.

The straps may be too wide for the child. Any gaps between the child and the straps should be filled with towels or blankets to prevent side-to-side movement.

Wedges are placed beside the head and neck to inhibit lateral movement. Lightweight head blocks are preferred to sandbag head stabilization. Sandbags increase the weight at the head end of the rigid longboard and may cause a loss of the neutral position or a fall from the rigid longboard [11].

The patient's head and neck position are secured with tape across the forehead and cervical collar. Tape should not be placed across the chin because it can interfere with airway management.

CERVICAL SPINE CLEARANCE — The approach to cervical spine clearance, including clinical clearance of the cervical spine without performing spinal motion restriction is discussed separately. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine clearance'.)

SUMMARY AND RECOMMENDATIONS

Indications – Spinal motion restriction is used for patients with a clinical suspicion of cervical spine injury including any one of the following clinical findings (see 'Indications' above):

High-risk blunt trauma mechanism (table 1)

Diving injuries or those involving axial load biomechanics

Physical examination findings:

-Altered mental status (including intoxication or drowsiness)

-Neck pain

-Tenderness at the posterior midline of the cervical spine

-Decreased range of neck motion on exam by patient report or based upon physical examination

-Neurologic deficits

-Multiple system trauma, particularly when associated with severe injuries to the head or torso

Children with predisposing cervical spine, bone, or soft tissue conditions (see "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Predisposing conditions')

Contraindications – Contraindications to rigid cervical collar placement include (see 'Contraindications' above):

Presence of fixed neck deformity

Massive cervical swelling for which collar placement may impinge upon the airway

Need to perform cricothyrotomy

Attempts at applying a collar worsen neurologic symptoms or neck pain

Penetrating trauma

Techniques – For trauma patients without contraindications to rigid collar placement, the order of spinal motion restriction in is as follows:

Manual in-line stabilization of the cervical spine (figure 2); do not put traction on the neck (see 'Manual in-line stabilization of the cervical spine' above)

Application of a rigid cervical collar; the user should follow the manufacturer's recommendations for sizing (see 'Rigid cervical collars' above)

Extrication of the patient from the scene (see 'Log-roll procedure' above and 'Rigid longboards' above):

-Use of a rigid long board should be limited to unconscious patients or patients who cannot assist with movement due injury. The log-roll procedure facilitates supine placement on a rigid longboard (figure 3 and figure 4). Some pediatric rigid longboards have depressed areas for the occiput in order to maintain neutral position (figure 1). Alternatively, the back can be elevated by the placement of padding under the shoulders and extending to the lumbar spine. If transport time on the board will exceed 30 minutes, pad pressure points or use a vacuum mattress to avoid development of decubitus ulcers. The rigid longboard should be secured to the transport stretcher.

-Conscious patients without debilitating injuries should be secured directly to the transport stretcher or in an age-appropriate car seat secured to the stretcher.

For children with contraindications to rigid cervical collar placement (neck swelling, fixed neck deformity, need for cricothyrotomy, or collar placement exacerbates neurologic symptoms), temporarily maintain cervical spine movement restriction with manual in-line stabilization. (See 'Alternatives to rigid cervical collars' above.)

Additional considerations – During hospital care, maintain spinal motion restriction until a cervical spine injury has been excluded clinically and/ or radiographically. The patient should be removed from the rigid longboard, if used, as soon as possible to avoid unnecessary pain and pressure sores. Patients in whom significant concern for spinal cord injury exists and who may remain on the rigid longboard for longer than 30 minutes during hospital care should have padding placed under the occiput, scapulae, sacrum, and heels (figure 4). (See 'Indications' above and 'Rigid longboards' above.)

If airway management is required, the cervical collar should be opened and the cervical spine should be manually stabilized to prevent exacerbation of a spinal cord injury (figure 2). (See 'Motion restriction during airway management' above.)

When transferring a patient requiring spinal motion restrictions from the gurney to a radiology table or a hospital bed, a scoop stretcher (figure 6) or slide board (figure 7) can be used to transfer the patient safely between surfaces, but it should not be used for continued spinal motion restriction. (See 'Patient transfer' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Alison Chantal Caviness, MD, who contributed to an earlier version of this topic review.

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