Version July 2025
| Radiologic study | History and physical |
| None | No multiple system trauma with substantial injuries* to head, face, or torso |
| Awake (GCS score = 15 and AVPU = A) and cooperative with exam, and | |
| Normal airway, breathing, and circulation; normal neck examination; and normal neurologic examination | |
| Lateral, AP, odontoid radiographs¶ | Multiple system trauma with substantial injuries* to head, face, or torso, or |
| Altered mental status (GCS score 9 to 14, AVPU = V or P, or other signs of altered mentation such as disorientation or lethargy), or | |
| Self-report of neck pain, or | |
| Neck tenderness on physical examination | |
| Computed tomography of the C-spine | Acute neurologic deficit (instead of plain radiographs), or |
| GCS score ≤8 or unresponsive (instead of plain radiographs), or | |
| Abnormal airway, breathing, or circulation (instead of plain radiographs), or | |
| Abnormal or suspicious C-spine finding on plain radiographs | |
| Flexion-extension radiographsΔ | 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), or |
| High index of suspicion for C-spine injury despite normal plain cervical radiographs |
AVPU: Alert, Verbal, Pain, Unresponsive scale; GCS: Glasgow coma scale; MRI: magnetic resonance imaging.
* Substantial injuries are those that warranted inpatient observation or surgical intervention (eg, basilar skull fracture, pneumothorax, pulmonary contusion, solid organ injury [liver, spleen, kidney, or pancreas]).
¶ 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.
Δ 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.