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Evaluation and acute management of cervical spine injuries in children and adolescents

Evaluation and acute management of cervical spine injuries in children and adolescents
Literature review current through: Sep 2023.
This topic last updated: Sep 19, 2023.

INTRODUCTION — The evaluation of cervical spine injuries in children and adolescents is reviewed here. Techniques for providing spinal motion restriction (ie, spinal precautions or spine immobilization) in children, diagnosis and treatment of spinal cord injury without radiographic abnormality (SCIWORA) in children, management of cervical spinal column injuries in adults, and other issues related to spinal cord injury are discussed separately:

(See "Pediatric cervical spinal motion restriction".)

(See "Spinal cord injury without radiographic abnormality (SCIWORA) in children".)

(See "Cervical spinal column injuries in adults: Evaluation and initial management".)

(See "Spinal column injuries in adults: Types, classification, and mechanisms".)

EPIDEMIOLOGY — Cervical spine injury is rare in children, occurring in 1 to 2 percent of pediatric blunt trauma patients [1-5]. The major causes of cervical spine injury include trauma that is associated with one of the following mechanisms [6,7]:

Severe mechanism such as [8]:

Motor vehicle collision (MVC) with patient ejection, death of another occupant, or intrusion into the patient's passenger compartment of >12 inches at the roof and/or >18 inches at any site

Fall of a distance >10 feet or two to three times the child's height

Diving and axial load (eg, force applied to the top of the head)

Acceleration-deceleration of the head (eg, hitting the head on the dashboard during a head-on collision)

Clotheslining force (eg, caused by a rope, cable, or similar item exerting traction on the neck while the body is in forward motion)

Multiple system trauma

Certain sports or recreational activities (eg, football, hockey, wrestling, bicycling, trampoline use, or all-terrain vehicle riding) (see "Evaluation of the child or adolescent athlete with neck pain or injury", section on 'Epidemiology')

Mechanisms of injury vary by age and influence observed patterns of cervical spine trauma and outcomes. The majority of cervical spine injuries result from trauma to the top of the head or the neck [9-12]:

Birth – Vaginal delivery of infants in the breech position

Birth to eight years – MVCs and falls

Older than eight years – MVCs and sports injuries

The location of injury also varies significantly by age. Axial cervical spine injuries (occiput to C2 region) account for approximately three-quarters of injuries in children younger than eight years of age [10]. In older children, the subaxial cervical spine (C3 to C7) is the site of injury in just over half of patients.

Cervical spine injuries frequently warrant surgical intervention and are associated with permanent neurologic deficits and death in up to 21 and 7 percent of patients, respectively [10].

ANATOMIC CONSIDERATIONS — Children younger than eight years of age are more susceptible to injury to the axial cervical spine (occiput to C2) than older children and adults because of certain features of their anatomic development (table 1) [1,2,10,11,13,14]:

They have relatively larger heads than bodies. The head circumference of a child reaches 50 percent of adult size by two years of age; by contrast, the chest circumference reaches 50 percent of adult size by eight years of age.

The approximate anatomic location of the cervical spine fulcrum progresses caudally from C2-C3 at birth to C5-C6 at eight years of age.

They have weaker cervical musculature and increased laxity of the ligaments, resulting in greater mobility of the upper cervical spine.

They have immature vertebral joints and horizontally inclined articulating facets that facilitate sliding of the upper cervical spine.

In addition, younger children may also incur fractures of the growth plate and ligamentous injuries (subluxation and distraction) [11]. Two factors may contribute to this problem:

The immature growth centers are susceptible to sheer forces during rapid deceleration or hyperflexion-extension, particularly at the synchondrosis between the odontoid and vertebral body of C2.

The young spinal column is more elastic than is the spinal cord and is able to tolerate more distraction before rupture (up to 5 cm versus only 5 to 6 mm in the spinal cord). This feature is also one of the reasons why spinal cord injury can occur without radiographic evidence of spinal column injury in children. (See "Spinal cord injury without radiographic abnormality (SCIWORA) in children".)

The most common injuries in older children are vertebral body and arch fractures. These fractures usually are in the lower cervical spine; such injuries are less common in children younger than eight years of age [12,15,16].

Anatomy of the cervical spine and neck is discussed in greater detail separately. (See "Evaluation of the child or adolescent athlete with neck pain or injury", section on 'Anatomy'.)

INITIAL MANAGEMENT — Children 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'.)

Spinal motion restriction (spinal immobilization) — During the initial assessment and management, the clinician must suspect a cervical spine injury in any patient with multisystem blunt trauma and take precautions to limit spine motion during the primary survey, especially in patients with significant head, neck, or torso trauma or with an altered level of consciousness. Padding under the shoulder and back and use of the "sniffing position" is important to open the airway maximally and maintain a neutral cervical spine position in the infant or young child (figure 1). Note that this positioning is markedly different from adults where padding under the head is frequently required to achieve neutral cervical spine position. (See "Pediatric cervical spinal motion restriction".)

Airway management — The emergency clinician should anticipate airway management problems in children with cervical spine injury. Unstable lesions above C3 may cause immediate respiratory paralysis, and lower cervical lesions may cause delayed phrenic nerve paralysis from ascending edema of the spinal cord. Cervical spinal column injury may also be associated with airway obstruction from retropharyngeal hemorrhage, edema, or maxillofacial trauma. (See "Anatomy and localization of spinal cord disorders", section on 'Cervical cord'.)

In patients who cannot maintain their airway, the clinician should employ a jaw thrust (figure 2) or chin lift to open the airway while maintaining the cervical spine in neutral position. When indicated by altered mental status or inadequate respiration, rapid sequence intubation (RSI) (table 2) should be performed with in-line cervical spine stabilization by an assistant (figure 3). Intubation should be accomplished using the orotracheal route. Laryngoscopy with a video laryngoscope may permit better visualization of the larynx while minimizing cervical spine movement. (See "Video laryngoscopy and other devices for difficult endotracheal intubation in children", section on 'Video laryngoscope'.)

RSI and emergency endotracheal intubation in children are discussed in greater detail separately. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Approach" and "Technique of emergency endotracheal intubation in children".)

Spinal shock — Transient loss of spinal cord function can occur following spinal injury leading to vasodilatory shock. However, clinicians must first assume that hypotension following trauma results from hemorrhage and ensure appropriate volume resuscitation. (See "Trauma management: Approach to the unstable child", section on 'Circulation'.)

Nevertheless, neurogenic shock from spinal cord injury (usually to the superior portion of the spinal cord) may cause hypotension requiring vasoactive medication infusions and bradycardia necessitating atropine and/or pacing. Neurogenic shock and the management of trauma-related shock are discussed separately. (See "Acute traumatic spinal cord injury", section on 'Cardiovascular complications' and "Trauma management: Approach to the unstable child", section on 'Circulation'.)

Specialty consultation — Evidence of a significant cervical spine injury (eg, fracture through the synchondrosis of the dens, vertebral body fracture, or any injury associated with a neurologic deficit) requires emergency consultation with a pediatric spine surgeon or a spine surgery team (often staffed by pediatric orthopedists and pediatric neurosurgeons) to guide supportive care and definitive management of the injury. If consultation is not available onsite, immediate transfer must be arranged to a pediatric trauma center that can provide these services.

EVALUATION — During the secondary survey, the cervical spine and neck should be palpated for signs of tenderness or deformity, and a focused neurologic examination should occur as part of a comprehensive head-to-toe evaluation of the trauma patient (table 3).

History — The elements in the history that suggest the likelihood of cervical spine injury include the mechanism of injury, the presence of neurologic symptoms at any time after the injury (even if they have resolved), neck complaints (eg, neck pain or decreased range of motion), and a past medical history of predisposing conditions [10,17].

Mechanism of injury — The clinician should suspect cervical spine injury in all children who are severely injured or have high-risk injuries such as high-risk MVC (motor vehicle collision; complete or partial ejection of patient, death of passenger in same compartment, or passenger compartment intrusion >12 inches at roof and/or >18 inches anywhere else), diving injuries, clotheslining mechanism, or those involving axial load biomechanics [17-20]. Serious head injury and multiple-system trauma are commonly associated with spinal injuries and may distract the child (and medical provider) from recognizing and appreciating cervical pain or other important symptoms.

Cervical spine injury can occur through flexion, extension, vertical compression, rotation, or a combination of these forces. Most spinal cord injuries result from direct compression or disruption of the cord by fracture fragments or subluxed vertebrae. In children younger than three years of age, it is especially prudent to suspect cervical spine injury based upon the mechanism of injury because they typically are unable to provide a history and cooperate with the examination. (See "Acute traumatic spinal cord injury", section on 'Pathophysiology'.)

The mechanism of injury may predict the type of injury and the radiologic findings:

Hyperflexion injuries may cause wedge fractures of the anterior vertebral body with disruption of the posterior elements in older children and adolescents (image 1). Examples include the clay-shoveler's fracture, an avulsion fracture of the base of the spinous process of C6, C7, or T1, and the teardrop fracture with anterior displacement of a triangular bony fragment of the anteroinferior portion of the vertebral body.

Hyperextension injuries may cause compression of the posterior elements and disruption of the anterior longitudinal ligament. An example is the hangman's fracture of the posterior neural arch of C1 or the pedicles of C2 (image 2).

Axial loading may cause burst or comminuted fractures of the arches of C1 in the upper cervical spine or of the vertebral bodies in the lower cervical spine. The Jefferson burst fracture, for example, consists of fractures of the arches of C1 and lateral displacement of C1 with respect to C2 (figure 4 and image 3). Axial loading also may cause compression fractures of the vertebra (image 4).

Rotational injuries may cause fracture or dislocation of the facets. These injuries are uncommon in isolation and occur more frequently in combination with flexion or extension injuries.

Atlantoaxial rotatory subluxation, a common, generally benign injury in younger children usually occurs as a result of minor trauma. (See "Acquired torticollis in children", section on 'Atlantoaxial rotary subluxation'.)

Symptoms — Children who have neurologic symptoms (eg, paresthesias, numbness, or weakness) or neck pain suggestive of spinal injury should have restricted spinal motion during initial evaluation and management and undergo rapid radiologic evaluation. If neurologic symptoms have been persistent since injury, imaging should be performed at first presentation, no matter how long after the injury. For patients with transient but resolved symptoms, cervical spine imaging is suggested up to four days after the injury by some experts based upon anecdotal experience. (See "Pediatric cervical spinal motion restriction", section on 'Techniques' and 'Cervical spine imaging' below.)

Neurologic symptoms – Patients may complain of either transient or persistent hyperesthesia, paresthesia, dysesthesia, numbness, or weakness. The distribution of symptoms is variable and ranges from involvement of single dermatomes to dramatic neurologic deficits, including quadriplegia. The patient's ability to walk does not exclude cervical spine injury.

Not all children who have spinal cord injuries complain of symptoms; some are asymptomatic, whereas others are unable to express their symptoms (eg, preverbal or severely injured). For example, in a retrospective review of 72 previously normal children with cervical spine injury, 10 patients were initially asymptomatic on evaluation. However, all asymptomatic patients had both a high-risk injury mechanism and comorbid injuries from multiple trauma [9].

The history should include the presence of symptoms at any time after the injury, even if they have resolved. Transient burning dysesthesias in the hands and fingers may indicate hyperextension of the cervical spine with central cord contusion (eg, the "burning hands" syndrome that has been observed in football players). (See "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete", section on 'Cervical cord neurapraxia'.)

Transient neurologic symptoms may also be the only indication of spinal cord injury without radiographic abnormality (SCIWORA). Thus, it is critical to have a high index of suspicion and to ask specifically about transient symptoms in any patient whose mechanism of injury is consistent with potential cervical spine injury. (See "Spinal cord injury without radiographic abnormality (SCIWORA) in children", section on 'Clinical features and diagnosis'.)

When nerve symptoms are unilateral, only involve the arm, and are associated with shoulder depression and lateral neck flexion (eg, tackling in football), then transient brachial plexus injury ("burner" or "stinger") may have occurred. However, careful evaluation is needed to exclude symptoms and signs of cervical spine injury (table 4). Furthermore, bilateral sensory symptoms (eg, paresthesia, hyperesthesia, dysesthesia, or numbness) suggest cervical spine injury, not brachial plexus injury [21]. (See "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete", section on 'Cervical burners'.)

Neck symptoms – The classic triad of neck symptoms includes localized cervical pain, muscle spasm, and decreased range of neck motion. If neurologic or neck symptoms have been persistent since injury, imaging should be performed at first presentation, no matter how long after the injury. (See 'Cervical spine imaging' below.)

Predisposing conditions — Cervical spine injury should be suspected in those children who have an underlying predisposition to such injuries, even with trivial mechanisms of injury [22-25]:

History of cervical spine surgery

History of cervical spine arthritis:

Ankylosing spondylitis (image 5) (see "Spondyloarthritis in children")

Systemic juvenile idiopathic arthritis (see "Systemic juvenile idiopathic arthritis: Clinical manifestations and diagnosis")

Congenital syndromes affecting the development of the cervical spine:

Down syndrome (approximately 15 percent have atlantoaxial instability) (see "Down syndrome: Clinical features and diagnosis")

Klippel-Feil syndrome (congenital fusion of variable numbers of cervical vertebrae and associated defects including scoliosis, renal anomalies, elevated scapula (Sprengel deformity), congenital heart disease, and deafness)

Morquio syndrome (mucopolysaccharidosis IV (picture 1)), which is associated with hypoplasia of the odontoid (image 6) (see "Mucopolysaccharidoses: Clinical features and diagnosis", section on 'MPS type IV (Morquio syndrome)')

Larsen syndrome, which may have associated cervical vertebrae hypoplasia and is otherwise characterized by multiple joint dislocations, flat facies, and short fingernails

Conditions affecting bone and soft tissue integrity:

Osteogenesis imperfecta (table 5 and image 2) (see "Osteogenesis imperfecta: An overview")

Marfan syndrome (table 6) (see "Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders")

Ehlers-Danlos syndrome (picture 2) (see "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes")

Rickets (see "Overview of rickets in children")

Chronic steroid use

Physical examination — The principal elements for examination in patients with a potential cervical spine injury consist of the vital signs, neck examination, and neurologic assessment. After the examination, spinal motion restriction can be discontinued if there are no signs or symptoms concerning for cervical spine injury (algorithm 1). Spinal motion restriction should be maintained for those children with signs or symptoms of cervical spine injury and appropriate diagnostic imaging obtained (algorithm 2 and algorithm 3). (See 'Cervical spine imaging' below.)

Infants and toddlers can often be clinically cleared without imaging after minor trauma if they have a normal neurologic examination (including mental status) and no other life-threatening injuries. The cervical spine can be carefully palpated, and active range of motion can be assessed. Decreased range of motion of the neck or apparent tenderness requires continued spinal motion restriction and imaging. (See 'Indications' below and "Detailed neurologic assessment of infants and children", section on 'Neurologic examination'.)

Vital signs — Axial injury (occiput to C2) causes abrupt cessation of respiration. Apnea or hypoventilation may result from injuries at the spinal level of diaphragmatic control (C3, C4, C5). Hypotension, bradycardia, or temperature instability may result from spinal shock. (See 'Initial management' above.)

Neck examination — While maintaining inline stabilization, the spinous processes are palpated for local tenderness, muscle spasm, or obvious deformity. With a cervical spine injury, midline cervical tenderness is more common than paraspinous muscular spasm or tenderness.

Neurologic examination — A neurologic examination should be completed with assignment of the Glasgow Coma Scale (GCS) Score (table 7) and evaluation of tone, strength, sensation, and reflexes. Up to 50 percent of children with cervical cord injuries have neurologic deficits [26,27]. The neurologic findings that correspond to spinal injury at different levels are presented in the following table and figure (table 8 and figure 5). (See "Detailed neurologic assessment of infants and children", section on 'Neurologic examination'.)

An isolated sensory deficit is the most common neurologic finding in patients with cervical spinal cord injury. The distribution and type of sensory impairment localizes the injury within the spinal cord. The ipsilateral posterior spinal column and contralateral anterior column are tested with light touch. The anterolateral spinal column is tested with pinprick (pain), and the ipsilateral posterior spinal column cord is tested with position sense. Dysesthesias localize to the central cord.

Muscle strength is best evaluated by noting if apnea is present (C2-C3), presence of spontaneous breathing (C3-C4) and by testing flexion of the biceps with the palm up (C5), extension of the wrist (C6), extension of the elbow (C7), extension of the knee (L2-L4), and dorsiflexion of the great toe (L5).

Paralysis may be difficult to evaluate in infants and young children. The level of paralysis, if present, localizes the injury. Mass withdrawal movements may occur as a reflex despite paralysis and may complicate the evaluation in the immediate post injury phase.

Flaccid muscle tone indicates a lower motor neuron lesion or spinal cord disruption.

Areflexia, which is the transient (usually lasting less than 24 hours) depression of reflexes below the level of the injury, indicates spinal cord injury. The level of abnormality may localize the injury.

Although insensitive for spinal cord injury, the absence of rectal tone on examination is a poor prognostic sign. The absence of the bulbocavernosus reflex indicates spinal shock. The bulbocavernosus reflex (S3-S4) is performed by squeezing the glans penis, tapping on the mons pubis, or by pulling on a urinary catheter while performing a rectal examination. These maneuvers normally stimulate the trigone of the bladder, causing a reflex contraction of the anal sphincter; a lack of response and flaccid sphincter tone indicate significant spinal cord injury or damage to the sacral elements of the spinal cord.

Several syndromes suggest specific types of injuries:

Anterior cord syndromes result from hyperflexion and anterior cord compression. Paralysis and loss of pain sensation without loss of light touch or proprioception sense below the level of injury occur. (See "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete", section on 'Anterior cord syndrome'.)

Central cord syndromes result from hyperextension injuries. They are associated with weakness that is greater in the upper than in the lower extremities and transient burning sensation in the hands and fingers. (See "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete", section on 'Central cord syndrome'.)

The Brown-Séquard syndrome results from cord hemisection. It is associated with ipsilateral paralysis, loss of proprioception, and loss of light touch and contralateral loss of pain and temperature sense. (See "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete", section on 'Brown-Séquard syndrome'.)

Horner's syndrome results from disruption of the sympathetic chain. It is associated with ipsilateral ptosis, miosis, and anhidrosis. (See "Horner syndrome".)

Cervical spine imaging — Children with suspected cervical spine injury based upon history or physical examination should undergo cervical spine imaging. At a minimum, radiologic evaluation should include two plain radiograph views (cross-table lateral and anterior-posterior [AP]), and, when obtainable, an open-mouth odontoid view. Depending upon whether abnormal findings are present on physical examination or plain radiographs, computed tomography (CT), magnetic resonance imaging (MRI), or both may also be indicated.

Children with clinical findings suggestive of spinal cord injury must be treated as if they have one, even if the radiologic evaluation is normal. (See "Spinal cord injury without radiographic abnormality (SCIWORA) in children", section on 'Initial management'.)

Indications — Based upon observational studies in children [3,8,17-19,28] and mixed populations of adults and older children (mostly ≥8 years of age) [29], we recommend that patients with concern for traumatic injury and any one of the following findings undergo cervical spine imaging:

Neck pain

Midline posterior neck tenderness

Decreased neck range of motion

Torticollis

Altered mental status (GCS score <14 (table 7)) either due to trauma or intoxication

Focal neurologic finding

Substantial co-existing injury, especially torso injuries

Predisposing conditions such as Down syndrome, cervical arthritis, or Ehlers-Danlos syndrome (see 'Predisposing conditions' above)

High-risk mechanisms:

MVC where patient partially or completely ejected from vehicle, passenger death, or passenger compartment intrusion >12 inches at roof and/or >18 inches at any site

Diving

Hanging

Axial load force

Clotheslining force

A multicenter, retrospective case-control study conducted in the Pediatric Emergency Care Applied Research Network (PECARN) that compared 540 children (0 to 15 years of age) with cervical spine injuries to almost 3000 control patients found that eight of the nine findings listed above identified cervical spine injury with a sensitivity of 98 percent (95% CI 96 to 99 percent) and specificity of 26 percent (95% CI 23 to 29 percent) [17]. In the PECARN study, midline posterior neck tenderness was not independently associated with cervical spine injury and was not included in the prediction model. Stratified analysis of these results by age found that the high sensitivity of these eight findings was maintained for the 167 children who had cervical spine injuries and were younger than eight years of age [18]. The PECARN risk factors are further supported by a prospective observational study conducted at four pediatric trauma centers that included over 4000 children with blunt trauma, 74 of whom had cervical spine injuries [19]. We retain midline posterior neck tenderness as a high-risk criterion because it has been useful for identifying cervical spine injuries in adult populations. (See "Cervical spinal column injuries in adults: Evaluation and initial management", section on 'Clinical decision rules'.)

Although widely used and highly accurate in adults and the source of some pediatric cervical spine clearance guidelines [30,31], the National Emergency X-ray Utilization Study (NEXUS) and Canadian clinical decision rules may have insufficient sensitivity for excluding cervical spine injury in children, especially patients younger than nine years of age [32,33]. In the prospective NEXUS study, low-risk criteria consisting of no posterior midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no painful, distracting injury identified cervical spine injury in 30 of over 3000 pediatric trauma patients with a sensitivity of 100 percent (95% CI 88 to 100 percent) and a negative predictive value of 100 percent (95% CI 99.2 to 100 percent, prevalence of pediatric cervical spine injury 1 percent). However, only four children younger than nine years of age and none younger than two years of age were included in the cohort which limits the applicability of these results in younger children. Furthermore, given the low numbers of children of any age with cervical spine injury in the NEXUS study, the lower limit of sensitivity of 88 percent on the confidence interval raises questions about applicability in older children as well.

Similarly, in a retrospective study of the Canadian cervical spine rule in patients 10 years of age or younger, it achieved a sensitivity of only 86 percent [34]. Application of either the NEXUS or Canadian cervical spine rules to skeletally mature adolescents may have adequate sensitivity to aid in imaging decisions. The components of these rules and evidence regarding their use in adults is discussed in detail separately. (See "Cervical spinal column injuries in adults: Evaluation and initial management", section on 'Clinical decision rules'.)

Choice of study — The clinical findings that direct radiologic evaluation in children with blunt trauma are summarized in the table (table 9). A child with a normal physical examination and an evaluation that otherwise indicates a low risk for cervical spine injury may be clinically cleared without diagnostic imaging (algorithm 1). The approach to imaging varies depending upon whether the patient has a reliable (algorithm 2) or unreliable examination (algorithm 3). (See 'Cervical spine clearance' below.):

Plain radiographs – Plain cervical spine radiographs are the initial radiologic study to evaluate for cervical spine injury in most children with normal mental status [35]. Plain radiographs have adequate sensitivity to identify or exclude unstable cervical spine fractures or dislocations, especially in awake children with reliable physical examinations (see 'Plain radiographs' below). Plain radiographs expose the patient to much less radiation than CT as discussed in greater detail below.

Computed tomography of the spine – In children with a GCS score <9 (table 7) or neurologic deficit on physical examination, imaging with CT of the cervical spine instead of plain radiographs is indicated.

CT may also be appropriate as the initial study in children with a GCS score of 9 to 12 (table 7) who require urgent CT of the brain.

Although some experts suggest CT of C1-C3 in all children eight years of age and younger who are undergoing head CT, regardless of findings on plain radiographs and neurologic examination [35], some clinicians may choose to only perform CT in those children in whom an adequate odontoid view cannot be obtained and to restrict imaging to C1-C2.

A CT should also be obtained in any of the following circumstances (table 9) [36,37]:

Inadequate cervical spine radiographs (three views in children over three years of age, inadequate lateral or open-mouth view in children under three years of age), if there is a high likelihood of injury based upon the combination of injury mechanism and physical findings. (See 'Indications' above.)

Suspicious or documented plain radiographic findings of fracture or dislocation

High-clinical index of suspicion based upon injury mechanism and physical findings despite normal radiographs

If CT is required because of inadequate plain radiographs, the study should ideally be limited to the vertebra of concern rather than imaging the entire cervical spine whenever feasible. Furthermore, the radiation dose should be adjusted according to the "as low as reasonably achievable" (ALARA) principle.

This approach to the use of CT for pediatric cervical spine imaging balances the potential long-term risk of radiation exposure and cost of the study with the need for diagnostic certainty in severely injured patients. A helical cervical spine CT delivers a 50 percent increase in mean radiation dose to the cervical spine in pediatric patients relative to conventional radiography [38]. In addition, the radiation dose to the skin and thyroid for CT evaluation of the cervical spine is approximately 10 times and 14 times, respectively, that of a five-view cervical spine series [39,40] and is even further magnified when compared to the standard three-view cervical spine series used in trauma patients. Children, especially those younger than five years, are more prone to radiation-induced malignancies due to increased radiosensitivity of certain organs and a longer latency period to develop a cancer [41]. Estimated lifetime cancer mortality risks attributable to the radiation exposure from a CT for a one year old is approximately 0.07 to 0.18 percent, which is a risk that is an order of magnitude higher than that for adults who are exposed to a CT of the cervical spine [42]. Thus, the risk of radiation exposure exceeds the benefit of CT imaging in the majority of children evaluated for cervical spine injury, except for those with a higher likelihood of abnormality as determined by the initial evaluation.

Magnetic resonance imaging – MRI should be performed in patients with an abnormal neurologic examination or when imaging of the spinal cord or other soft tissues of the spinal column is required [35]. MRI is less sensitive than CT for the detection of fractures of the posterior elements of the cervical spine and injuries to the craniocervical junction. The performance of an MRI in severely injured children is hampered by the extended time needed for the study, the requirement for sedation or anesthesia to perform the study in most children, the need for compatible equipment (eg, monitors and ventilators), and limited access to the patient during the study. The capability and limitations of MRI for cervical spine injuries are discussed in greater detail separately. (See "Suspected cervical spine injury in adults: Choice of imaging", section on 'Further evaluation with magnetic resonance imaging'.)

Spinal MRI may also be performed for documentation of the full extent of injury in children who are victims of abusive head trauma. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Associated injuries'.)

Additional imaging in patients with abnormal studies — Children who have sustained multiple trauma and have abnormalities on cervical spine imaging should also undergo radiologic assessment of the thoracolumbar spine. The mode of imaging depends upon the mechanism of injury and physical findings. For example, plain radiographs may be sufficient in neurologically intact patients for whom examination of the thoracic and lumbar spine does not identify pain or deformity whereas CT of the relevant region may be necessary in patients with a neurologic examination that identifies a spinal cord level of deficit (table 8). Specific imaging is best guided by a pediatric spine surgeon.

Utility and interpretation — As discussed above, the mechanism of injury may predict the type of injury. Radiographs must be evaluated carefully for injuries located in the axial cervical spine (occiput to C2), including odontoid fractures, atlantoaxial dislocations or subluxations, and hyperextension fractures of the axis.

Plain radiographs — The three-view spine series (cross-table lateral, AP, and, when obtainable, open-mouth odontoid) provides a reasonable assessment of cervical spine integrity for the majority of injured children [43]. Observational studies in children indicate a sensitivity of 79 percent for the cross-table lateral view [9]. Sensitivity increases to 90 percent (95% CI 85 to 94 percent) with the addition of at least one other view (AP or odontoid) [44,45]. Addition of oblique views does not significantly improve sensitivity for clinically important abnormalities and is not recommended [46-48]. Obtaining a suitable cervical spine series is extremely important; the most frequent cause of a missed or unappreciated vertebral body injury is an inadequate film series [49].

The interpretation of cervical spine radiographs in children may be difficult. Although the bony anatomy of the pediatric cervical spine is similar to that of an adult by 8 to 10 years of age, radiographic findings may differ until 15 years of age. In younger children, avulsions and epiphyseal separation are more common than are fractures. Furthermore, normal anatomic variants of the cervical spine in children (such as absence of cervical lordosis, incomplete ossification of the posterior elements, ligamentous laxity, and pseudosubluxation of C2 on C3 (figure 6)) must be distinguished from pathological findings (table 10) [15,50-52].

Lateral view — Complete evaluation of the lateral cervical spine requires that all seven cervical vertebrae be visualized. Gentle traction on the arms or a transaxillary (swimmer's) view may be necessary to bring C7 and T1 into view. However, the swimmer’s view should not be performed if there is a high suspicion of cervical spine injury. The bony integrity, alignment, and cartilaginous and soft tissue spaces of the cervical spine should be systematically evaluated. Any abnormality of these elements indicates the possibility of a fracture and/or ligamentous injury.

Bony structures of the cervical spine can be readily identified on a lateral radiograph. The following abnormalities indicate a cervical spine injury:

Fractures, displacements, subluxations, and dislocations (image 1 and image 2)

Alterations of height or uniformity of disc spaces (image 4)

Overriding of the facets

Rotation of the spinous processes of the vertebral bodies

Disruption of the alignment of the four curvilinear cervical spine contour lines (the anterior vertebral body line, the posterior vertebral body line, the spinolaminar line, and the tips of the spinous processes) identified on a lateral radiograph may indicate one of the following (figure 7):

Muscle spasm can cause disruption of the lordotic curve. However, lordosis may be normally absent in children up to the age of 15 years and for those that are imaged in collars or in supine positioning.

Pseudosubluxation (C2 on C3 only) can be differentiated from true subluxation by evaluating the posterior cervical (Swischuk) line between the anterior aspects of the C1 and C3 spinous processes (figure 6) [53]. True subluxation should be suspected if the posterior cervical line misses the anterior aspect of the C2 spinous process by 2 mm or more.

With ligamentous disruption, the tips of the spinous processes may not align uniformly.

An unstable occipitoatlantoaxial injury, which is associated with disruption of the tectorial membrane, is suggested when the distance between the spinous processes of C1 and C2 is increased [54]. In a retrospective review describing children with occipitoatlantoaxial injury, an interspinous ratio (C1-2:C2-3) was calculated by measuring the shortest distance between the inferior cortex of the spinous process of C1 and the superior cortex of the spinous process of C2 (C1-C2) and dividing it by the shortest distance between the inferior cortex of the C2 spinous process and the superior cortex of the C3 spinous process (C2-C3) (figure 8). A ratio of 2.5 or more had a sensitivity of 87 percent and a specificity of 100 percent for detecting tectorial membrane injury [16,55].

Soft tissue spaces that should be evaluated on a lateral cervical spine radiograph include the predental space and the prevertebral space. The predental space is between the anterior arch of C1 and the odontoid process (dens) of C2. The distance between these landmarks is called the atlantodental index (ADI). In children younger than eight years, the ADI should be no more than 5 mm (3 mm in adults) (figure 7). The prevertebral space is located between the prevertebral fascia anteriorly and the vertebral bodies and longus colli posteriorly. The prevertebral space at C3, C4 should be no more than one-third the AP diameter of the vertebral body (7 mm in adults) [56,57].

Widening of the predental space suggests underlying blood or edema, often secondary to atlantoaxial instability or a burst fracture of C1 (Jefferson fracture) (image 7).

Widening of the prevertebral space suggests hematoma, abscess, or bony injury. However, the space also may appear widened in exhalation (crying child), flexion (uncooperative child), or the presence of a nasogastric or endotracheal tube.

Anterior-posterior view — The anterior-posterior (AP) view may identify lateral mass fractures that are not identified on lateral films (eg, isolated oblique pillar or isolated transverse process fractures). In this view, the spinous processes should be well aligned in the midline.

Loss of vertebral body height may also be apparent in patients with compression fractures (image 4).

Odontoid view — The odontoid process (dens) and body of C2 between the lateral masses of C1 are best visualized with the open-mouth odontoid view in children ≥9 years of age [58-60] and through the foramen on the Waters' view in younger children who cannot cooperate with an open-mouth view.

The dens should be examined for any longitudinal or transverse fractures. The lateral aspects of C1 should be symmetric, and they should have equal amounts of space on both sides of the dens. The lateral aspects of C1 also should line up with the lateral aspects of C2.

Odontoid fractures are classified according to their location:

Type 1 – Apex of the dens

Type 2 – The waist of the dens (most common)

Type 3 – Extending into the body of C2

Bilateral widening between the dens and the lateral masses suggests a fracture of the ring of C1 (Jefferson fracture) (figure 4 and image 3).

Atlantoaxial rotatory subluxation, one of the most common cervical spine injuries in children, may be suggested on the odontoid view when there is normal alignment of the lateral aspects of C1 and C2, but asymmetry in the spaces between the dens and the C1 lateral masses. With rotatory subluxation of C1 on C2, the dens is pulled closer to the affected side. This finding can also occur normally when the head is tilted or turned during imaging. The definitive diagnosis of atlantoaxial rotatory subluxation is made using dynamic CT or MRI and is often deferred to the outpatient setting, as it is usually a benign self-limiting process. (See "Acquired torticollis in children".)

Flexion-extension views — Flexion-extension plain radiograph views usually add little to the acute evaluation of patients with blunt trauma [35,61]. In the past, these views were used to identify cervical instability, atlantoaxial joint instability, and ligamentous injuries [62,63]. They may be useful in the rare instances when the three-view cervical spine series and CT are negative despite the presence of cervical pain, tenderness, or spasm. In the NEXUS study described above, 2 of the 818 patients with cervical spine injuries had stable bony injuries that were detected only with flexion-extension views. Another four patients had subluxation detected on flexion-extension views; they all had other injuries that were apparent with routine cervical spine imaging.

Flexion-extension views require the cooperation of the patient; they must be done only with active flexion and extension that is stopped if the patient has pain. Passive or painful flexion or extension should never be performed because they may precipitate or worsen spinal cord injury. Obtaining radiographs subacutely, after muscle spasm subsides, may be necessary to detect occult ligamentous injury [64].

Computed tomography — The sensitivity and specificity of CT for detecting cervical spine bony injury are 98 percent or better [65,66]. It is therefore a valuable adjunct for identifying an injury in selected pediatric patients as described above. (See 'Indications' above.)

Multidetector CT with sagittal and coronal reconstructions is the recommended study. Cervical spine CT images should be read by a radiologist or spine surgeon either of whom should have pediatric expertise.

Magnetic resonance imaging — MRI is the imaging procedure of choice in any patient with neurologic signs or symptoms and normal plain radiographs and/or CT [67]. MRI is superior to CT for visualizing soft tissues and identifying intervertebral disk herniation, ligamentous injuries and spinal cord edema, hemorrhage, compression, and transection [68-75]. SCIWORA was defined in 1982 as objective signs of myelopathy as a result of trauma in the absence of findings on plain radiographs, flexion-extension radiographs, and cervical CT. However, with MRI, most cases previously described as SCIWORA have demonstrable injury to the spinal cord or spinal ligaments. (See "Spinal cord injury without radiographic abnormality (SCIWORA) in children", section on 'Radiologic evaluation'.)

MRI has limited utility in the emergency setting because it is not available in many centers, may require the child to be sedated given the long imaging time, and does not permit easy access to the critically ill child during the study.

CERVICAL SPINE CLEARANCE — A systematic review has led to consensus cervical spine clearance guidelines for children with reliable (algorithm 2) and unreliable physical examinations (algorithm 3) [35].

It is possible to clinically clear children of all ages without radiographs when the history does not identify a predisposition to cervical spine injury and there is a normal neurologic and neck examination (algorithm 1 and table 9). Special attention should be paid to the neurologic exam of the infant and young child. (See "Detailed neurologic assessment of infants and children", section on 'Neurologic examination'.)

In a retrospective observational study of over 1000 children, younger than 21 years of age, that evaluated a cervical spine clearance algorithm similar to the consensus guidelines above, the sensitivity of the algorithm was 94 percent and the negative predictive value was 99.9 percent when the prevalence of cervical spine injury was 1.7 percent [76]. Computed tomography of the neck was obtained in 10 percent of all patients and in 3 percent of the 135 children younger than three years of age. One injury was missed; a low cervical spinous process fracture in a teenager who was maintained in a collar.

DEFINITIVE MANAGEMENT AND DISPOSITION — The disposition of children with cervical spine injuries primarily depends upon fracture stability and concomitant injuries. 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.

Treatment of unstable cervical fractures consists of closed reduction under fluoroscopic guidance and halo-vest immobilization. The halo is constructed of graphite or metal and is secured to the frontal and parietal areas of the skull with metal pins. The halo is the most common device applied for treatment of unstable cervical and upper thoracic fractures and dislocations as low as T3 [77].

If plain radiographs or computed tomography (CT) demonstrate minor spinal fracture patterns and there is no neurologic deficit, then outpatient management may be possible, depending upon the extent of other injuries. Isolated spinous process and transverse process fractures identified by CT appear to be one example of fractures suitable for conservative management [78,79]. Treatment should include analgesics, and follow-up care should be arranged in all instances because even minor spinal column injuries may be associated with prolonged disability. If there is any ambiguity regarding spinal stability on plain radiographs, spine surgery consultation is warranted and a CT scan (and possibly an MRI if ligamentous injury is suspected) should be obtained.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cervical spine injury".)

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 5th to 6th 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 10th to 12th 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 topic (see "Patient education: Neck fracture (The Basics)")

SUMMARY AND RECOMMENDATIONS

Stabilization

Spinal motion restriction – During the initial assessment and management, the clinician must suspect a cervical spine injury in any patient with multiple blunt trauma and take precautions to limit spine motion during the primary and secondary surveys, especially in patients with significant head, neck, or torso trauma or with an altered level of consciousness. (See 'Spinal motion restriction (spinal immobilization)' above.)

Airway – In patients who cannot maintain their airway, the clinician should employ a jaw thrust (figure 2) or chin lift to open the airway while maintaining the cervical spine in neutral position. When indicated by altered mental status or inadequate respiration, rapid sequence intubation by the orotracheal route (table 2) should be performed with in-line cervical spine stabilization by an assistant (figure 3). (See 'Airway management' above.)

Spinal shock – Transient loss of spinal cord function can occur following spinal injury. Clinicians must assume that hypotension following trauma results from hemorrhage and ensure appropriate fluid resuscitation. Nevertheless, neurogenic shock from spinal cord injury (usually to the superior portion of the spinal cord) may cause hypotension requiring vasoactive medication infusions and bradycardia necessitating atropine and/or pacing. (See "Acute traumatic spinal cord injury", section on 'Cardiovascular complications' and "Trauma management: Approach to the unstable child", section on 'Circulation'.)

Specialty consultation – Evidence of a significant cervical spine injury (eg, fracture through the synchondrosis of the dens, vertebral body fracture, or any injury associated with a neurologic deficit) requires emergency consultation with a pediatric spine surgeon or a spine surgery team (often staffed by pediatric orthopedists and pediatric neurosurgeons) to guide supportive and definitive management of the injury. If consultation is not available onsite, immediate transfer must be arranged to a pediatric trauma center that can provide these services. (See 'Specialty consultation' above.)

Evaluation – Cervical spine injury must be suspected in all children who are severely injured or have high-risk injuries. Serious head injury and multiple-system trauma are associated with spinal injuries. In addition, cervical spine injury should be suspected in those children who have an underlying predisposition to such injuries. (See 'History' above.)

The classic triad of neck symptoms includes localized posterior cervical pain, muscle spasm, and decreased range of motion of the neck. Patients also may complain of early or immediate transient or persistent paresthesias, numbness, or weakness. The distribution of transient symptoms is variable and ranges from involvement of the hands or feet to dramatic neurologic deficits, including quadriplegia. (See 'Symptoms' above and 'Physical examination' above.)

The principal elements of the physical examination of a child suspected of having a cervical spine injury include the vital signs, neck examination, and neurologic examination. The cervical collar may be removed for examination, with the maintenance of manual cervical spine motion restriction. The collar must be replaced, and radiologic evaluation must be performed if any signs or symptoms suggestive of cervical spine injury are detected during the examination. (See 'Physical examination' above.)

Cervical spine imaging – We recommend that patients with concern for traumatic injury and any one of the following findings undergo cervical spine imaging (see 'Indications' above):

Neck pain

Midline posterior neck tenderness

Decreased neck range of motion or torticollis

Altered mental status (Glasgow coma scale score <14 (table 7)) either due to trauma or intoxication

Focal neurologic finding

Substantial co-existing injury, especially torso injuries

Predisposing conditions (see 'Predisposing conditions' above)

High-risk mechanisms:

-MVC (motor vehicle collision; partially or completely ejected from vehicle, passenger death, or passenger compartment intrusion >12 inches at roof and/or >18 inches at any site)

-Diving

-Hanging

-Axial load force

-Clotheslining force

The clinical findings that direct radiologic evaluation in children with blunt trauma are summarized in the table (table 9). A child with a normal physical examination and an evaluation that otherwise indicates a low risk for cervical spine injury may be clinically cleared without diagnostic imaging (algorithm 1). Cervical spine clearance in children who can cannot be clinically cleared depends upon the mental status and age (algorithm 2 and algorithm 3).Children who have sustained multiple trauma and have abnormalities on cervical spine imaging should also have radiologic assessment of the thoracolumbar spine. (See 'Choice of study' above and 'Additional imaging in patients with abnormal studies' above.)

Disposition – The disposition of children with cervical spine injuries is determined by cervical spine stability and concomitant injuries. A pediatric spine surgeon and team should provide definitive care for all children with neurologic abnormalities on examination or potentially unstable cervical spine injuries on imaging. (See 'Definitive management and disposition' above and 'Additional imaging in patients with abnormal studies' above.)

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

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