Summary of indications for radiologic evaluation of the cervical spine in children and adolescents with blunt trauma

Radiologic study	History and physical
None	Low risk mechanism of injury, and
	No multiple system trauma with comorbid injuries to head, face, or torso and no high-risk biomechanics^, and*
	No conditions that predispose to cervical spine injury^¶, and
	Awake (GCS 15) and able to verbalize and cooperate with exam, and
	No neck pain, tenderness, deformity, or limitation of movement,^Δ and
	No neurologic deficits
Lateral, AP, odontoid radiographs^◊	High-risk mechanisms of injury or biomechanics^*, or
	Multiple system trauma with comorbid injuries to head, face, or torso, or
	Conditions that predispose to cervical spine injury^¶, or
	Altered mental status (GCS 14), or
	Neck pain, tenderness, deformity, or limitation of movement
Computed tomography of the C-spine	Acute neurologic deficit (instead of plain films), or
	As part of initial evaluation of severe head trauma (GCS 3 to 13) instead of plain films, or
	Abnormal or suspicious C-spine on plain films, or
	High index of suspicion for C-spine injury despite normal plain cervical radiographs
Flexion-extension radiographs^§	Normal C-spine films, and
	No neurologic deficit referable to C-spine, and
	Continued neck pain, tenderness, or muscle spasm, and
	Able to actively flex and extend neck for the examination
MRI	Children with an abnormal neurologic examination and those requiring imaging of the soft tissues of the spinal column and spinal cord (eg, patients with normal plain films but persistent concern for neurologic injury based upon history, patients with prolonged loss of consciousness in whom cervical spine cannot be cleared by 24 to 72 hours post injury)

GCS: Glasgow coma scale.
* High-risk motor vehicle crashes (speed >55 mph, death of occupant, partial or complete ejection, and intrusion into the passenger compartment [12 inches at sides 18 inches at roof]), diving, or mechanisms associated with axial load to the head, hyperextension or hyperflexion of the neck, or acceleration-deceleration of the head. Patients with painful injuries not due to high risk mechanisms for cervical spine injury (eg, isolated extremity fracture despite low force mechanism) may still undergo clinical clearance.
¶ For example, Down syndrome, Klippel Feil syndrome, Morquio syndrome, Larsen syndrome, ankylosing spondylitis, cervical arthritis, prior cervical spine injury, or cervical spine surgery.
Δ Able to move head in flexion and extension and rotate 45 degrees to both sides without pain.
◊ Odontoid plain radiographs may be omitted in uncooperative children. However, children with possible upper cervical spine injury by history or physical examination, should undergo computed tomography of C1.
§ If biomechanics of injury and clinical findings do not indicate a high index of suspicion for ligamentous injury, flexion-extensions radiographs may be deferred to outpatient follow-up.

Source: Chung S, Mikrogianakis A, Wales PW, et al. Trauma Association of Canada Pediatric Subcommittee National Pediatric Cervical Spine Evaluation Pathway: Consensus Guidelines. J Trauma 2011; 70:873.

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Summary of indications for radiologic evaluation of the cervical spine in children and adolescents with blunt trauma