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

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 (C-spine) injury is rare in children, occurring in 1 to 2 percent of pediatric blunt trauma patients [1-5]. The major causes of C-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 other object exerting traction on or striking the neck while the body is in forward motion)

●Multisystem 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 C-spine trauma and outcomes. The majority of C-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 C-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 C-spine (C3 to C7) is the site of injury in just over half of patients.

C-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 (C-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 C-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 C-spine.

●They have immature vertebral joints and horizontally inclined articulating facets that facilitate sliding of the upper C-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 C-spine; such injuries are less common in children younger than eight years of age [12,15,16].

Anatomy of the C-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 (C-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 C-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 C-spine position in the infant or young child (figure 1). Note that this positioning is markedly different from adults, for whom padding under the head is frequently required to achieve neutral C-spine position. (See "Pediatric cervical spinal motion restriction".)

Airway management — The emergency clinician should anticipate airway management problems in children with C-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 C-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 C-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 C-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 'Hemodynamic management' and "Trauma management: Approach to the unstable child", section on 'Circulation'.)

Specialty consultation — Evidence of a significant C-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 (C-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 C-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 C-spine injury in all children who are severely injured or have high-risk injuries such as high-risk motor vehicle collision (MVC; with 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 and torso trauma are associated with spinal injuries.

C-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 appropriate to suspect C-spine injury based upon the mechanism of injury because they typically are unable to provide a history and cooperate with the examination [21]. (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 C-spine or of the vertebral bodies in the lower C-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 rotatory 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. (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 C-spine injury.

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 C-spine injury (table 4). Furthermore, bilateral sensory symptoms (eg, paresthesia, hyperesthesia, dysesthesia, or numbness) suggest C-spine injury, not brachial plexus injury [22]. (See "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete", section on 'Cervical burners'.)

The absence of symptoms at the time of evaluation does not exclude C-spine injury:

●No symptoms – 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 C-spine injury, 10 patients were initially asymptomatic on evaluation. However, all asymptomatic patients had both a high-risk injury mechanism and comorbid injuries from multisystem trauma [9].

●Transient symptoms – 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 C-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 C-spine injury. (See "Spinal cord injury without radiographic abnormality (SCIWORA) in children", section on 'Clinical features and diagnosis'.)

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 — C-spine injury should be suspected in children who have an underlying predisposition to such injuries, even with trivial mechanisms of injury [23-26]:

●History of C-spine surgery

●History of C-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 C-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 examination elements for patients with a potential C-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 C-spine injury (algorithm 1). Spinal motion restriction should be maintained for children with signs or symptoms of C-spine injury, and appropriate diagnostic imaging obtained. (See 'Cervical spine clearance' below and '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 C-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 'Clinical indications for imaging' 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 C-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 [27,28]. 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 syndrome results from disruption of the sympathetic chain. It is associated with ipsilateral ptosis, miosis, and anhidrosis. (See "Horner syndrome".)

Clinical indications for imaging — Observational studies in children with concern for C-spine injury performed by the Pediatric Applied Research Network (PECARN) have identified specific clinical findings associated with C-spine injury in children [17-19]. Based upon this evidence, patients with concern for traumatic injury and any one of the following findings should undergo C-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 or child abuse, especially patients with abusive head trauma

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

●High-risk mechanisms:

•Diving

•Hanging

•Axial load force

•Clotheslining force

•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

The specific findings determine the choice of study (table 9). (See 'Cervical spine clearance' below and 'Choice of study' below.)

Clinical prediction rules derived from the PECARN studies have demonstrated high sensitivity and negative predictive value for C-spine injury. For example, in a prospective observational study of over 4000 children (1.8 percent with C-spine injury), seven risk factors achieved a sensitivity of 92 percent (95% CI 86-98 percent) and a negative predictive value of 99.7 percent (95% CI 99.5-99.9 percent) and, if used for clinical decision-making, had the potential to markedly reduce C-spine imaging [19].

CERVICAL SPINE CLEARANCE — During evaluation of trauma patients, the clinician must quickly determine if there is concern for cervical spine (C-spine) injury based upon history, physical examination, and/or imaging or if clinical findings indicate an absence of injury that permits removal of cervical spinal motion restriction.

A child with a Glasgow Coma Scale (GCS) scale score ≥14, a normal physical examination, and an evaluation that otherwise indicates a low risk for C-spine injury may be clinically cleared without diagnostic imaging (algorithm 1). Otherwise, C-spine imaging is necessary. (See 'Clinical indications for imaging' above and 'Cervical spine imaging' below.)

To determine the need for and choice of C-spine imaging in children with blunt trauma, we advise use of consensus pediatric C-spine clearance guidelines [29,30]. The consensus guidelines developed by the Pediatric C-spine Clearance Working Group (PCSCWG) of the Pediatric Orthopedic Society of North America is our preferred approach (algorithm 2) [29]. Use of the Trauma Association of Canada (TAC) consensus guidelines for reliable (algorithm 3A) and unreliable (algorithm 3B) physical examination is a reasonable alternative [30].

Both guidelines emphasize that it is possible to clinically clear children of all ages without radiographs when the history does not identify a predisposition to C-spine injury and there is a normal neurologic and neck examination (algorithm 1 and algorithm 2 and table 9) [29,30]. The clinician should pay special attention to the neurologic examination in infants and young children. (See "Detailed neurologic assessment of infants and children", section on 'Neurologic examination'.)

When it is not possible to clinically clear the pediatric trauma patient, both guidelines recommend the use of plain radiographs (cross-table lateral C-spine at minimum) as the initial study of choice in children with GCS scores of 14 to 15 [29,30]. They also recommend computed tomography (CT) of the C-spine for children with unreliable examinations and/or a GCS score ≤8; the PCSCWG differs from the TAC guidelines by suggesting plain radiographs for children with GCS scores 9 to 13 and a potential to improve to 14 or 15 [29]. In addition, the PCSCWG guidelines deemphasize the mechanism of injury except for the following mechanisms: non-accidental trauma (child abuse), diving, axial load, clothes-lining, and high-risk motor vehicle collisions (MVCs).

Two studies have evaluated the ability of these approaches to identify C-spine injury but limit excessive C-spine imaging (especially CT):

●PCSCWG – In a trauma registry study that compared C-spine clearance and imaging before and after implementation of the PCSCWG clearance guidelines in 359 children with concern for C-spine injury (CSI), protocol implementation was associated with more clinical clearance (43 versus 15 percent) and significantly fewer radiographs (55 versus 72 percent) or CT scans (5 versus 15 percent) [31]. No CSI was missed in either time period (prevalence of CSI 2 to 3 percent). Protocol adherence was 87 percent.

●TAC – These consensus guidelines provide guidelines for children with reliable and unreliable physical examinations [30]. In a retrospective observational study of over 1000 children that evaluated a C-spine clearance algorithm similar to the TAC consensus guidelines, the sensitivity of the algorithm was 94 percent, and the negative predictive value was 99.9 percent when the prevalence of C-spine injury was 1.7 percent [32]. 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.

CERVICAL SPINE IMAGING — Children with suspected cervical spine (C-spine) injury based upon history or physical examination should undergo C-spine imaging. (See 'Clinical indications for imaging' above.)

Choice of study — The clinical findings direct the choice of C-spine imaging in children with blunt trauma, as summarized in the table (table 9). A child with a normal physical examination and an evaluation that otherwise indicates a low risk for C-spine injury may be clinically cleared without diagnostic imaging (algorithm 1).

Plain C-spine radiographs are the initial radiologic study to evaluate for C-spine injury in most children with normal mental status [30]. Plain radiographs have adequate sensitivity to identify or exclude unstable C-spine fractures or dislocations, especially in awake children with reliable physical examinations. Radiographs expose the child to much less radiation than CT. (See 'Plain radiographs (cervical spine series)' below and 'Computed tomography' below.)

Plain radiographs (cervical spine series) — The three-view C-spine series (cross-table lateral, anterior-posterior [AP], and, when obtainable, open-mouth odontoid) provides a reasonable assessment of C-spine integrity for the majority of injured children [33].

Diagnostic accuracy — 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) [34,35]. Addition of oblique views does not significantly improve sensitivity for clinically important abnormalities and is not recommended [36-38].

Lateral view — Complete evaluation of the lateral C-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 C-spine injury. Any abnormality of these elements indicates the possibility of a fracture and/or ligamentous injury. Obtaining an adequate view is extremely important; an inadequate film series is the most frequent cause of a missed or unappreciated C-spine vertebral body injury [39].

Interpretation of the cross-table lateral C-spine radiograph requires systemic evaluation of the bones, vertebral body alignment, and soft tissue spaces:

●Bones – Bony structures of the C-spine can be readily identified on a lateral radiograph. The following abnormalities indicate a C-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

●Alignment – Disruption of the alignment of the four curvilinear C-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 6):

•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 who 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 7) [40]. 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 [41].

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 [16,42].

●Soft tissue spaces – Soft tissue spaces of importance on a lateral C-spine radiograph include the:

•Predental 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 6).

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).

•Prevertebral space – 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) [43,44].

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 — In this view, the spinous processes should be well aligned in the midline. 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). 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 [45-47] 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 C-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 magnetic resonance imaging (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 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 [48].

Flexion-extension plain radiograph views usually add little to the acute evaluation of patients with blunt trauma [30,49]. In the past, these views were used to identify cervical instability, atlantoaxial joint instability, and ligamentous injuries [50,51] They may be helpful in rare cases in which the three-view C-spine series and CT are negative despite the presence of cervical pain, tenderness, or spasm.

For example, in a study over 800 patients with C-spine injuries, two individuals had stable bony injuries that were detected only with flexion-extension views [52]. Another four patients had subluxation detected on flexion-extension views; they all had other injuries that were apparent with routine C-spine imaging.

Computed tomography — Multidetector C-spine CT with sagittal and coronal reconstructions is the recommended study [53]. Based on consensus guidelines, C-spine CT is indicated in children with (table 9):

●Glasgow Coma Scale (GCS) score ≤8 (table 7) or neurologic deficit on physical examination instead of plain radiographs.

●GCS score of 9 to 12 who require urgent CT of the brain and have concern for C-spine injury.

●Abnormality on plain radiographs or a high index of suspicion due to having the combination of a severe injury mechanism and concerning physical examination findings despite normal C-spine radiographs [54,55].

●Inability to obtain adequate C-spine 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 C-spine whenever feasible. Furthermore, the radiation dose should be adjusted according to the "as low as reasonably achievable" (ALARA) principle. 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 [30], 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.

C-spine CT images should be read by a radiologist or spine surgeon either of whom should have pediatric expertise. The sensitivity and specificity of CT for detecting C-spine injury are 98 percent or better [56,57].

This approach to the use of CT for pediatric C-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. This is best accomplished by adopting institutional guidelines for obtaining C-spine CT in children after blunt trauma. Institutional practice should follow pediatric CT protocols to ensure that the radiation dose is adjusted according to the ALARA principle. A helical C-spine CT delivers a 50 percent increase in mean radiation dose to the C-spine in pediatric patients relative to conventional radiography [58]. In addition, the radiation dose to the skin and thyroid for CT evaluation of the C-spine is approximately 10 times and 14 times, respectively, that of a five-view C-spine series [59,60] and is even further magnified when compared with the standard three-view C-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 [61]. 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 C-spine [62]. Thus, the risk of radiation exposure exceeds the benefit of CT imaging in the majority of children evaluated for C-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 [30]. MRI is superior to CT for visualizing soft tissues and identifying intervertebral disk herniation, ligamentous injuries and spinal cord edema, hemorrhage, compression, and transection [63-70].

MRI is less sensitive than CT for the detection of fractures of the posterior elements of the C-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 C-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'.)

Spinal cord injury without radiographic abnormality (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'.)

THORACOLUMBAR SPINE IMAGING — Children who have sustained multiple trauma and have abnormalities on cervical spine (C-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.

DEFINITIVE CARE — Emergency consultation with a pediatric spine surgeon or spine surgery team (often staffed by pediatric orthopedists and pediatric neurosurgeons) is recommended for all children with neurologic abnormalities on examination or imaging that demonstrates potentially unstable cervical spine (C-spine) injuries (algorithm 2 and algorithm 3A and algorithm 3B).

If pediatric spine consultation is not available onsite, immediate transfer must be arranged to a center that can provide these services. Patients with unstable C-spine injuries 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.

Further care depends upon the type of injury:

●Cervical spine fracture – A pediatric spine surgeon or team should determine the definitive management of C-spine fractures in children based upon the neurologic examination and the specific injury seen on imaging:

•Cervical spine fractures with neurologic deficit – Children who have C-spine fractures, neurologic deficits on examination, and documented cervical spinal cord injury on imaging require surgical fracture fixation and spinal cord decompression. The surgical approach depends upon the degree and type of C-spine injury [71,72].

•Unstable cervical spine fractures – Unstable C-spine fractures may be treated with surgery followed by postoperative immobilization (typically halo-vest with the halo secured to the frontal and parietal areas of the skull with pins) or, for selected upper C-spine (C1 to C3) fractures, conservative treatment (halo-vest immobilization or halo traction) [71,73-75]. Several factors such as specific location, type of fracture, and patient age determine the preferred approach [71].

•Stable cervical spine fractures – If plain radiographs or CT demonstrate stable spinal fracture patterns and if there is no neurologic deficit, then outpatient management may be possible depending upon the extent of other injuries. Discussion with a pediatric spine surgeon should occur if there is any doubt as to the stability of the C-spine fracture prior to discharge.

Based on experience in adults, isolated spinous process and transverse process fractures identified by CT are examples of fractures potentially suitable for outpatient management with spine team management. Treatment should include analgesics, semi-rigid C-spine immobilization, and follow-up care with the spine team in all instances because even minor spinal column injuries may be associated with prolonged disability. (See "Cervical spinal column injuries in adults: Evaluation and initial management", section on 'Stable injury'.)

●Spinal cord injury without plain radiograph or CT abnormality (SCIWORA) – Children with clinical findings suggestive of spinal cord injury must be treated as if they have one, even if the radiologic evaluation by plain radiographs and/or CT is normal. The management is determined by physical examination and whether neurologic abnormalities are persistent or transient, as discussed separately. (See "Spinal cord injury without radiographic abnormality (SCIWORA) in children", section on 'Initial management'.)

●Traumatic atlantoaxial rotatory subluxation – Management of traumatic atlantoaxial rotatory subluxation (AARS) in children depends upon the type of subluxation, degree of pain, and presence of neurologic deficit. Traumatic AARS is uncommon in children. Children often have a delayed presentation with neck pain and torticollis after a fall. Most AARS is limited to rotatory fixation with no ligamentous damage and is managed conservatively. (See "Acquired torticollis in children", section on 'Atlantoaxial rotatory subluxation'.)

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 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 topic (see "Patient education: Neck fracture (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Stabilization

•Spinal motion restriction – The clinician should suspect a cervical spine (C-spine) injury in any child with blunt trauma and provide C-spine motion restriction during evaluation, especially in patients with altered mental status or significant head, neck, or torso trauma. (See 'Spinal motion restriction (spinal immobilization)' above.)

•Airway – In patients who cannot maintain their airway, the clinician should use a jaw thrust (figure 2) or chin lift to open the airway while maintaining the C-spine in neutral position. For patients who require rapid sequence intubation (RSI), the clinician should ensure in-line C-spine stabilization by an assistant (figure 3) during the procedure. (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 (see "Trauma management: Approach to the unstable child", section on 'Circulation'). Nevertheless, neurogenic shock from spinal cord injury may cause bradycardia and hypotension requiring atropine, vasoactive medications, and and/or pacing. (See "Acute traumatic spinal cord injury", section on 'Hemodynamic management'.)

•Specialty consultation – Children with C-spine injury require 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. If consultation is not available onsite, immediate transfer must be arranged to a trauma center that can provide these pediatric services. (See 'Specialty consultation' above.)

●Evaluation – The clinician should suspect C-spine injury in all children with high-risk mechanisms, neck or neurologic symptoms, or predisposing conditions. (See 'History' above.)

Physical examination of a child with possible C-spine injury includes the vital signs, neck examination, and neurologic examination with assessment of a Glasgow Coma Scale (GCS) score (table 7). The cervical collar may be removed for neck examination while maintaining manual C-spine motion restriction (figure 3). (See 'Physical examination' above.)

●Cervical spine clearance – Consensus guidelines for pediatric C-spine clearance include (see 'Cervical spine clearance' above):

•PCSCWG – The pediatric C-spine clearance working group (PCSCWG) of the Pediatric Orthopedic Society of North America is our preferred approach (algorithm 2).

•TAC – The Trauma Association of Canada (TAC) consensus guidelines for reliable and unreliable physical examination (algorithm 3A-B) are reasonable alternatives to the PCSCWG approach.

Children with a normal mental status (GCS score ≥14), normal neck and neurologic examinations, and no other risk factors for C-spine injury may be cleared without imaging (algorithm 1).

●Cervical spine imaging

•Clinical indications – Pediatric trauma patients with any one of the following findings should undergo C-spine imaging (see 'Clinical indications for imaging' above):

-Neck pain

-Midline posterior neck tenderness

-Decreased neck range of motion or torticollis

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

-Focal neurologic finding

-Substantial co-existing injury, especially head and torso injuries

-Predisposing conditions (see 'Predisposing conditions' above)

-High-risk mechanisms (motor vehicle collision [MVC] with partial or complete ejection 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; child abuse)

•Choice of study – For children with indications for C-spine imaging, the choice of imaging study is based upon clinical findings (table 9). The three-view C-spine series (cross-table lateral, anterior-posterior [AP], and, when obtainable, open-mouth odontoid) is the preferred initial imaging study for most pediatric trauma patients with a normal mental status. (See 'Choice of study' above and 'Plain radiographs (cervical spine series)' above.)

Children with a GCS score ≤8, neurologic deficit, or abnormality on plain radiographs should undergo multidetector C-spine computed tomography (CT) with sagittal and coronal reconstructions. CT is also indicated in children with GCS score 9 to 12 who require urgent brain CT. (See 'Computed tomography' above.)

When CT is performed because of inability to obtain adequate plain radiographs, the study should restrict imaging to the non-visualized region (eg, C1 or C-6 to C-7) rather than the entire C-spine.

C-spine MRI should be performed in patients with abnormal neurologic examinations or for imaging of the spinal cord or other soft tissues. (See 'Magnetic resonance imaging' above.)

Children who have sustained multisystem trauma and have abnormalities on C-spine imaging should also have imaging of the thoracolumbar spine. (See 'Thoracolumbar spine imaging' above.)

●Definitive care – A pediatric spine surgeon and team should provide definitive care and determine disposition for all children with blunt trauma and any one of the following (see 'Definitive care' above):

•C-spine fractures and neurologic deficit

•Potentially unstable C-spine fractures

•Stable C-spine fractures that have the potential to become unstable or cause delayed spinal cord injury

•Normal imaging but clinical findings of spinal cord injury (SCIWORA)

For children with selected stable C-spine fractures (eg, isolated spinous or transverse process fractures) and no neurologic deficits on physical examination), we suggest conservative outpatient management (Grade 2C). This treatment consists of a semi-rigid cervical collar (eg, Philadelphia or Miami J collar) and analgesia (eg, ibuprofen or acetaminophen). These patients require assured follow-up with the spine surgery team, typically within 1 to 2 weeks. Prior to discharge, consultation with a pediatric spine surgeon should occur if there is any doubt as to fracture stability.

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