Evaluation of the child or adolescent athlete with neck pain or injury

INTRODUCTION — The anatomy of the cervical spine and the diagnostic approach to the young athlete with complaints of neck pain or injury will be discussed here.

The care of the athlete with an acute neck injury and specific cervical spine injuries and the evaluation and acute management of cervical spine injuries in children are discussed separately. (See "Field care and evaluation of the child or adolescent athlete with acute neck injury" and "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete" and "Overview of musculoskeletal neck injuries in the child or adolescent athlete" and "Evaluation and acute management of cervical spine injuries in children and adolescents".)

ANATOMY — A basic understanding of cervical spine anatomy is critical to the evaluation and management of the young athlete with complaints of neck pain or injury.

Cervical spine — The main function of the vertebral column is to protect the spinal cord. The vertebrae of the cervical spine are smaller and more delicate than those of the thoracic and lumbar spine. Nonetheless, during contact-collision sports, the cervical spine may be required to dissipate axial forces that are several times the individual player's body weight.

The first two cervical vertebrae are specialized bones that function as an important unit. The atlas (C1) articulates with the occiput of the skull superiorly and with the axis (C2) inferiorly (figure 1). Approximately 50 percent of cervical spine motion occurs at these two joints [1,2]. The atlanto-occipital joint permits the majority of flexion and extension, whereas the atlantoaxial joint permits the majority of rotation [3]. Varying amounts of flexion, extension, lateral bending, and rotation occur from C3 through C7. In the child older than eight years and in the adult, flexion is centered in the area of C5-C6, and extension in the area of C6-C7 [1]. These areas are particularly vulnerable to injuries and degenerative changes.

The vertebral bodies make up the anterior aspect of the spinal column. A bony lip on the lower surface of the vertebral body forms the uncovertebral joint with the adjacent vertebra. Below C2, the intervertebral discs separate the vertebral bodies and provide cushion and flexibility to the vertebral column.

The anterior and posterior longitudinal ligaments stabilize the vertebral bodies. The posterior vertebral column consists of the pedicles, laminae, facets, and spinous processes. The facet joints, which are true synovial joints, comprise the posterior articulations of the vertebrae. The posterior column is stabilized by the nuchal ligament complex (supraspinous, interspinous, and infraspinous ligaments), the capsular ligaments, and the ligamentum flavum. Disruption of these ligaments results in cervical spine instability.

Spinal cord and nerves — The spinal cord originates from the medulla oblongata and continues caudally through the vertebral foramina until it terminates in the lumbar area. The spinal cord possesses three main tracts, the location and function of which are important in the evaluation of patients with spinal cord injuries (figure 2). These tracts include:

●The posterior columns, which carry fine touch, vibration sense, proprioception, and pressure from the ipsilateral side

●The corticospinal tract, which lies in the posterolateral spinal cord and carries motor fibers to the ipsilateral side of the body

●The spinothalamic tract, which is located in the anterolateral spinal cord and carries pain and temperature fibers from the contralateral side of the body

Paired spinal nerve roots, which contain the motor and sensory neurons, exit from the spinal cord at each vertebral level via the intervertebral foramina. There are eight pairs of cervical spinal nerves, which are named for the vertebral body above which they exit. C5, for example, exits above the fifth vertebra. The exception is the C8 nerve root, which exits between the C7 and T1 vertebrae. Spinal nerves are subject to local pressure phenomena from herniated discs or narrowing of the foramen, which can produce neurologic symptoms in the distribution of the affected nerve.

The sensory cervical dermatomes are illustrated in the figure (figure 3). The biceps and brachioradialis reflexes are mediated by the C5-6 roots, and the triceps reflex by the C6-7 roots (mainly C7). Peripheral motor innervation from the cervical spine is as follows (table 1):

●C3-C5 innervate the diaphragm; respiratory paralysis may be present with injuries above C4

●C5 innervates the deltoid and biceps muscles

●C6 innervates the wrist extensors and abductor and extensors of the thumb

●C7 innervates the triceps, wrist flexors, and finger extensors

●C8 innervates the finger flexors

●T1 innervates the intrinsic hand muscles.

The brachial plexus is a complex network of neurons formed primarily by the roots of the fifth through eighth cervical nerves and the first thoracic nerve (figure 4). It lies in the lateral part of the neck in the clavicular region, extending from the scalenus anterior to the axilla [4]. The brachial plexus supplies motor and sensory innervation to the upper limb and limb girdle. Its location in the neck makes it particularly susceptible to traction and compression during contact-collision sports.

Muscles — The muscles of the neck may be categorized into anterior and posterior anatomic divisions.

Anterior — The anterior division includes the platysma, sternocleidomastoid, anterior vertebral muscles, and the lateral vertebral muscles (figure 5A-B).

●The platysma is the most superficial muscle in the anterior neck. It is a broad, thin muscle that overlies the other muscles and neck structures.

●The sternocleidomastoid arises from the sternum and the medial third of the clavicle and passes obliquely across the side of the neck to insert into the mastoid process. It flexes, laterally bends, and rotates the neck.

●The anterior vertebral muscles, which have attachments to the vertebrae and occipital region of the skull, assist the sternocleidomastoid in neck flexion, rotation, and lateral bending. They include the longus colli, longus capitis, rectus capitis anterior, and rectus capitis lateralis (figure 5A-B).

●The lateral vertebral muscles, or the scalene muscles, attach from the cervical vertebrae to the first or second ribs (figure 5A-B). They act as weak movers of the neck and are also accessory muscles of respiration. The nerves of the brachial plexus pass between the anterior and middle scalene muscles in route to the subclavian area.

Posterior — The muscles of the posterior division include the trapezius, splenius capitis, semispinalis capitis, and levator scapulae (figure 6). The posterior muscle groups maintain posture and act as neck stabilizers and extensors. They are stronger than the anterior groups.

●The trapezius is the flat, triangular muscle that covers the posterior portion of the neck, shoulders, and thorax. It originates in the occiput, nuchal ligament, spinous processes of C7-T12, and the supraspinal ligaments. It inserts into the lateral clavicle, acromion, and scapular spine. In addition to its role in the maintenance of cervical posture, it is an important scapular mover and stabilizer.

●The splenius capitis and semispinalis capitis arise from the lower cervical and upper thoracic vertebrae and insert at the base of the skull.

●The levator scapulae originates in the upper four cervical vertebrae and inserts into the superomedial corner of the scapula.

Vasculature — Important vessels in the neck include the common carotid arteries, vertebral arteries, jugular veins, and vertebral veins. The common carotid arteries originate in the great vessels in the chest and course superiorly, lateral to the esophagus and trachea. At the level of the hyoid bone, the common carotid branches into the internal and external carotid arteries, which supply blood to the brain, head, and some neck structures (figure 7).

The vertebral arteries arise from the subclavian arteries. They angle backwards to the transverse processes of C6 and run superiorly through the transverse foramina of C6-C1 to the inferior surface of the skull [4]. The vertebral arteries join together at the base of the brain to form the basilar artery. Damage to the vertebral arteries associated with cervical spine or neck trauma can result in disability or death [5].

The jugular and vertebral veins drain blood from the cranial cavity, face, and neck. The internal jugular vein courses from the sigmoid sinus of the brain to the subclavian veins, lying just lateral to the carotid arteries. The external jugular veins begin at the parotid gland, cross superficially over the sternocleidomastoid, and empty into the subclavian vein. They can be seen readily in many people. The vertebral veins travel with the vertebral arteries through the transverse foramina of the first six cervical vertebrae.

Other structures — In addition to the cervical spine and neck vessels, the neck contains other important structures, including the larynx, trachea, esophagus, and thyroid gland. The larynx and trachea are situated anteriorly in the midline of the neck. The larynx contains cartilage that protects the airway and the vocal cords from injury. Additional structural support is provided by the trachea's C-shaped rings of cartilage and the hyoid bone, located in the anterior neck between the chin and the larynx. Trauma to any of these structures may result in airway compromise.

The esophagus is located behind the trachea and retropharyngeal space. The retropharyngeal space is a fascial plane that is continuous with the mediastinum. This anatomic relationship is important in cases of penetrating trauma to the esophagus and/or retropharyngeal space because of the potential for direct spread of microorganisms.

EPIDEMIOLOGY — Cervical spine injury is rare in children, occurring in 1 to 2 percent of pediatric blunt trauma patients. The risk for serious injury in sports increases with age, since larger, stronger, and faster participants are able to deliver greater forces to the head and neck area [6]. Adolescents are more likely than younger children to sustain fractures and injuries to the lower cervical spine, whereas younger children more often sustain ligamentous injuries and injuries to the upper cervical spine [7]. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Anatomic considerations'.)

The injuries that occur in organized sports tend to receive the greatest attention. However, a large number of sports-related spinal injuries occur during unsupervised activities, such as swimming, diving, surfing, cycling, skiing, trampoline use, and various winter sports [1,8-13]. These injuries are more sporadic and probably underreported [6]. Diving accounts for up to 75 percent of recreation-related spinal cord injuries [14], most of which occur at C5 and result in quadriplegia [12,15].

In the United States, the youth sports with the highest risk for head and spine injuries include football, gymnastics, cheerleading, and ice hockey [13,16-18]. Because more children participate in football than in the other sports, the absolute numbers of severe injuries are highest in football [17]. Other sports with high risk for head and spine injury are listed in the table (table 2).

The incidence of catastrophic cervical spine injuries in high school football players has declined significantly over the past three decades to the current estimate of 1 cervical spine injury per 100,000 athletes or about six high school players sustaining catastrophic cervical spine injuries annually [19,20]. The reduction is thought to be related to increased emphasis on safety measures, including prohibition of initial contact with the head in blocking and tackling, football helmet standards, improved medical care for the injured athlete, and improved coaching methods in teaching the fundamental skills of blocking and tackling [21,22].

INITIAL MANAGEMENT — Children and adolescent athletes in whom cervical spine injuries are suspected should undergo initial assessment and management according to the priorities established by Advanced Trauma Life Support guidelines. (See "Trauma management: Approach to the unstable child", section on 'Primary survey' and "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Initial management'.)

Essential actions include:

●Spinal motion restriction

●Airway management and orotracheal intubation in patients who cannot maintain their airway or have respiratory paralysis

●Rapid treatment of shock with fluid resuscitation followed by assessment for spinal shock

●Emergency consultation with a pediatric spine team

A discussion of immobilization of patients wearing helmets and helmet removal is provided separately. (See "Field care and evaluation of the child or adolescent athlete with acute neck injury", section on 'Spinal motion restriction (immobilization)' and "Field care and evaluation of the child or adolescent athlete with acute neck injury", section on 'When to remove helmet and/or shoulder pads'.)

EVALUATION — Once spinal motion restriction and initial management has occurred, the evaluation of neck pain and injury should include a complete history, physical examination, and, as indicated, cervical spine imaging.

History — The history should encompass the chief complaint, a full characterization of neck pain and/or associated symptoms, the mechanism of injury, past medical history (particularly regarding injuries and medications), and review of systems. The characterization of pain should include:

●The exact location of the pain or numbness, and whether there is any radiation

●The onset of pain (eg, slow and insidious or after a traumatic episode)

●The nature of pain (eg, burning, tingling, tightness)

●Aggravating and relieving factors (eg, movement, posture)

●Temporal patterns (association with work, activities, particular time of day)

●Associated symptoms (headache, neck stiffness, upper-extremity paresthesia, numbness, or weakness)

●Shoulder or upper-extremity pain (may indicate cervical spinal cord or nerve root pathology)

●Previous evaluation and treatment, and whether treatment helped to relieve symptoms

The nature of the pain may give some insight into the diagnosis. Burning pain or paresthesias suggest a neurologic condition, whereas neck tightness and spasm is usually a musculoskeletal problem (possibly a fracture) and may be the only sign of an unstable fracture. Upper-extremity symptoms suggest neurologic injury or disease. (See "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete" and "Overview of musculoskeletal neck injuries in the child or adolescent athlete".)

Cervical spine injury should be suspected in those children who have an underlying predisposition to such injuries, such as a patient with Down or Klippel-Feil syndrome, even with a trivial mechanism of injury. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Predisposing conditions'.)

Mechanism of injury — The mechanism of injury and position of the head during the event can help narrow the differential diagnosis by suggesting the path through which force is dissipated, as described below [6,17]. Eyewitness reports or videotapes of the injury may help determine the mechanism of injury.

●Flexion injuries compress the anterior elements and disrupt the posterior elements. Potential injuries include anterior wedge vertebral body fractures, chip fractures, anterior dislocations, rupture of the posterior ligaments or ligamentum flavum, and rupture of the posterior half of the disc. In addition to the above, combined flexion-rotation injuries can cause anterior subluxation. (See "Overview of musculoskeletal neck injuries in the child or adolescent athlete".)

●Extension injuries compress the posterior elements and disrupt the anterior elements. Potential injuries include posterior bony injury to the spinous processes, facets, and neural arch, and rupture of the anterior longitudinal ligament and anterior disc. (See "Overview of musculoskeletal neck injuries in the child or adolescent athlete".)

●When the head is in the neutral position, with the normal cervical lordotic curve, forces transmitted to the head are dissipated in the cervical muscles (figure 8) [6]. When the neck is flexed to 30 degrees, the cervical spine is straight; forces transmitted to the head are minimally dissipated to the cervical muscles and directly transmitted from one vertebra to the next. If the impact force is greater than the strength of the bone, a compression fracture may result [15]. Compression injuries include vertebral end-plate fractures, or propulsion of the vertebra and disc into the spinal canal. (See "Overview of musculoskeletal neck injuries in the child or adolescent athlete" and "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete".)

Neck examination — The physical examination is essential in narrowing the diagnostic possibilities. A careful examination, coupled with an understanding of the neck anatomy, can help determine which structures are responsible for the patient's symptoms.

Initial examination consists of palpation for local tenderness, muscle spasm, and tenderness or deformity of the posterior spinous processes while maintaining inline stabilization of the neck. Patients with significant neck pain, midline posterior neck tenderness, high risk mechanisms of injury (eg, hockey player going headfirst into the board or American football player with neck pain after a spear tackle), or focal neurologic findings warrant cervical spine imaging before permitting range of motion or performing provocative testing (eg, axial compression or Spurling test). (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging'.)

Once serious cervical spine injury has been excluded by initial examination, including appropriate cervical spine imaging, as indicated, the examination should include inspection, palpation, active range of motion, passive range of motion, strength testing, and special/provocative tests:

●Inspection – Inspection of the neck should be performed from the anterior, posterior, and lateral views. The patient's posture should be noted, as should any rotational deformity or muscle atrophy. Absence of the normal cervical lordosis suggests spasm of the neck muscles. Any abnormalities should be further evaluated radiographically. (See 'Radiologic evaluation' below.)

●Palpation – Careful palpation of the neck structures helps to identify subtle deformities (eg, facet dislocation). Point tenderness of the spinous processes, particularly with a recent history of trauma, implies a bony abnormality such as a vertebral fracture. If muscle spasm is present, identification of the involved muscle(s) can provide important clues about the underlying problem. (See 'Anatomy' above.)

●Range of motion – Assessment of the patient's range of motion is a vital portion of the neck examination. Active range of motion should always be assessed before attempting provocative maneuvers that require passive range of motion.

Active range of motion for cervical flexion, extension, lateral bending, and lateral rotation should be assessed. Limitation in range of motion or poor segmental spinal movement suggests underlying pathology that warrants cervical spine motion restriction and imaging. (See "Pediatric cervical spinal motion restriction", section on 'Rigid cervical collars' and "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Choice of study'.)

•Flexion-extension: Ask the patient to touch the chin to the chest and then to look up at the ceiling. The sternocleidomastoid muscles are the primary flexors, the paravertebral extensor and trapezius are the primary extensors [2]

•Lateral bending: Ask the patient to touch the ear to the ipsilateral shoulder without raising the shoulder. Normal range of lateral bending is approximately 45 degrees; the primary lateral benders are the scaleni anterior, medial, and posterior [2]

•Lateral rotation: Ask the patient to twist the chin toward the right and left. Normal range of rotation is 60 to 80 degrees; the sternocleidomastoid muscles are the primary rotators [2]

●Strength testing – The neck muscles should be tested for strength in all directions (ie, flexion, extension, lateral bending, and rotation). Strength testing is particularly important when muscle wasting is present and in evaluating whether the athlete may return to play.

●Provocative tests of the neck – Provocative tests of the neck are designed to detect compression of nerve roots. These tests should only be performed after cervical spine injury has been excluded clinically or by appropriate imaging. Special or provocative tests that help to identify the etiology of symptoms in the neck include the axial compression test, Spurling test, and the distraction test [23]:

•To execute the axial compression test, with the patient in the seated or standing position, the examiner places his or her hands on top of the patient's head and applies a compressive force inferiorly. A positive test reproduces pain or radicular symptoms, implying nerve root compression.

•The Spurling or neck compression test is a variant of the axial compression test in which the patient's neck is extended and rotated toward the involved side as the axial load is applied (picture 1). This neck position narrows the intervertebral foramina on the affected side and reproduces the radiating pain if there is pathology at the root or foramen [24]. This maneuver is highly specific for the presence of cervical root compression, but the sensitivity is low [25]. Thus, a positive test is helpful, but a negative test does not rule out radiculopathy.

•Manual cervical traction (the distraction test) is used to confirm the diagnosis of radiculopathy. Vertical traction is gently applied to the seated or supine patient's head (picture 2). Because this maneuver reduces pressure at the level of the disk and facet joints, symptoms due to compressed nerve roots may be temporarily relieved.

Neurologic examination — The presence of a neurologic deficit also requires immediate spinal motion restriction followed by emergency spine imaging. Every patient with neck pain should have a neurologic examination to determine whether a neurologic deficit is present, and if so, its distribution. Neurologic signs can occur in patterns that suggest a central lesion, a nerve root radiculopathy, or peripheral nerve entrapment. A thorough understanding of the neuroanatomy, including the sensory and motor dermatomes of the upper extremities, is necessary to localize the lesion (table 1 and figure 3). (See 'Spinal cord and nerves' above.)

A detailed neurologic examination should be performed in any patient presenting with signs or symptoms consistent with a neck injury. The examination should include upper-extremity strength testing, assessment of reflexes and sensation, and testing for upper motor neuron function. Depending upon the history, cranial nerve evaluation also may be appropriate. (See "Detailed neurologic assessment of infants and children", section on 'Neurologic examination'.)

RADIOLOGIC EVALUATION — The clinical findings that direct radiologic evaluation are summarized in the table (table 3). Among athletes, injuries sustained in diving, falls from a distance greater than the athlete's height, and axial compression injuries are considered to be high-risk injuries. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging'.)

Plain cervical spine radiographs consisting of AP, lateral, and open mouth views are the initial radiologic study to evaluate for cervical spine injury in most children and adolescents. Plain radiographs have adequate sensitivity to identify or exclude unstable cervical spine fractures or dislocations, especially in awake children with reliable physical examinations (see "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Choice of study'). Plain radiographs expose the patient to much less radiation than CT as discussed in greater detail below. However, in children with a GCS score <9 (table 4) or neurologic deficit on physical examination, imaging with CT of the cervical spine instead of plain radiographs is indicated.

DEFINITIVE MANAGEMENT — Consultation with a pediatric spine service is recommended for all children with neurologic abnormalities on examination or potentially unstable cervical spine injuries on imaging. If consultation is not available onsite, immediate transfer must be arranged to a center that can provide these services. Patients with unstable fractures have commonly sustained multisystem trauma, and the extent of their other injuries determines whether they require admission to an intensive care unit or other monitored setting once the cervical fracture is stabilized. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Definitive management and disposition'.)

RETURN TO PLAY — Decisions regarding return to play must be made on a case-by-case basis, particularly for contact-collision sports. The safety of the athlete is the most important consideration in making the decision, and the decision-making process should involve consultation with members of the specialty teams who have participated in the athlete's care (eg, neurosurgery, orthopedics, sports medicine, physical therapy).

As a general rule, athletes who have unstable injuries should be prohibited from returning to play. Additional contraindications to participation include injuries resulting in permanent central nervous system dysfunction, permanent and significant peripheral nerve root dysfunction, and spinal fusion above the C-5 level [26].

On the other hand, athletes with stable fractures, stable ligamentous injuries, and stable one-level surgical fusions can usually participate after appropriate treatment and rehabilitation. Stability of the cervical spine should be assessed with dynamic (ie, flexion-extension) radiographs, and clearance from the athlete's neurosurgeon should be obtained before participation is permitted. Athletes with cervical burners may return to play when completely asymptomatic [27], whereas return to play for those who have transient quadriplegia (cervical cord neurapraxia) is controversial. (See "Overview of musculoskeletal neck injuries in the child or adolescent athlete", section on 'Subluxation and dislocation' and "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete", section on 'Cervical burners' and "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete", section on 'Cervical cord neurapraxia'.)

One author has categorized cervical spine conditions and injuries into three groups: no contraindication, relative contraindication, and absolute contraindication to participation in contact sports (table 5A-B). The recommendations are based upon information compiled from the National Football Head and Neck Injury Registry (including more than 1200 cervical spine injuries), literature review, and the author's experience and understanding of pathophysiology [28].

Despite these recommendations, and the existence of other sets of guidelines [29,30] controversy remains regarding return to play for athletes with borderline injuries and/or conditions for which available data are inadequate for decision-making (eg, cervical spinal stenosis with transient quadriplegia) [28,31]. (See "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete", section on 'Cervical cord neurapraxia'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topics (see "Patient education: Neck pain (The Basics)" and "Patient education: Whiplash (The Basics)")

●Beyond the Basics topic (see "Patient education: Neck pain (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Initial management – Children and adolescent athletes with suspected cervical spine injuries should undergo initial assessment and management according to the priorities established by Advanced Trauma Life Support guidelines. Essential actions include (see 'Initial management' above):

•Spinal motion restriction

•Airway management and orotracheal intubation in patients who cannot maintain their airway or have respiratory paralysis

•Rapid treatment of shock with fluid resuscitation followed by assessment for spinal shock

•Emergency consultation with a pediatric spine team

●Spinal motion restriction – The restriction of cervical spine motion should occur in any child who is suspected of having a cervical spine injury until the injury is excluded. Motion restriction should be established in the prehospital setting, or failing that, upon presentation to the health care facility and should continue until injury is ruled out clinically or radiographically. (See 'Initial management' above and "Field care and evaluation of the child or adolescent athlete with acute neck injury", section on 'Spinal motion restriction (immobilization)'.)

●Evaluation – Once spinal motion restriction and initial management has occurred, the evaluation of neck pain and injury should include a complete history, physical examination, and, as indicated, cervical spine imaging. (See 'Evaluation' above.)

Initial neck examination consists of palpation for local tenderness, muscle spasm, and tenderness or deformity of the posterior spinous processes while maintaining inline stabilization of the neck. Patients with neck pain, midline posterior neck tenderness, high risk mechanisms of injury (eg, hockey player going headfirst into the board or American football player with neck pain after a spear tackle), or focal neurologic findings warrant cervical spine motion restriction and imaging before permitting range of motion or performing provocative testing (eg, axial compression or Spurling test). (See 'Neck examination' above.)

The presence of a neurologic deficit also requires immediate spinal motion restriction followed by emergency spine imaging. Neurologic signs can occur in patterns that suggest a central lesion, a nerve root radiculopathy, or peripheral nerve entrapment. A thorough understanding of the neuroanatomy, including the sensory and motor dermatomes of the upper extremities, is necessary to localize the lesion (table 1 and figure 3). (See 'Neurologic examination' above.)

●Radiologic evaluation – Additional historical and physical findings that direct radiologic evaluation are summarized in the table (table 3). Among athletes, injuries sustained in diving, falls from a distance greater than the athlete's height, and axial compression injuries are considered to be high-risk injuries. (See 'Radiologic evaluation' above.)

Plain cervical spine radiographs consisting of AP, lateral, and open mouth views are the initial radiologic study to evaluate for cervical spine injury in most children and adolescents. However, in children with a GCS score <9 (table 4) or neurologic deficit on physical examination, imaging with CT of the cervical spine instead of plain radiographs is indicated (See 'Radiologic evaluation' above.)

●Definitive management – Consultation with a pediatric spine service is recommended for all children with neurologic abnormalities on examination or potentially unstable cervical spine injuries on imaging. If consultation is not available onsite during acute management, then immediate transfer must be arranged to a center that can provide these services. (See 'Definitive management' above.)

●Return to play – Decisions regarding return to play must be made on a case-by-case basis, particularly for contact-collision sports. The safety of the athlete is the most important consideration in making the decision, and the decision-making process should involve consultation with members of the specialty teams who have participated in the athlete's care (eg, neurosurgery, orthopedics, sports medicine, physical therapy). The tables provide guidance by specific injury (table 5A-B). (See 'Return to play' above.)