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Emergency Medicine Practice
An Evidence-Based Approach To PEDIATRIC Emergency Medicine s ebmedicine.net
Emergency Evaluation Of The
Pediatric Cervical Spine
The Friday night shift brings a variety of traumatic injuries. First, a 15year-old football player tackled the opposing quarterback while leading with
his helmet. At the end of the play, he could not stand and stated his arms
were tingling and both his legs were numb. Next, a 3-year-old fell down
a flight of stairs after tripping on a toy. She is alert and crying but will
not allow anyone other than her parents near her. Finally, an 8-year-old is
brought in as a trauma alert, following a motor vehicle crash where another
passenger was killed at the scene. This boy is unresponsive and is being
bag-mask ventilated by the emergency response team.
Each of these children arrives to the emergency department with
a cervical-spine-immobilizing collar in place. Despite very different
mechanisms, each will require a complete cervical spine evaluation.
What is required to safely remove the collar? Could any of these children
be clinically cleared? What radiographic studies are indicated? When is
expert consultation required?
W
hile cervical spine injuries (CSIs) in children are relatively
rare, acute care providers are often called upon to assess pediatric patients for CSI as part of an overall trauma evaluation. The developing cervical spine has unique anatomic and biomechanical features that impact injury patterns and outcomes. Certain genetic and
metabolic anomalies can also predispose patients to additional harm.
Prompt stabilization at the scene and accurate diagnostic evaluation
in the emergency department (ED) are imperative; not recognizing
a CSI can prove disastrous. Several developmental anatomic and
radiographic findings can simulate injury and make radiographic
clearance of the cervical spine more challenging in children. Simple
management algorithms that can be used to treat adults are not
AAP Sponsor
Michael J. Gerardi, MD, FAAP,
FACEP
Martin I. Herman, MD, FAAP FACEP Clinical Assistant Professor,
Professor of Pediatrics, UT
Medicine, University of Medicine
College of Medicine, Assistant
and Dentistry of New Jersey;
Director of Emergency Services,
Director, Pediatric Emergency
Lebonheur Children’s Medical
Medicine, Children’s Medical
Center, Memphis, TN
Center, Atlantic Health System;
Department of Emergency
Editorial Board
Medicine, Morristown Memorial
Jeffrey R. Avner, MD, FAAP
Hospital, Morristown, NJ
Professor of Clinical Pediatrics
and Chief of Pediatric Emergency Ran D. Goldman, MD
Associate Professor, Department
Medicine, Albert Einstein College
of Pediatrics, University of Toronto;
of Medicine, Children’s Hospital at
Division of Pediatric Emergency
Montefiore, Bronx, NY
Medicine and Clinical Pharmacology
T. Kent Denmark, MD, FAAP,
and Toxicology, The Hospital for Sick
FACEP
Children, Toronto, ON
Residency Director, Pediatric
Mark A. Hostetler, MD, MPH
Emergency Medicine; Assistant
Assistant Professor, Department
Professor of Emergency Medicine
of Pediatrics; Chief, Section of
and Pediatrics, Loma Linda
Emergency Medicine; Medical
University Medical Center and
Director, Pediatric Emergency
Children’s Hospital, Loma Linda, CA
Department, The University
of Chicago, Pritzker School of
Medicine, Chicago, IL
Alson S. Inaba, MD, FAAP, PALS-NF
Pediatric Emergency Medicine
Attending Physician, Kapiolani
Medical Center for Women &
Children; Associate Professor of
Pediatrics, University of Hawaii
John A. Burns, School of Medicine,
Honolulu, HI; Pediatric Advanced
Life Support National Faculty
Representative, American Heart
Association, Hawaii and Pacific
Island Region
Andy Jagoda, MD, FACEP
Professor and Vice-Chair of
Academic Affairs, Department
of Emergency Medicine, Mount
Sinai School of Medicine; Medical
Director, Mount Sinai Hospital,
New York, NY
Tommy Y. Kim, MD, FAAP
Attending Physician, Pediatric
Emergency Department; Assistant
July 2008
Volume 5, Number 7
Authors
Julie A. Haizlip, MD, RPh
Assistant Professor, Department of Pediatrics, Division
of Pediatric Critical Care, University of Virginia Children’s
Hospital, Charlottesville, VA
Patricia D. Scherrer, MD
Assistant Professor, Department of Pediatrics, Division
of Pediatric Critical Care, University of Virginia Children’s
Hospital, Charlottesville, VA
Peer Reviewers
Lisa Freeman-Grossheim, MD, FAAM
Assistant Professor, Department of Emergency Medicine,
University of Texas Medical School at Houston, Houston, TX
Paula J. Whiteman, MD, FACEP, FAAP
Medical Director, Pediatric Emergency Medicine, EncinoTarzana Regional Medical Center; Attending Physician,
Ruth and Harry Roman Department of Emergency
Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
CME Objectives
Upon completing this article, you should be able to:
1. Identify the epidemiology, mechanisms of injury, and
specific types of pediatric cervical spine injuries.
2. Assess the unique anatomic, developmental, and
functional aspects of the pediatric cervical spine.
3. Evaluate the radiological imaging modalities and
management algorithms available for evaluating the
pediatric patient with a cervical spine injury and discuss
their advantages and limitations.
4. Recognize and summarize special circumstances and
diagnoses that increase the risk of cervical spine injury
in the pediatric patient.
Date of original release: July 1, 2008
Date of most recent review: June 10, 2008
Termination date: July 1, 2011
Time to complete activity: 4 hours
Medium: Print and Online
Method of participation: Print or online answer
form and evaluation
Prior to beginning this activity, see “Physician CME
Information” on the back page.
Professor of Emergency Medicine
and Pediatrics, Loma Linda
Medical Center and Children’s
Hospital, Loma Linda, CA
Gary R. Strange, MD, MA, FACEP
Professor and Head, Department
of Emergency Medicine, University
of Illinois, Chicago, IL
Brent R. King, MD, FACEP, FAAP,
Adam Vella, MD, FAAP
FAAEM
Assistant Professor of Emergency
Professor of Emergency Medicine
Medicine, Pediatric EM Fellowship
and Pediatrics; Chairman,
Director, Mount Sinai School of
Department of Emergency Medicine,
Medicine, New York
The University of Texas Houston
Michael Witt, MD, MPH, FAAP
Medical School, Houston, TX
Attending Physician, Division of
Robert Luten, MD
Emergency Medicine, Children’s
Professor, Pediatrics and
Hospital Boston; Instructor of
Emergency Medicine, University of
Pediatrics, Harvard Medical School,
Florida, Jacksonville, FL
Boston, MA
Ghazala Q. Sharieff, MD, FAAP,
Research Editor
FACEP, FAAEM
Christopher Strother, MD
Associate Clinical Professor,
Children’s Hospital and Health Center/ Fellow, Pediatric Emergency
Medicine, Mt. Sinai School of
University of California, San Diego;
Medicine; Chair, AAP Section on
Director of Pediatric Emergency
Residents, New York, NY
Medicine, California Emergency
Physicians, San Diego, CA
Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical
Education (ACCME) through the joint sponsorship of Mount Sinai School of Medicine and Pediatric Emergency Medicine Practice. The Mount Sinai School of Medicine is
accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Haizlip, Dr. Scherrer, Dr. Freeman-Grossheim, and Dr. Whiteman report no significant
financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: Pediatric Emergency Medicine Practice does not accept any commercial support.
readily applicable to children because of the unique
patterns of injury. Because failure to recognize a CSI
can prove to be disastrous, prompt stabilization at
the scene and accurate diagnostic evaluation in the
emergency department are imperative.
Critical Appraisal Of The Literature
The variability in defining and therefore categorizing pediatric CSIs results in difficulty synthesizing
the available literature about these injuries. The inclusion or exclusion of older teenagers can skew the
patterns and types of injuries that are reported from
a study population. Data collected from emergency
room records and trauma registries may miss the
most serious of injuries that occur in patients who
expire at the scene of an accident. Also, diagnosis
codes used to query databases must be uniform to
allow meaningful comparisons.
Most of the current recommendations for the
management of pediatric CSIs are based on class II and
class III studies with primarily adult patient populations. While there have been a number of recent retrospective analyses of the mechanisms and types of CSIs
sustained by children, there is still a relative paucity of
rigorous randomized controlled trials concerning the
emergency evaluation and management of the pediatric cervical spine. ED practitioners must therefore
make clinical judgments regarding the management of
Table 1. Radiographic Development Of The
Pediatric Cervical Spine
Age
Developmental Change
6 months Body of C1 not visible; all synchondroses open
1 year
Body of C1 now visible
3 years
Synchondroses of posteriorly located spinous processes
fuse
3-6 years Neurocentral synchondroses fuse; synchondrosis between
odontoid and body of C2 fuses; summit ossification center
appears at superior aspect of odontoid; anterior wedging of
vertebral bodies resolve
8 years
Pseudosubluxation and widening of predental space
resolve; spine assumes a more lordotic appearance
Puberty
Secondary ossification centers appear at the tips of the
spinous processes; superior and inferior epiphyseal rings
appear; summit ossification center of odontoid fuses
25 years Secondary ossification centers at tips of spinous processes
fuse; superior and inferior epiphyseal rings fuse to the main
body
Reprinted with permission from Fesmire FM, Luten RC. The pediatric
cervical spine: developmental anatomy and clinical aspects. J Emerg
Med. 1989;7:133-142.
Pediatric Emergency Medicine Practice © 2008
acute pediatric CSIs by synthesizing the unique developmental aspects of such injuries in children with the
available management data from adults.
Anatomy And Development Of The Pediatric
Cervical Spine
The major structures of the cervical spine that
provide support and protect from injury include the
bony vertebrae, the multiple ligaments, the intervertebral discs, the facet and interfacet joints, and
the neck musculature. Bonadio’s two-part review
article from 1993 provides a thorough overview of
the subject.17-18
Table 1 describes the age related radiographic
development of the pediatric cervical spine.24
The pediatric cervical spine is in a constant
state of functional development from birth through
adolescence. Infants and toddlers have a higher axis
of movement, with torque and acceleration stress
occurring higher in the cervical spine, secondary to
their relatively large head size and relatively weak
neck musculature and ligamentous support. The fulcrum of cervical motion is much lower, in the C5 to
C6 region, in adolescents and adults. With increasing
age, the relative head to neck and body size decreases, and the strength of the neck muscles increases.
The combination of maturation of the interspinous
ligaments and ossification of the vertebral bodies
lowers the axis of movement.
In younger children, physiologic anterior
wedging of the upper cervical spine causes this
area to be more susceptible to anterior dislocation by allowing for forward vertebral movement
and displacement. The articulating facet joints in
children are oriented more horizontally than in
adolescents and adults, predisposing the upper
cervical spine in particular to increased instability.
Also, the posterior joint capsules and cartilaginous
end plates are much more elastic than those found
in adults.1,24,25 This laxity of the architecture of the
cervical spine decreases the likelihood of vertebral
fracture in association with trauma; however, it
increases the possibility of other injuries, including
subluxation and spinal cord injury without radiographic abnormality (SCIWORA).26
Epidemiology
CSIs in children comprise approximately 5% of all
CSIs. While only 30%-40% of adult vertebral injury
occurs in the cervical region, 60%-80% of pediatric
spinal injuries are CSIs. A recent review of the Kids’
Inpatient Database found the overall incidence of
pediatric CSI in the U.S. to be 1.99 cases per 100,000
children, with a peak age of incidence of 14 years.4,5
Male children comprise 60%-75% of those injured.1,4-7
In a multicenter evaluation of 3065 pediatric blunt
July 2008 • EBMedicine.net
trauma victims by the National Emergency X-Radiography Utilization Study (NEXUS) group, 30
children sustained a CSI; none of these children
were below the age of 2 years, and only 4 of them
were younger than 9 years of age.8 Similarly, a 5 year
review of the National Pediatric Trauma Registry
demonstrated that an average of 81 CSIs per year
were reported in patients from birth to 20 years of
age and that fewer than 8 of these per year occurred
in children under the age of 2 years.1
and/or muscular injuries. Dislocations and distractions have approximate combined incidences of 25%44%, but both are much more common in younger
children.1,6,10,27,28 Younger patients are more susceptible
to growth plate fractures, particularly at the synchondrosis between the odontoid and vertebral body
of C2.27 Vertebral body and arch fractures are more
common in older children. Occult injuries, including
those involving vertebral growth centers, ligaments,
muscles, intervertebral discs, and/or the spinal cord,
account for 40%-70% of all pediatric CSIs.29
Injuries in younger children more often involve
the upper cervical spine, C1 and C2, due to the higher axis of movement. From the ages of 8 to 12, either
upper or lower cervical cord injury may be seen. In
teenagers, the pattern of CSI more closely resembles
that of adults with the lower cervical spine, C3 to C7,
more commonly affected.1,3,6,9,10,28,30,31 However, the
previous age generalizations that have been made
in the literature can be dangerously misleading. In
a 2001 review of pediatric CSIs at a level 1 pediatric trauma center, Brown et al found that, of the 28
patients who presented with a sports related injury,
75% involved the upper cervical region (C1 to C4),
even though the mean age of this patient group was
13.8 years.5 Similarly, 10 of the 20 children below
8 years of age cared for at the Children’s Hospital
of Alabama over a 36 month period were found to
have CSIs below C4.25
Occipitoatlantal and atlantoaxial injuries are
perhaps the most common CSIs in young children.
Because of the high axis of motion, the young
child’s cervical spine is more susceptible to injuries
related to the inherent lack of bony stability in the
occipital to C2 region. The paired alar ligaments
extend from the tip of the odontoid to the occipital
condyle.32 The tectorial membrane is a cephalad
extension of the posterior longitudinal ligament
that extends to the ventral surface of the foramen
magnum. These 2 structures are the primary stabilizers of the cranium on the cervical spine, as there
is no significant ligamentous support between the
occiput and the atlas.33 Ligamentous or soft tissue
disruptions are frequent in young children since
the supporting muscular structures are underdeveloped and the ligaments are more lax. Such injuries
are often immediately fatal or result in subsequent
death from hypoxic ischemic encephalopathy secondary to cardiorespiratory arrest from brain stem
injury.34 Figure 1 illustrates the lateral plain radiograph of one unfortunate child with this type of
injury.28 In a review of 227 pediatric CSIs occurring
between 1976 and 1992, Nitecki et al reported 19
fatalities (8.4%), 11 of which were associated with
atlantoaxial fracture or dislocation. All of these children suffered cardiorespiratory collapse and died
soon after the injury.31 In a 13-year retrospective
review from Canada, occipitoatlantal dislocation
Etiology
The etiologies of pediatric CSI are diverse. Motor
vehicle accidents (MVAs), falls, and sports injuries
are the predominant causes. The most common
mechanism of injury is motor vehicle related, representing 44%-56% of the total injuries.1, 4, 5, 9 Data
from the National Pediatric Trauma Registry and
from the National Trauma Data Bank show that
over 65% of children who sustain a CSI in an MVA
were not wearing a seat belt at the time of the
injury.1,4 Inappropriate use of available restraint
systems can also be associated with MVA-related
CSI.10 While children of all ages have similar rates
of CSI related to MVA injury, children under the
age of 10 are more likely to sustain CSIs from falls
and pedestrian accidents. In contrast, children
above age 10 have a higher incidence of sports and
bicycle related injuries.1 Alcohol and drug abuse are
involved in 30% of older pediatric CSI cases.4
Sports activities most commonly associated
with pediatric CSI include diving, football, gymnastics, and hockey. Most pediatric CSIs occur with
football since participation rates in this sport are
much higher.12 A recent review of catastrophic CSIs
in football players found that the total number of
quadriplegic events in high school and college players is approximately 6 per year.13 Axial loading of the
cervical spine is the major etiologic factor in sports
related CSIs; in football, this type of injury most
often results from spear tackling.14,15 Submersion and
diving injuries are more likely to be associated with
CSI in children over 15 years of age because of the
higher incidence of risk taking behaviors and high
speed watercraft use.16
Although unusual, child abuse is another unfortunate cause of pediatric CSI. While most reports
in the literature detail only isolated cases of CSI associated with shaken impact syndrome, Brown et al
reported a 3% incidence of child-abuse-related CSI at
a level 1 pediatric trauma center.5
Mechanisms And Types Of Injury
The most common types of CSIs are fractures, with an
approximate incidence of 56% of total pediatric CSIs.
Fractures are commonly associated with ligamentous
EBMedicine.net • July 2008
Pediatric Emergency Medicine Practice © 2008
and/or atlantoaxial fracture with subluxation was
found at autopsy in 15% of fatal pediatric spine injuries; more than 80% of these children died at the
accident scene.35 Bohn et al described 19 children
with a mean age of 6.3 years who were found at the
scene of MVAs and presented to the ED with absent
vital signs or profound hypotension without clear
etiology.36 All of these patients subsequently died,
and 16 of them were later found by autopsy to have
suffered injury to the high cervical spine and cord.
In more recent years, prehospital care has
improved, and more children with occipitoatlantal
and atlantoaxial injuries are now surviving.21,32-33 In a
review of children under 10 years of age who underwent cervical MRI for evaluation of traumatic injury,
Sun et al found 20 of these patients, with a mean
age of 3.5 years, demonstrated a number of different
injuries in the atlantoaxial region, including spinal
cord injuries with atlantoaxial dislocation/distraction, intraspinal hemorrhage, and ligamentous
injuries.37 Only 2 of these children suffered bony
injuries. One child became brain dead at the scene
Figure 1. Occipitoatlantal Dissociation
Lateral plain film of a 7-year-old boy who was struck by an automobile
and sustained an occipitoatlantal dissociation. He died shortly after
presentation, and autopsy revealed complete transaction of the spinal
cord. Reprinted with permission from McGrory BJ, Klassen RA, Chao
EYS, et al. Acute fractures and dislocations of the cervical spine in
children and adolescents. J Bone Joint Surg Am. 1993;75:988-995.
Pediatric Emergency Medicine Practice © 2008
of the accident from anoxia; the rest demonstrated a
spectrum of motor deficits ranging from mild limb
weakness to quadriplegia. The authors of this study
noted that many of the ligamentous and tectorial injuries, and their resulting instability, would not have
been diagnosed without MRI evaluation.
Deployment of passenger airbags has recently
been identified as a causative factor in craniocervical junction injuries in younger children involved in
MVAs. More than 30 children who were improperly
restrained or were in rear facing safety seats in the
front seat of the vehicle have been killed in MVAs
involving airbag deployment.38 Giguère, Saveika, and
others have reported fatalities due to occipitoatlantal dissociation in children who were appropriately
restrained but were in the front seat of the vehicle.38-39
The Centers for Disease Control have identified at
least 8 airbag-related deaths in low speed crashes
where the children might have otherwise survived;
the cause of death in these children was significant
closed head injury.40 The National Highway Traffic Safety Administration now recommends that all
children younger than 13 years ride in the rear seat of
motor vehicles. If a rear seat is not available, the passenger airbag should be turned off (a feature available
in many newer vehicles) or the child should be placed
as far back as possible from the airbag. Since 1997,
changes in the Federal Motor Vehicle Safety Standards have allowed the redesign of frontal airbags to
reduce the force with which they deploy, and a recent
cross sectional study demonstrated a decrease in
overall risk of injury to front seat pediatric passengers
with these second-generation airbags.41
In older children, atlantoaxial injuries are more
likely to be associated with bony fractures. Odontoid fractures are the most common CSI in pediatric
patients.42 Along with its accompanying ligamentous
support, the odontoid is the primary stabilizer of
atlantoaxial articulation.43 In a review of 22 patients
with atlantoaxial injury, Lui et al reported that 8 of
the 12 children with odontoid fractures were over 13
years of age and that 7 of the 10 dislocations without fracture occurred in children under 13 years.43
Most patients with odontoid fractures present with
minimal associated neurological deficits because the
larger diameter of the spinal canal at the C1 level
allows for displacement without compromise of
the spinal cord.44 There are 3 characteristic types of
odontoid fractures: avulsion fracture of the tip, fracture through the base of the odontoid, and fracture
through the vertebral body of C2.17 If the transverse
ligament remains intact, the odontoid is displaced
anteriorly from its normal position, and there is
resultant atlantoaxial instability in all planes of motion. Less common odontoid fractures can be seen
in younger children, often occurring at the synchondrosis between the odontoid and the body of C2.45
Atlantoaxial injury has a lower incidence of neuroJuly 2008 • EBMedicine.net
logical dysfunction in the presence of a fractured
odontoid than with an intact odontoid because if the
odontoid is intact, the force of injury has more likely
been displaced to the spinal cord.46
Os odontoideum represents a failure of the
odontoid to fuse with the body of C2. While the
etiology of this finding as either posttraumatic or
congenital continues to be debated in the literature, most authors now suspect that this finding
occurs after a previously undiagnosed odontoid fracture.47 In a prospective evaluation of 35
symptomatic patients who were found to have os
odontoideum, the traumatic episode preceded discovery of the lesion by an average of 3.5 years.48
Radiography demonstrates a radiolucent oval or a
round ossicle with a smooth cortical bony border.34,49 Lack of stability in this region predisposes
patients to atlantoaxial instability and further
injury, potentially from even minor trauma.42,50
In patients with underlying atlantoaxial instability, os odontoideum may be a consequence of the
hypermobility rather than its cause.51
Jefferson fractures, usually occurring through
the anterior and posterior arches of the ring of C1,
are typically caused by axial loading injury. Most
often, the child lands directly on his or her head.52
With this mechanism, force is transmitted from compression on the skull through the lateral occipital
condyles to the lateral masses of C1.34,53 The degree
of fracture spread is typically controlled by stretch of
the transverse ligament.52 If the transverse ligament
is disrupted as well, these injuries are quite unstable
and carry a high incidence of mortality.34
The classically described hangman’s fracture
occurs secondary to a hyperextension mechanism
and is extremely unusual in children. Bilateral
fractures of the pars interarticularis of the axis lead
to anterior subluxation of C2 on C3 and an unstable
injury.34 Typically this injury is not associated with
resultant neurological impairment.20 Physiologic
pseudosubluxation in children can be confused with
hangman’s fracture, as will be discussed in differential diagnoses.
Subaxial CSIs are more often seen in adolescent
patients. Common patterns of injury include fracture-dislocations, burst fractures, simple compression fractures, and facet dislocation.20 These types of
injuries are similar to those found in adults and can
be found at other levels of the vertebral column.
The incidence of injury to the cervical spine at
multiple levels reported in the literature ranges from
7% to 22%.5,10,30 Concomitant fractures in the upper
cervical spine can occur at any age, although they
are better described in adolescent and adult patients.54 Frequently combined injuries include dens
fracture, fracture of the posterior arch of C1, bipedicular fracture of the axis, Jefferson fracture, or fracture of the superior articular process of C2. Mazur et
EBMedicine.net • July 2008
al reported the case of an unfortunate 5-year-old boy
who suffered a combined Jefferson and odontoid
fracture after falling on his head when his fourwheeler rolled over.52 Multiple fractures of the lower
cervical spine are well described in older children.
Dogan et al found that 18% of subaxial CSIs involve
more than one level.30 Injury to multiple segments,
with obvious injury at one level and more subtle
pathology at another, may easily be underestimated
in pediatric CSIs.55
Neurological disability that results from CSIs
in children is relatively uncommon. In a review
of 10 years of data collected in the National Pediatric Trauma Registry, Patel et al found that only
one-third of pediatric patients with CSIs had neurological deficits, and half of those patients had no
initial evidence of radiographic abnormality.6 Less
than 10% of children demonstrated a complete cord
injury. Dogan et al reported that of 51 patients with
subaxial injuries, 64% were neurologically intact on
admission, 16% had incomplete neurological injuries, and 14% had a complete spinal cord injury.30
Cervical spine dislocations are associated with a
much higher incidence of mortality and neurological
dysfunction. Although only 19% of the 103 pediatric
patients with CSIs suffered a cervical spine dislocation in the group studied by Brown et al, this group
had a mortality rate of 40%, in part related to the
high degree of association with severe traumatic
brain injury (TBI).5
SCIWORA was initially described by Pang and
Wilberger in 1982 and is a phenomenon that is considerably more common in pediatric patients than
adults.56 SCIWORA is defined as “spinal cord injury
without observable abnormality on conventional
radiographs or computed tomography (CT) images.” Cervical SCIWORA comprises 15%-38% of all
pediatric CSIs in reviews based in the US.1,5,9,10,57,58
In 2004, Pang reviewed the literature since 1969 for
all children from birth to 17 years of age with SCIWORA type injuries and found the mean incidence
to be 34.8%.26 The exact incidence does seem to
depend on the strictness with which the definition
of SCIWORA is applied. Because of the increased
laxity of the cervical spine’s supporting structures
in younger children, a traumatic event can lead to
distortion or contusion of the spinal cord without
vertebral fracture; during the trauma, the vertebrae
are transiently displaced but return to their normal
configuration and alignment. The child’s vertebral
column allows for up to 2 cm of stretch, but less
than 0.25 cm of stretching to the spinal cord can be
associated with distortion and injury.59 The elasticity of the spine is inversely proportional to age;
therefore, the risk of occult cord injury is greatest in the youngest children.57 Other mechanisms
that may result in SCIWORA include ligamentous
bulging, reversible subluxation, indirect transmis
Pediatric Emergency Medicine Practice © 2008
sion of kinetic injury to the spinal cord, or vascular
or ischemic phenomena.58,60 SCIWORA can result
from trauma that leads to hyperextension, hyperflexion, longitudinal distraction, rotation, or axial
loading.18,61 While this type of injury, particularly
in the upper cervical region, is much more common in younger patients, SCIWORA is also seen in
older pediatric patients, particularly in association
with sports related injuries.5 When patients with
SCIWORA have been studied by MRI, most have
demonstrated abnormalities of the spinal cord,
most commonly swelling with occlusion of the subarachnoid space.44 Thus, the more frequent use of
MRI to evaluate CSIs does challenge the semantics
of the term SCIWORA.62 With the accumulation of
MRI data in pediatric CSI, any and all of the ligamentous and soft tissue supporting structures have
been demonstrated to potentially be involved.
Children with SCIWORA present with a variety of neurological syndromes. Mild partial cord
syndromes are just as common as complete cord
transections.26 Unfortunately, even in the absence
of further trauma, a small subset of children with
SCIWORA do not have paralysis initially but instead
have a latent period of 30 minutes to as long as 4
days. In a group of 15 patients with delayed neurological deterioration, once sensorimotor paralysis
began, it progressed inexorably, and 2 of the children
ultimately progressed to complete cord transaction.63 This progression may reflect ongoing ischemia
with infarction of the spinal cord.60 The incidence
of delayed onset SCIWORA may be decreasing in
association with more conservative immobilization
practices for pediatric patients.26 Recurrent SCIWORA can occur if the spine is not adequately immobilized, either from improper stabilization or from an
inadequate duration of time. A recent meta-analysis
found an overall incidence of recurrent pediatric
SCIWORA to be 17% in the available literature.58
CSIs related to child abuse are most commonly
SCIWORA type injuries. Hadley et al found that, in
6 patients on whom autopsy was performed who
had presented with classic findings of non-accidental trauma from shaking (profound neurological
impairment, seizures, retinal hemorrhages, and
intracranial subarachnoid and/or subdural hemorrhages), 5 also had injuries at the cervicomedullary
junction consisting of subdural or epidural hematomas of the cervical spinal cord with proximal spinal
cord contusions.64 MRI findings in the subset of child
abuse patients evaluated by Brown et al included
diffuse edema and hemorrhage of the cervical spinal
cord.5 Abuse can also be associated with hangman’s
fracture secondary to the hyperflexion and hyperextension that occurs with shaking. While fortunately
not a common injury, several case reports have
described infants with hangman’s fracture secondary to abuse.65,66 Rooks et al described 2 twins who
sustained fracture-dislocation injuries of the cervical
Pediatric Emergency Medicine Practice © 2008
spine along with numerous other fractures in the
axial and appendicular skeleton.67
Atlantoaxial rotary subluxation is also relatively unique to children. When rotation exceeds
40°-45°, the anterior facet of C1 becomes locked on
the facet of C2, so children can present with either
limited rotation of the neck or complete fixation.19,53
Although associated with trauma in up to 70% of
patients, other causes can include recent upper
respiratory infection or inflammation from recent
surgery.21,68 The inciting traumatic event can often
be minor, such as with falls and low speed MVAs.
Recently, several cases of atlantoaxial subluxation
and fixation have been reported from trampoline
use.69 The classic presentation is the “cock robin”
position, where the child’s chin is rotated to one
side and the head is flexed to the other side. Traumatic subluxation can occur from rupture of the
transverse ligament, but this injury is unusual in
children because the odontoid usually fails before
the transverse ligament.18 Fortunately, the cervical
canal is at its widest at this level, so subluxation
does not often result in spinal cord impingement.34
Atlantoaxial rotary subluxation, even when associated with fixation, is only rarely associated with
any neurological deficits.70
Differential Diagnosis
Several normal anatomic variants can be seen in radiographic evaluation of the pediatric cervical spine
and can lead to diagnostic confusion.
Absent Lordosis
While absence of lordosis on a lateral view of the
cervical spine in adults is concerning for possible
ligamentous injury, this finding is frequent in children and does not necessarily suggest injury.
Anterior Vertebral Wedging
Ossification of the subaxial vertebral bodies is more
advanced at the dorsal aspect and progresses anteriorly with age. Incomplete ossification creates the
radiographic appearance of anterior wedging of the
vertebral bodies.71 A similar appearance would suggest compression fractures in adults.
Pseudosubluxation
Most commonly seen between C2 and C3, pseudosubluxation occurs in children secondary to ligamentous laxity. In a classic study evaluating flexion
and extensions radiographs in healthy children, Cattell and Filtzer demonstrated that 32 of 70 children
(46%) studied under the age of 8 years had 3 or more
millimeters of anteroposterior movement of C2 on
C3.72 Anterior displacement of C3 on C4 was also
seen in 14% of this population. The posterior cervical line devised by Swischuk can help to evaluate for
July 2008 • EBMedicine.net
fracture or subluxation.73 A line that is drawn down
from the anterior spinous process of C1 to C3 should
come within 1.5 mm of the anterior spinous process
of C2 in the absence of injury. In pathologic dislocation of C2 on C3, the posterior cervical line misses
the posterior arch of C2 by 2 mm or more. From
a practical standpoint, radiographic subluxation
should reduce with extension; patients who have a
true traumatic subluxation typically cannot be reduced by extension due to pain and muscle spasm.23
An abnormal posterior cervical line measurement is
often indicative of a hangman’s fracture at C2.53
from C3 through C7 fuse between 3 and 6 years of
age.74 The posterior synchondroses between each
vertebral body and the 2 supporting pedicles fuse
within the first 2 years. Also, both the synchondrosis between the body of the atlas and the odontoid
and the neurocentral synchondrosis between the
body of the atlas and the neural arch fuse by 4 to 6
years of age. Prior to fusion, the appearance of these
synchondroses can be mistaken for fracture. Similarly, the secondary ossification center within the
odontoid appears between 3 and 6 years of age and
fuses by age 12. This V-shaped epiphyseal area of
the odontoid can also be confused with a traumatic
fracture. Secondary ossification centers can be seen
at the tips of the transverse and spinous processes of
Pseudo-Jefferson Fracture
The lateral masses of the odontoid can be developmentally displaced up to 4 mm in up to 90% of
children under 2 years of age.74 As a result, the radiographic appearance, with pseudospread of the atlas
on the axis, resembles that of a true Jefferson fracture
in older children and adults.53
Figure 2a. Young Child Positioned On A
Standard Adult Backboard
Atlantoaxial Widening
While a distance greater than 2.5 mm between C1
and C2 in adults is strictly considered to be abnormal, infants and small children may have an intervertebral distance of greater than 3 mm without
underlying injury.74 Younger patients, especially
infants, are much more likely to have physiologic
atlantoaxial widening. This finding can be accentuated in young children with Down syndrome due to
underlying ligamentous laxity.
Because the occiput of the child is more prominent and the head is
larger relative to the body as compared to an adult, the neck becomes
flexed and the cervical spine does not assume a neutral alignment.
Figure 2b. Young Child Positioned On A
Standard Adult Backboard With Padding
Widened Predental Space
The study by Cattell was also the first to report that
widening of the predental space or an increase in
the distance between the odontoid process and the
anterior arch of the atlas can be a normal radiologic
variant.72 While a distance of greater than 3 mm
of predental space can be associated with a torn
transverse ligament, the same increase in distance
in children likely represents developmental laxity of
this ligament and not injury.24
Young child positioned on a backboard with a double thickness mattress pad that raises the chest relative to the head allowing for neutral
positioning of the cervical spine.
Widened Prevertebral Space
Figure 2c. Young Child Positioned On A
Modified Backboard
Widening of the prevertebral soft tissue space can
occur from injury associated edema and hemorrhage.
Measurement of this space is standardized in the
adult patient, but in children the size of this space can
be markedly influenced by the position of the neck
at the time films are obtained. Also, an increase in
width can be seen in association with breath holding
or forced expiration with crying.71 Therefore, defining normal values for the width of this space in the
pediatric patient remains challenging.
Young child positioned on a modified backboard with a recessed area
for the occiput that again allows for neutral positioning of the cervical
spine. Reprinted with permission from Herzenberg JE, Hensinger
RN, Dedrick DK, et al. Emergency transport and positioning of young
children who have an injury of the cervical spine. J Bone Joint Surg.
1989; 71:15-22.
Synchondroses
The neurocentral synchondroses between each vertebral body and the neural arch ossification centers
EBMedicine.net • July 2008
Pediatric Emergency Medicine Practice © 2008
C3 through C7; although well described, these can
persist into adulthood and can simulate fractures.15
In general, epiphyseal plates are smooth and regular
and occur in predictable locations as compared to
the radiographic appearance of fractures.53
Prehospital Care
The primary goal of preadmission management of
the pediatric cervical spine is to “first do no harm.”
The key to preventing further injury is immobilization of the cervical spine.75 Although it can be very
difficult to place an injured or frightened child in an
appropriate cervical collar, all reasonable attempts
should be made to provide adequate immobilization. When appropriately sized and applied, semirigid cervical collars provide approximately 60%70% limitation of movement. However, providers
should be aware that attempting to manipulate and
immobilize the cervical spine forcefully could lead
to additional injury.
Spine boards with stabilizing sand bags or
blocks and tape can provide additional immobilization. However, consideration of a child’s physical
habitus is paramount to proper positioning. Snyder
et al determined that a child’s head achieves 50%
of its post-natal growth by the age of 18 months. In
contrast, the chest circumference of a child does not
reach 50% of its post-natal growth until the age of
8 years.76 As a result of this growth dissymmetry, a
child’s head is disproportionately large. Positioning young children in the supine position can lead
to unrecognized flexion or anterior displacement of
the cervical spine (Figure 2A).77 This cervical flexion can exacerbate unstable cervical spine injuries.
Herzenberg et al suggested that using padding to
elevate the torso (Figure 2B) or using a modified
backboard with an occipital recess (Figure 2C) can
prevent this problem by bringing the cervical spine
back into a neutral position.77 Subsequent articles
have supported the assertion that current spine
immobilization techniques are inadequate to assure
neutral positioning of the pediatric cervical spine.78-80
Nypaver and Treloar demonstrated that padding under the thorax can be sufficient to correct flexion of
a child’s cervical spine while supine; however, there
was significant variability in the height of padding
required (5-41 mm).78 Curran et al found that 61%
of children transported with spinal immobilization
had greater than 5 degrees of kyphosis or lordosis by
lateral cervical spine radiograph and more than 30%
had greater than 10 degrees of flexion. In this study,
investigators found that children older than 12 years
most frequently had excessive cervical spine angulation with standard immobilization techniques.
However, since none of the subjects of their study
had spinal injury, they could not assess the associated clinical impact.79
Pediatric Emergency Medicine Practice © 2008
ED Evaluation
When faced with a pediatric patient with a traumatic injury, the clinician should first determine
if the mechanism of the injury is one that could
produce a CSI. Whereas it is unlikely that a child
who has fallen off a bike into a bush would have
sufficient impact to injure the cervical spine, a
child who was jumping a ramp and fell from a bike
might. For this reason, the emergency physician
must try to obtain the most accurate description of
the injury as possible, either from the patient or an
eyewitness. Unfortunately, traumatic injuries are
often not witnessed and the child may be amnestic
of the event or too distressed to answer questions.
In these cases, one must assume there was a possible mechanism for injury and fully evaluate the
cervical spine.
“Clearing” the cervical spine involves evaluating the bony and ligamentous structures of the neck.
Clearance indicates that there are no injuries present that could lead to instability of the spine which
could lead to cervical cord or nerve root injury in
the absence of intervention. In 2002, the Section on
Disorders of the Spine and Peripheral Nerves of the
American Association of Neurological Surgeons
(AANS) performed a comprehensive literature
review with a goal of producing evidence-based
guidelines for the evaluation and management of
pediatric cervical spine and spinal cord injuries.
Despite the plethora of articles addressing the issue
of the pediatric cervical spine, the authors concluded
that there was insufficient evidence to support a
diagnostic standard.75
In the ideal situation, a trained clinician can
clear the cervical spine clinically by physical examination. The NEXUS study determined that imaging
of the cervical spine following blunt trauma could
be avoided in the absence of 5 clinical criteria (Table
2).81 The validation of these criteria included pediatric patients (2.5% of 34,069 patients were < 8 years
old and 1.3% of 818 patients with documented CSI
were ≤ 8 years old). Subsequently, Viccellio and the
NEXUS group published prospective observational
data from 3065 children varying in age from 0 to
18 years to validate the use of NEXUS criteria in children.8 The authors found the NEXUS criteria correct-
Table 2. NEXUS Criteria For Radiographic
Evaluation Of The Cervical Spine Following
Blunt Trauma81
1.
Midline cervical tenderness
2.
Focal neurologic deficits
3.
Altered level of consciousness
4.
Evidence of intoxication
5.
Painful distracting injury
July 2008 • EBMedicine.net
ly identified all children at high risk for injury. However, given the low incidence of injury (30 patients,
0.98%), the confidence interval for the sensitivity of
the instrument remained wide (88%-100%).8 Nonetheless, this study will likely serve as the definitive
study on the validity of the NEXUS tool in children,
given that a prospective study to address the question authoritatively would require more than 80,000
children based on the low incidence of CSI in children.8 Of note, the study authors point out that children under the age of 2 were underrepresented and
recommend that caution be observed when applying
the NEXUS criteria to this population.8 However,
other authors suggest that preverbal children should
automatically be considered high-risk.75,82
One of the greatest controversies associated
with the NEXUS criteria is the determination of
what constitutes a painful distracting injury. This
question is important because high CSIs, such as
those to which young children are predisposed,
have been shown to be correlated with increased
incidence of other orthopedic injuries.83 In the
original article, Hoffman et al defined a distracting
injury as one that “could potentially distract the
patient from a cervical spine injury.” To address the
question of what injuries are potentially distracting,
Hefferman et al studied a series of 406 adult trauma
patients. They determined that only 7 patients with
cervical spine injury failed to report cervical pain.
Each of these 7 patients had an upper torso injury.
They concluded that isolated lower torso injury did
not distract adult patients from accurate reporting
of cervical pain.84 It is unknown whether this data
would be applicable to pediatric patients. A clinician must also consider that a careful neurological
exam can be limited by pain or deformity in the
region of a significant injury.
In 2003, Stiell et al published the Canadian
C-spine Rule (CCR) and found that their algorithm
was significantly more sensitive and specific in
identifying adult patients at low risk for cervical
spine injury and had fewer missed injuries than the
NEXUS criteria.85 Using the CCR, any patient under
the age of 65 years without a dangerous mechanism
or paresthesias may be initially evaluated clinically.
It is considered safe to evaluate the patient’s range
of motion without radiographs if the patient was
involved in a simple rear-end motor vehicle collision, is sitting upright, has been ambulatory, did not
have immediate neck pain, or does not have midline
tenderness. At that point, if the patient is able to
actively rotate the neck 45˚ to the left and right, no
radiographs are required to achieve clinical cervical
spine clearance.85 While the data to support use of
this algorithm in adults is compelling, no children
under the age of 16 were evaluated in this study, and
to our knowledge, no further studies to evaluate this
tool in children have been performed.
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There have been attempts to derive a clinical
decision tool specifically for the evaluation of the pediatric cervical spine. Based on a retrospective chart
review, Jaffe et al proposed an 8 variable screening
tool to determine which children required radiographic evaluation.86 Neck pain, neck tenderness,
abnormal reflexes, abnormal strength, and abnormal
sensation were each statistically associated with
CSI. Additional criteria included a history of neck
trauma, limitation of neck mobility, and abnormal
mental status. Screening with these 8 criteria produced a sensitivity of 98% and a specificity of 54%.
This tool was believed to minimize unnecessary
radiographs and time spent in cervical immobilization. The authors cautioned widespread application
of this algorithm until it can be further studied, since
this tool failed to identify a 2-year-old with an odontoid fracture and dislocation.86
Radiographs can be avoided if an alert and
cooperative child will allow an appropriate examination. First, a complete neurological assessment
including evaluation of sensory and motor function
and reflexes should be done. Any new neurological abnormality in a child with a history of recent
trauma should increase the index of suspicion
for a CSI. Most children with SCIWORA present
with some transient neurological findings, including weakness or paresthesias. If the neurological
examination is normal, the clinician should then
visually inspect the neck for deformity, abrasions,
and bruising. Inspection is followed by gentle
palpation of the cervical spine in a neutral position
for tenderness, deformity, or muscular spasm. If the
patient is pain-free, the collar may be removed. The
patient is then instructed to move his neck through
the range of motion (flexion, extension, and lateral
rotation.)23,87 If the patient remains pain-free, the
cervical spine is clinically cleared.
In many circumstances, however, an alert child
is too scared, too uncomfortable, or too young to
complete an adequately informative examination. In
this case, or if the child has an altered mental status,
additional evaluation must be undertaken.
Diagnostic Studies
The only diagnostic studies relevant to the clearance
of the pediatric cervical spine are radiological imaging. Multiple imaging modalities are available.
Plain Films
Anteroposterior (AP), cross table lateral, and
odontoid films comprise the standard three-view
evaluation of the cervical spine. Lateral radiographs must fully image from C1 to the C7/T1
junction.23,87 Downward traction on the arms may
be required to obtain full visualization of the
cervicothoracic junction. Alternately, a swimmer’s
Pediatric Emergency Medicine Practice © 2008
view may be used. Oblique radiographs may
be useful to review detail of pedicles and facet
joints.23 Detailed discussion of the interpretation
of these films has been previously published23 and
is beyond the scope of this article.
One of two guidelines recommended by the
AANS in their 2002 review of the management of
pediatric cervical spine and spinal cord injuries was
that AP and lateral cervical spine x-rays be obtained
in children who have experienced trauma and do
not meet NEXUS criteria.75 The omission of the
odontoid film from this recommendation is significant since this has been an area of some controversy.
Odontoid films are difficult to obtain and often
inadequate in children less than 8 years of age.19,88,89
Young children may not be able or willing to open
their mouths sufficiently to obtain this film. In a retrospective review of 51 children with CSI, Buhs et al
found that the odontoid view was omitted in 33% of
evaluations and not helpful in 63%. Only one patient
in this series had an injury identified by odontoid view that would not have been seen on other
views.88 Similarly, Swischuk et al found in a survey
of pediatric radiologists that, while 64% of the group
attempted an odontoid view in children less than 5
years of age, 70% of those that tried stopped if the
first attempt was unsuccessful. Respondents to this
survey reported having missed a total of 46 injuries
on lateral cervical spine films that were identified
by odontoid view over the course of a cumulative
nearly 7000 practice years.89
While plain films have reasonable sensitivity for
bony injury,88 it is generally accepted that they are
unreliable for the identification of most pediatric soft
tissue injuries.29
motion on physical examination, cross sectional
imaging with CT or MRI is of greater utility.91
Computed Tomography (CT)
In acute spinal trauma in adults, CT scanning of the
cervical spine has been demonstrated to be more
sensitive in detecting fractures than plain films and
more time efficient.92,93 With multidetector CT, images are rapidly obtained and may be reconstructed
to provide three-dimensional images.92 In adult
patients, CT has a reported sensitivity for cervical
spinal fracture between 90% and 99% and a specificity of 72%-89%.92 This is far superior to the sensitivity of 39%-94% and variable specificity reported
for plain films.92
In the pediatric population, however, the increased sensitivity of CT for the detection of fractures and malalignment has not been demonstrated.94,95 In one retrospective review of the radiologic
evaluation of 606 children less than 5 years of age,
147 children had CT scans performed. Of those, only
4 (2.7%) had significant findings of fracture, dislocation, or instability and each of those injuries had
been identified on the initial plain film evaluation.95
While Keenan et al found that utilizing CT for evaluation of the pediatric cervical spine in children with
head trauma decreased the number of plain radiographs required at a relatively equivalent cost, those
children evaluated by CT were exposed to a higher
effective dose of radiation.96 Adelgais and colleagues
further demonstrated that the use of helical CT for
the evaluation of the traumatic pediatric cervical
spine increased health care costs, increased radiation exposure by a factor of 3.4, and did not diminish either emergency department length of stay or
sedative medication requirement when compared to
plain films.94
The concerns of increased radiation exposure
have limited the routine use of CT for evaluation of
the pediatric cervical spine. While CT accounts for
only 5% of all radiographic imaging, CT examinations account for 40%-67% of all medically based
radiation exposure.97 One report demonstrated that
compared with plain radiography, helical CT of the
pediatric cervical spine increased the mean radiation dose by 50%.94 Furthermore, Rybicki and others
found a 10-fold increase in skin radiation and 14-fold
increase in thyroid radiation when cervical spine
CT was compared to a 4- or 5-view radiographic
evaluation of the cervical spine.98 This is of particular significance in children less than 5 years old, for
whom it has been stated that glandular tissues (such
as thyroid and gonadal tissues) are at greater risk for
the development of radiation induced malignancy.97
In circumstances when the benefits of the use of CT
is thought to outweigh the radiation risks, individual settings should be based on the size of the child
and the regions of the body to be scanned.97
Flexion-Extension Radiographs
Flexion-extension cervical radiographs are used as
an adjunct to standard three-view evaluation (AP,
lateral, and odontoid).90 Indications have included
evaluation for ligamentous injury when 3-view
evaluation is suggestive of possible injury, evaluation of abnormal physical examination findings
when three-view evaluation is normal, and clinical
concern for SCIWORA.90 Flexion views may be of
particular use in revealing transverse ligament rupture associated with C1/C2 injuries in children or
posterior ligamentous complex instability associated
with hyperflexion injuries.90
Flexion-extension films may be limited in the
acute setting by muscular spasm.90 In a prospective
study to assess the utility of flexion-extension radiographs in adult patients with blunt trauma, Insko et
al found that when patients could produce adequate
cervical flexion and extension, there were no missed
injuries. However, they found that 30% of studies
were inadequate due to limited range of motion. The
investigators concluded that in patients with limited
Pediatric Emergency Medicine Practice © 2008
10
July 2008 • EBMedicine.net
While CT can clearly be of benefit in evaluation
of bony injury, a prospective series of 1577 patients
confirmed that CT is not an effective imaging technique for evaluation of ligamentous injury. This series
demonstrated that the sensitivity of CT in identifying
ligamentous injury was 32% and the negative predictive value was 78% when compared to MRI.99 For this
reason, a negative CT scan result is not sufficient to
clear the C-spine in the obtunded patient.100
22 of 25 obtunded, intubated, or uncooperative children were able to have their cervical spines cleared
by MRI. The remaining 3 children were found to have
significant injuries. Final diagnosis after MRI differed
from the preliminary diagnoses made by plain films
and/or CT in 25 (34%) patients.29 Figures 4 and 5
demonstrate 2 cases of pediatric cervical spine injury
in which MRI demonstrated abnormal findings not
fully appreciated on plain film or CT.
In a retrospective review, Keiper et al demonstrated that MRI studies performed within 48 hours
Magnetic Resonance Imaging (MRI)
MRI is emerging as an integral tool for the evaluation and management of a child with a potential CSI
that cannot be cleared clinically. While flexion and
extension views are optimal to determine functional
stability of the cervical spine, these films require an
alert, cooperative patient with a normal neurological examination. Pediatric patients are rarely able to
adequately cooperate with this process, and since
they must be alert, anxiolytic medications cannot be
used. Since ligaments and cervical soft tissues can be
imaged directly with MRI, these images can be used
as a surrogate for the determination of stability.92
Trauma to the spinal cord and surrounding tissue results in hemorrhage or edema. These
anatomic disruptions are represented by increased
water content of tissues that can be detected by
MRI.101 MRI has a unique ability to evaluate soft issue pathology and is, therefore, of significant value
in direct evaluation of the spinal cord, discs, and
ligamentous structures.92 The T2-weighted MRI in
Figure 3 demonstrates soft tissue and spinal cord
injury that would not be evident on other imaging
modalities.20 The level of anatomic detail obtainable
has made MRI a desirable modality for evaluation
of the atlantooccipital and cervicothoracic regions.101
Bone edema may also be detected on short TI inversion recovery (STIR) and fat-saturated T2 images.
This finding can aid in determination of the acuity
of bony injury.92 However, compared to CT, MRI is
much less sensitive (46%-71%) in identification of
osseous injury.101
Flynn et al prospectively studied the use of
MRI for evaluation of the cervical spine in pediatric trauma patients.29 Indications for obtaining an
MRI included: 1) an obtunded or non-verbal child
with a mechanism of injury that could be consistent
with CSI, 2) equivocal plain films, 3) neurological
symptoms without radiographic findings, and 4) an
inability to clear the cervical spine by other diagnostic means within 3 days following injury. Based
on these criteria, 74 children obtained cervical spine
MRI evaluation. Results from this study showed that
MRI revealed injury not seen on plain films in 23%
of children (ligamentous injury, muscle injury, and 1
C1 lateral mass fracture). Ten children with equivocal
plain films and 3 with concern for odontoid fracture
on CT were able to be cleared after MRI. Additionally,
EBMedicine.net • July 2008
Figure 3. Child With Spinal Cord Transection
T2 weighted magnetic resonance image of a child who sustained cord
transection and extensive posterior soft tissue injury. Reprinted with
permission from Reilly CW. Pediatric spine trauma. J Bone Joint Surg
Am 2007; 89:98-107.
11
Pediatric Emergency Medicine Practice © 2008
of injury provided information that ultimately altered therapy.102 In their study, 6 of 52 patients were
found to have unstable injuries, 4 of which required
operative intervention. In each of these 4 cases, MRI
demonstrated more extensive ligamentous injury
than was appreciated by CT, and in each case, the
extent of posterior fusion was extended. This study
also demonstrated that none of the 36 children with
normal MRI findings developed delayed instability
or symptoms.102
In SCIWORA, extra-axial compressive lesions
are rarely detected and therefore, MRI rarely affects
acute management. Nonetheless, MRI is valuable
for prognostic information. Major cord hemorrhage
(>50% of transverse area or cord discontinuity)
predicts complete lesions. Minor cord hemorrhage is
associated with good recovery but long term defects.
Normal MRI findings suggest complete recovery
independent of presenting symptoms.100 Given that
it may take up to 4 hours to detect traumatic cord
Figure 4.
Figure 5.
This series of images demonstrates findings on plain film, CT and
MRI for an 18 month old. Plain film and CT depict a complete fracture
through the base of the dens with anterior dislocation and angulation.
MRI also demonstrates disruption of the anterior and posterior longitudinal ligaments, edema of prevertebral tissue and posterior paraspinal
musculature, and an epidural hematoma at C6-7. Images courtesy of
Julie Matsumoto, MD.
Pediatric Emergency Medicine Practice © 2008
This series of images from a 10
year old illustrates very subtle
findings on plain film and CT with
significant abnormality visualized
on MRI. The lateral cervical spine
film shows no evidence of gross
malalignment but minimal narrowing of the C3-C4 intervertebral
disc space. CT demonstrates mild
asymmetry of the lateral space between C1 and C2 (anterior view)
and inferior and anterior fractures at the base of C6 (lateral view).
MRI reveals a near complete transection of the spinal cord at the C1C2 level with distraction injury of the atlantooccipital and atlantoaxial
joints. Images courtesy of Julie Matsumoto, MD.
12
July 2008 • EBMedicine.net
Clinical Pathway For Evaluation Of The Pediatric Cervical Spine
Awake and alert child with possible CSI
Is child: > 3 years old, AND cooperative, AND
with no developmental delay AND with no high risk
mechanism?
Is child: < 3 years of age, OR uncooperative, OR
developmentally delayed, OR with high risk mechanism?
NO
Yes
Yes
Are you ordering
a head CT?
Does child meet NEXUS
criteria?
Yes
NO
NO
Order AP and lateral c-spine. Order odontoid if
child is > 9 years of age.
If odontoid is insufficient, order CT of occiput
to C2.
Is child > 9 years of age?
Yes
NO
Order CT of cervical
spine.
Order AP and lateral
c-spine and CT
occiput to C2.
Are test abnormal or is there pain on exam?
Is CT abnormal or is
there pain on exam?
NO
NO
Yes
Patient is normal AND
meets NEXUS criteria.
Yes
Yes
Cervical spine is cleared.
Order expert consultation.
EBMedicine.net • July 2008
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Pediatric Emergency Medicine Practice © 2008
edema, delaying the MRI scan may be reasonable.
Based on the above information, it seems that
MRI is nearly the ideal imaging modality for the
evaluation of the pediatric cervical spine. MRI
images can provide diagnostic and prognostic
information and there is evidence to suggest the
information obtained alters therapy. Additionally, Frank et al demonstrated that utilizing MRI
in obtunded or mechanically ventilated patients
allowed cervical spine clearance approximately 2
days earlier. This was associated with non-significant decrease in ICU and hospital lengths of stay
and an estimated cost savings of $7700.100 However,
the majority of studies done to compare the utility and sensitivity of MRI are not referenced to a
true “gold standard.” Frequently, findings on MRI
have been empirically accepted to be most reliable.
There have been few studies that have attempted to
correlate MRI findings with operative or pathologic
findings.104 Yet when directly compared to intra-operative findings, there is some evidence to suggest
that MRI may overestimate the degree of injury and
there is variable sensitivity for detection of injury
(45% for posterior osseous structures, 71% for the
anterior longitudinal ligament, 100% for intraspinous soft tissues and vertebral body injuries).104
Nevertheless, given the potentially devastating
injury that can result from missing a cervical spine
injury, it is preferable to overestimate an injury
than to miss one.
MRI does have some other distinct disadvantages. First, MRI is not as readily available as plain
radiography or CT. The acquisition of MRI images
is time consuming. Patients with metallic devices
such as pacemakers or embedded metallic fragments cannot be safely placed in the MRI scanner. Many intracranial pressure monitors are MRI
incompatible. It is difficult to manage mechanically
ventilated or critically ill patients in the scanner
since specific MRI compatible ventilators must be
used and medication pumps cannot be in close
proximity to the scanners. Additionally and of significant importance, the majority of conscious children require sedation to tolerate the study. To be
performed safely, this procedural sedation requires
a trained clinician to remain with the child for the
duration of the MRI and until the child wakes.105,106
For these reasons, despite the considerable imaging
advantages, MRI may not be a practical consideration for use in the emergency department.
Treatment
A child with concern for CSI should not be discharged from the emergency department unless
the injury has been ruled out or a specific injury
has been identified and no acute intervention is
required.23 If a CSI is excluded, no specific therapy
is warranted, with the possible exception of mild
analgesics for trauma associated pain. In the event
that an injury is identified, expert consultation with
either orthopedics or neurosurgery is indicated.
Even if no acute intervention is required, outpatient
follow-up will be necessary. More significant injuries
may require transfer of the patient to a tertiary or
quaternary care center for immediate evaluation by
a spine specialist.
Discussions of the surgical management of an
unstable CSI can be found in the AANS Guidelines
for the Management of Pediatric Cervical Spine and
Spinal Cord Injuries.75 However, their review found
insufficient evidence to support the development of
treatment standards or guidelines.75 Primary indications for operative intervention include cervical
instability and need for decompression of an incomplete CSI. Determining the ideal timing for intervention can be controversial.107
Despite the fact that pharmacological therapy
for spinal cord injury in children has not been addressed in the literature,75 high dose methylprednisilone may be considered when there is evidence
Cost- And Time-Effective Strategies
1. Clinically clear the cervical spine when possible. Avoiding radiographic studies saves not only
their cost, but also time in the emergency room.
2. Don’t waste a lot of time or effort on getting
the odontoid view. Successful attempts to obtain this view are rare in children under the age
of 9 years.
3. If ordering a head CT, consider extending it to
include the cervical spine from the occiput to
C2. This eliminates the need for an odontoid and
guarantees adequate visualization of the area
most prone to injury in the small child.
Pediatric Emergency Medicine Practice © 2008
4. If the patient has cervical pain or an abnormality on plain film, consult an expert early. An
orthopedic surgeon or neurosurgeon may have
preferences about which further studies will be
done. This can prevent redundant or unnecessary imaging.
5. REMEMBER: The cost of a missed injury is
far greater than the cost of additional imaging.
During the time period from 1997 to 2000, the
average hospital bill for a pediatric CSI patient
was $57,280, and the average length of hospital
stay was 13.47 days.4
14
July 2008 • EBMedicine.net
of spinal cord injury with neurological deficits. A
bolus of 30 milligrams per kilogram of body weight
is given over 15 minutes followed by infusion of 5.4
milligrams per kilogram of body weight per hour for
23 hours.107 We believe that this intervention should
be done in consultation with the neurosurgeon or
orthopedic surgeon who will be assuming care for
the patient.
ties including occipitoatlantal instability, odontoid
hypoplasia, os odontoideum, hypoplasia of the
posterior arch of C1, and spondylolisthesis of the
midcervical vertebrae.2 While children with Down
syndrome are advised not to participate in contact
sports or other activities that could lead to acute hyperflexion or hyperextension of the neck if they have
any radiographic evidence of atlantoaxial instability,
several reports have failed to demonstrate an increase in incidence of neurological injury in children
who were allowed to fully participate in all activities.111,112 More often, patients present with a stable
decline in neurological function that has occurred
over months to years. The most common constellation of symptoms at presentation for neurological
compromise from atlantoaxial instability in children
with Down Syndrome includes easy fatigability,
difficulties in walking, abnormal gait, neck pain,
limited neck mobility, torticollis or head tilt, incoordination and clumsiness, sensory deficits, spasticity,
hyperreflexia, clonus, extensor plantar reflexes, and
other upper motor neuron and posterior column
signs and symptoms.113 While children with Down
syndrome can present with catastrophic injury to
the spinal cord, nearly all of them have experienced
weeks to years of precedingly less severe neurological abnormalities.
Klippel-Feil syndrome is classically characterized by a low hairline, short neck, and oc-
Special Circumstances
Pediatric patients with certain genetic or metabolic
syndromes are at increased risk of CSI.
Children with Down syndrome have a variably
reported incidence of atlantoaxial instability secondary to congenital ligamentous laxity. When defined
as hypermobility, up to 60% of Down syndrome
children have some degree of increased laxity.71 Only
1%-2% of individuals with laxity go on to develop
spinal cord compression.51,108 The American Academy of Pediatrics (AAP) currently recommends that
plain films be obtained at 3-5 years of age to look for
evidence of atlantoaxial instability or subluxation.109
However, these screening films can be unreliable, so
all children with Down syndrome who present for
care in the ED should be managed as if they are vulnerable, especially during the course of anesthesia
or neck manipulation.108,110 These children are also at
risk for a variety of other cervical spine abnormali-
Key Points
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Although CSIs are rare in children, they comprise 60%-80% of all pediatric spinal traumas,
with most common etiologies including MVAs,
sports activities, and falls.
The developing pediatric cervical spine demonstrates unique anatomic and functional characteristics, including multiple ossification centers,
an initially weak and elastic ligamentous support system, a higher axis of movement, and anterior wedging of the upper cervical vertebrae,
all of which predispose it to unique patterns of
injury.
As in adults, fractures are the most common
pediatric CSIs, but dislocations and distractions,
especially of the occipitoaxial region, are much
more common in children.
SCIWORA is a relatively unique phenomenon in
children, with a higher incidence of initial and
subsequent neurological abnormalities.
A multitude of normal anatomic variants on
radiographic evaluation of the pediatric cervical
spine increases the complexity of evaluation and
diagnosis.
EBMedicine.net • July 2008
15
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Appropriate prehospital stabilization of the cervical spine is critical in the prevention of subsequent injury.
Clearing the cervical spine of a child by physical examination alone requires that the child be
awake and alert, of an appropriate developmental level, free from distracting injury, and cooperative with a complete neurological examination.
Of the available radiographic evaluation methods, plain films and CT scans are reasonably
sensitive at identifying bony injury but lack the
ability to identify ligamentous injury; therefore,
MRI has become the gold standard for evaluation of the child who cannot be cleared clinically.
Children with Down syndrome, Klippel-Feil
syndrome, skeletal dysplasias, mucopolysaccharidoses, and other genetic and metabolic
syndromes have an increased risk of CSIs, most
notably atlantoaxial instability.
All practitioners who care for pediatric patients
should encourage proper restraint and seating
systems in motor vehicles and should counsel
children and families about prevention of CSIs.
Pediatric Emergency Medicine Practice © 2008
Risk Management Pitfalls For Cervical Spine Injuries
1. “I didn’t think she needed a cervical collar
because she was up and walking around at the
scene of the accident.”
It is safer to provide cervical spine immobilization until the history can be reviewed, the child
can be examined thoroughly, and the appropriate
radiographic evaluations can be performed.
2. “They didn’t have a pediatric backboard in the
ambulance, and they forgot to put anything
under him. Since he’s already secured on the
adult board, we’ll just leave him on it.”
Immobilization on an adult backboard with no
adjustment to allow for the proportionately greater
head and occiput size keeps the cervical spine of a
child from being positioned in neutral alignment.
The resulting position, with the neck flexed and the
chin tucked, can lead to upper airway obstruction.
3. “She said her neck didn’t hurt, so I thought it
was OK to take her out of the collar.”
Remember that children will often tell you
whatever you want to hear, partly to please you
and partly because they don’t want to wear a
cervical collar! This is especially true if the child
is scared or overwhelmed by the situation. Also,
the impact of other distracting injuries can be
more challenging to sort out in young children. It
is most prudent to leave the collar in place until
other injuries have been cared for and the child
can be reassured by a more familiar face.
4. “I’m pretty sure that line on the x-ray is just a
growth plate. He seems just fine, and the likelihood of a kid his age having a cervical spine
fracture is really low anyway.”
Ouch. While it is true that the incidence of CSIs
in children is quite low and that children do
have a number of growth plate findings on x-ray
that can be confused with fracture, children DO
get cervical spine fractures and often are neurologically intact with minimal complaints. Unless
your radiologist is confident that what you’re
seeing is a growth plate, further evaluation is
definitely in order.
5. “The x-ray tech has had it! He has tried but he
simply cannot get this little girl to hold still and
open her mouth for the odontoid view.”
Odontoid views are notoriously challenging
to obtain in younger children and they often
provide inadequate views anyway. Rather than
struggling with a frightened or frustrated child,
consider another method of evaluation.
6. “The patient you sent over for flexion and extension films is crying because he says his neck hurts
too much to bend. What do you want us to do?”
Stop! The quality of flexion and extension films
will be limited by this child’s inability to bend his
Pediatric Emergency Medicine Practice © 2008
7.
8.
9.
10.
16
neck. More importantly, first do no harm. Forcing a child with an unrecognized subluxation or
instability through a broad range of motion could
precipitate neurological abnormalities.
“I’m worried that I’ll miss a fracture in a pediatric
patient, so just to be on the safe side, I get a CT on
every child with a possible mechanism for a CSI.”
Although CT scanning is still an important adjunct
in the evaluation of pediatric patients for CSI, it
should not be employed haphazardly. Increased
sensitivity when using CT for fracture detection in
younger children has not been borne out thus far
in literature. The increase in total radiation exposure, combined with the fact that CT is not particularly effective at diagnosing ligamentous injury,
should be a deterrent for over-use of CT.
“Her cervical spine CT was normal, and so
were her bedside plain films. I know she’s
unconscious so I can’t clinically clear her, but
the plastic surgeon really wants her collar off
so she can sew her up. It should be fine to leave
the collar off once they’re done.”
Again, ouch. You’ve failed to get adequate
clearance on this child who may be at risk for
ligamentous injury or a SCIWORA. While the
collar can certainly be loosened or removed in
order for other diagnostic or therapeutic procedures to be performed, in line stability should be
provided at all times. Once those procedures are
completed, put the collar back on!
“I know he’s a child with Down syndrome, but
his screening plain films were read as OK a few
months ago. That means his cervical spine is
stable and I should be fine to intubate him, right?”
Wrong. Most children with Down syndrome
have some degree of atlantoaxial hypermobility, and screening films that look for atlantoaxial
subluxation in this population can be unreliable. These children should be managed as if
they are at risk for instability and potential cord
compression, and the technique of stabilization
with intubation or any other manipulation of the
head and neck should be managed accordingly.
“All of her films were clear and she seems fine,
so I told her parents they didn’t have anything
to worry about.”
The risk of occult injury with a normal physical
examination and normal plain films is admittedly
quite low. However, there have been case reports
of children with SCIWORA who have presented
with neurological deficits up to 4 days later that
were not present on their initial examination.
Always review concerning signs and symptoms
with families as well as specific instructions on
where and how to return for care.
July 2008 • EBMedicine.net
cipitoatlantal fusion.44 Estimated to occur in 1 in
every 40,000 births, this syndrome is considered
to be a congenital malformation of proper cervical
segmentation that results in a fusion of 2 or more
cervical vertebrae.114 In the majority of patients,
the congenital fusions occur in the upper cervical spine.115 A wide range of other anomalies can
occur in association with this diagnosis, including
renal anomalies, congenital heart disease, impaired
hearing, and limb malformations. In the upper
cervical spine, instability and hypermobility in the
region above the fusion can result in neurological
abnormalities from cord or nerve root impingement.116 Hypermobility of the cervical spine below
the region of fusion can lead to degenerative disc
disease. Cord transection from fracture-dislocation
above or below the fused spinal segments may be
observed.117 Because the cervical spine of children
with Klippel-Feil syndrome is unable to compensate for excessive flexion, extension, or lateral bending through the fused segments, seemingly minor
traumatic events in these children can result in a
fracture of the fused area and subsequent neurological devastation.118 Therefore, ED practitioners
should pay careful attention to positioning and
management of these children to avoid iatrogenic
injury. Klippel-Feil syndrome is also associated
with an increased incidence of os odontoideum.34
The osteochondrodysplasias include a wide
variety of skeletal, genetic, and metabolic anomalies
that can be associated with cervical spine disorders.
These heritable disorders are characterized by intrinsic abnormalities of bone and cartilage growth and
remodeling.115 Upper cervical spinal stenosis and
atlantoaxial instability can occur with many of these
disorders.119 Achondroplasia is associated with cervical spine stenosis especially at the cervicomedullary
junction at the foramen magnum.15 These children
have a significantly higher risk of spinal cord injury
resulting from hyperextension and hyperflexion.
Patients with one of the many variants of mucopolysaccharidoses, a group of metabolic skeletal dysplasias, can demonstrate odontoid hypoplasia and
atlantoaxial subluxation and instability.119 With any
of these disorders, the possibility of iatrogenic injury
associated with anesthetic preparation and airway
positioning, as well as with any other manipulation
of the head and neck region, must always be considered. For children with achondroplasia, uncontrolled
neck movement (as may occur during the process
of endotracheal intubation) can lead to spinal cord
compression secondary to constriction of the foramen magnum.120
there is no clear consensus. While there is no national standard, it has been shown that an organized,
consistent approach is of benefit. In a prospective
single center study at a level 1 trauma center, implementation of a standard protocol for evaluation of the
pediatric cervical spine led to a significant increase
in the proportion of children whose cervical spines
were cleared by non-neurosurgical personnel with no
late injuries identified.124 Clinical algorithms for the
evaluation of CSI should be designed to maximize
the sensitivity because missing even a small number
of true CSIs could have tragic ramifications.86 However, emergency physicians should be mindful that
children differ from adults in anatomy, mechanisms
of injury, and patterns of injury, and as such, it is
inappropriate to simply apply cervical spine imaging
protocols for adults to pediatric patients.29
121-124
Disposition
The ultimate disposition of the pediatric patient with
a demonstrable CSI is often inpatient management.
For the patient whose cervical spine has been cleared
in the ED, subsequent disposition often depends on
the severity of other associated injuries. Because of
the possibility of SCIWORA, all patients who are
discharged from the ED with any history of a potential mechanism of trauma to the cervical spine should
receive detailed written follow-up instructions. These
instructions should review symptoms and signs relative to CSI, including numbness, paresthesias, paresis,
and shock-like sensations in the extremities and
should include clear instructions for where, when,
and how families can seek subsequent care. The decision regarding return to play for the pediatric athlete
can be complex and should be considered in light of
the presenting injury and other associated findings.15
Typically, recommendations regarding return to play
are delayed until the athlete has no neurological
symptoms and has regained pre-injury strength, especially in the neck musculature.125 While assessment
scales that attempt to establish objective guidelines
for return to play do exist in the literature, application
of these grading systems in the ED in the immediate
post-injury period in adults have undergone no evidence-based evaluation. No grading scales exist that
are specific for pediatric patients.
Prognosis
Overall mortality rates in pediatric patients with
CSI are between 15% and 30%.1,3,9 Neurological
status at the time of presentation to the ED clearly
defines the likely outcome. Non-survivors most
often have evidence of devastating neurological
injury at the time of initial evaluation. Often, these
are patients who are unresponsive and apneic at
the scene of the accident but who survive to reach
Controversies/Cutting Edge
While many algorithms for the approach to imaging
the pediatric cervical spine have been published,87,
EBMedicine.net • July 2008
17
Pediatric Emergency Medicine Practice © 2008
the ED because of rapid prehospital ventilatory
support.7 Dietrich et al found that the level of injury was above C3 in 88% of children who did not
ultimately survive and that 88% of children exhibited distraction of vertebral bodies.7
Pediatric CSI mortality is highly correlated
with the presence of severe TBI. Overall, 30%-60%
of pediatric CSIs occur in association with head
injury.9,27 In a review of National Pediatric Trauma
Registry data from 1994 to 1999, 93% of pediatric CSI
deaths were associated with severe TBI.1 Glasgow
Coma Score (GCS) has been evaluated as a predictor of pediatric CSI outcome based on 1997 and 2000
National Trauma Data Bank documentation.4 In
this retrospective review of pediatric patients who
presented with CSIs, a GCS of 3 upon arrival to the
emergency department was associated with a mortality of greater than 40%. For patients with a GCS of
4 or higher, the survival rate was 99%.
Children who suffer cervical dislocations
have an extremely low incidence of neurological
sequelae. More than 80% of children with cervical spine fractures from 1994 to 1999 are free of
lasting neurological impairment.1 During that
same time period, only 4.4% of children with CSIs
demonstrated complete cord lesions. Follow up of
102 pediatric CSI patients by Eleraky et al found
that all patients who were neurologically intact
at the time of injury remained so and that 83% of
patients with some degree of neurological impairment recovered completely.9 Similarly, Orenstein
et al found that 79% of children had no residual
motor or sensory impairment.27 Even patients who
present with initial cardiopulmonary compromise
and quadriplegia can have complete recovery of
neurological function, as was the case for a 4-yearold girl in Japan who presented for care following a
C2-C3 fracture-dislocation.126 SCIWORA syndromes
in particular seem to have some lasting degree of
neurological dysfunction. Of 19 patients who presented with complete cord deficits with SCIWORA
type injuries, only 1 demonstrated any significant
neurological recovery.62 However, 95% of patients
in the same review who did not sustain a complete
injury made a full recovery.
ride rear facing in a convertible seat or in an infant
seat approved for higher weights until at least 1
year of age.127 The rear facing position for infants
helps to distribute the force of acute deceleration
over the entire back and pelvis and into the shell of
the car seat.27 Placing an infant in the forward facing position markedly increases the risk for cervical
distraction injury. There are many reported cases of
restrained children younger than 12 months of age
who suffer CSIs who were prematurely placed in
forward facing car seats. Moreover, there have been
several cases of children above the age of 1 year
who died from CSIs when restrained in the forward
facing position as is recommended.128 There are no
current cases in the literature reporting catastrophic
CSI for any child restrained properly in a rear-facing seat. A forward facing seat, a combination seat,
or a belt-positioning booster seat should be used
when a child outgrows a convertible safety seat but
is too small to use the vehicle’s safety belts.127 Typically, children are restrained in a forward facing
child safety seat until they are 4 years of age and
weigh 40 pounds. At that time, a child should be
transitioned to a belt-positioning booster seat until
the seat belt fits properly (approximately 80 pounds
and 57 inches in height, typically at least 8 years of
age).129 A number of studies in the literature have
demonstrated a reduction in CSIs, and other injuries in general, with booster seat use as compared
to seatbelt use in children.130-134 Unfortunately,
62% of children aged 4-8 years remain inappropriately restrained in adult seat belts.129 Customized
restraint systems are available for children with
special health care needs.135
Children and adolescents who participate in
sports activities should wear proper fitting protective gear. Spear tackling in football remains the
primary mechanism of CSI leading to quadriplegia. While it is an illegal form of tackling, players
should receive education on safe techniques to
avoid this potentially catastrophic move. In other
sports, children should be taught to avoid “head
first” maneuvers. Neck conditioning exercises to
strengthen muscular and ligamentous support
structures may provide additional protection and
are a typical part of conditioning regimens in
contact sports. Given the nearly 100,000 injuries
that occur on trampolines each year, the AAP has
recommended that trampolines should not be used
at home, in schools, or on playgrounds.136
Adolescents have the highest incidence of CSIs
in the pediatric age group as a whole. Although
some of these injuries may be difficult to prevent,
many are associated with the combination of motor vehicles, excessive rates of speed, lack of seatbelt use, and substance use. Adolescents should be
counseled at any available opportunity about the
dramatic increase in CSI with risk taking behaviors
Prevention
The association of pediatric CSI incidence and lack
of seat belt use offers just one of many reasons for
anticipatory guidance regarding motor vehicle safety and age appropriate restraints at any encounter
with children, teenagers, and their families. Restraint systems should be age and weight appropriate as recommended by the AAP. Children should
be over the age of 1 year and should weigh at least
20 pounds before they are turned to a face forward
position in a motor vehicle. Infants who weigh
more than 20 pounds before 1 year of age should
Pediatric Emergency Medicine Practice © 2008
18
July 2008 • EBMedicine.net
as well as the significant danger of combining them
with drug and alcohol use.
reference, pertinent information about the study,
such as the type of study and the number of patients
in the study, will be included in bold type following
the ref­erence, where available. In addition, the most
infor­mative references cited in this paper, as determined by the authors, will be noted by an asterisk (*)
next to the number of the reference.
Summary
Evaluation of a child with a potential CSI is a relatively frequent procedure in the emergency department. To do this properly, the emergency physician
must have a complete understanding of the factors
that make children unique. The developmental anatomy of the cervical spine impacts the mechanism of
injury and predisposes children to higher-level fractures and injuries that are not readily apparent on
standard imaging. The incidence of injury is incredibly low but the ramifications of a missed injury are
significant and could be life altering for the patient
and his family. A standardized approach to children
at risk for CSI can assist emergency physicians in
their evaluation and determining the need for expert
consultation.
1.
2.
3.
4.
5.
Case Conclusions
6.
Each of the three patients had a mechanism of injury that
required cervical spine evaluation. Neurosurgery was
consulted to see the 15 year-old football player. A cervical
spine CT demonstrated no bony injury. An urgent MRI
demonstrated soft tissue and spinal cord edema. Cervical
spine immobilization was continued, and he was admitted
for neurological monitoring. At the time he was transported to his room, the tingling in his arms was subsiding, but his lower extremity deficits persisted.
After some time, the three year old became less
distressed and more active. Despite her cervical collar,
she was playful and walked to the soda machine with her
mom. At that point she cooperated with a physical exam,
during which she had no neck tenderness and she demonstrated a full active range of motion. Her cervical spine
was cleared clinically and she was discharged to home.
The 8 year old was admitted to the Pediatric Intensive Care Unit, where an intracranial pressure monitor
revealed severe intracranial hypertension. Despite no
obvious bony abnormality on plain films, his clinical
course prevented MRI evaluation for ligamentous injury
within 72 hours of his accident. Therefore, he remained in
a cervical collar at the time of transfer to a rehabilitation
facility. He was scheduled to follow up with Orthopedics
for further evaluation in 6 weeks.
7.
*8.
9.
10.
11.
12.
13.
14.
15.
References
16.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are
equally robust. The findings of a large, prospective,
random­ized, and blinded trial should carry more
weight than a case report.
To help the reader judge the strength of each
EBMedicine.net • July 2008
*17.
*18.
19.
19
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(Case reports and discussion)
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and discussion)
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(Cross sectional study; 6102 children 4-7 years involved in
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seats and reduction in risk of injury among children in vehicle
crashes. JAMA. 2003; 289:2835-2840. (Cross sectional study; 4243
Pediatric Emergency Medicine Practice © 2008
children 4-7 years involved in MVAs)
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trampolines at home, school, and recreational centers. Pediatrics.
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CME Questions
1. Cervical spine injuries represent what percentage of all pediatric spinal injuries in the
United States?
a. 0-20%
b. 20-40%
c. 40-60%
d. 60-80%
e. 80-100%
2. Most common etiologies of pediatric cervical spine injuries include all of the following
EXCEPT:
a. Motor vehicle accidents
b. Falls
c. Child abuse associated injuries
d. Football related injuries
e. Bicycle related injuries
3. Which of the following statements regarding
the functional development of the pediatric
cervical spine is TRUE?
a. All of the bony centers of ossification are fused at birth.
b. Infants and toddlers have a lower axis of movement in the cervical spine than do adolescents and adults.
c. Physiologic anterior wedging of the upper cervical spine causes this region to be less susceptible to anterior dislocation.
d. Each of the cervical vertebrae has 2 centers of ossification.
e. The laxity of the entire structure of the cervical spine in younger children decreases the likelihood of fracture secondary to trauma.
4. Cervical spine injuries in younger children are
more likely to:
a. Occur in the lower region of the cervical spine
b. Be associated with a lack of plain film radiographic evidence of injury
c. Include vertebral body and arch fractures
d. Include a fracture of the odontoid
e. Spare the ligaments and soft tissues of the upper cervical spine
22
July 2008 • EBMedicine.net
5. Which of the following statements regarding
atlantoaxial rotary subluxation in children is
TRUE?
a. Children classically present in the “cock robin” position.
b. Association of subluxation with trauma is rare.
c. The inciting traumatic event must involve a great deal of force to lead to this finding.
d. Subluxation frequently results in spinal cord impingement and neurological deficits.
e. Atlantoaxial rotary subluxation is more common in adults.
9. Indications for obtaining MRI in the prospective evaluation of cervical spine injury in
pediatric trauma by Flynn et al included all of
the following EXCEPT:
a. Inability to clear the cervical spine by other diagnostic means within 3 days following injury
b. An obtunded or nonverbal child with a mechanism of injury that could be consistent
with cervical spine injury
c. Clinical clearance of the cervical spine and normal CT scan findings
d. Neurological symptoms without radiographic findings
e. Equivocal plain films
6. Normal radiographic anatomic variants in evaluation of the pediatric cervical spine include
all of the following EXCEPT:
a. Atlantoaxial widening
b. Pseudosubluxation of C2 on C3
c. Anterior vertebral wedging
d. Jagged irregular line through a vertebral arch
e. Smooth regular line between the body of C1 and the arch
10. Which of the following is an advantage of MRI
evaluation of the pediatric cervical spine when
compared with other imaging modalities?
a. Need for sedation
b. Duration of time required for study to be completed
c. Ease of use of monitoring equipment in the scanner
d. Widespread availability of MRI scanners
e. Improved detection of ligamentous injury
7. Prehospital care of the child with a potential
injury to the cervical spine should include:
a. Stabilization on a adult backboard without modification
b. Leaving the cervical collar off if the child is awake and moving around
c. Forceful manipulation and immobilization of the cervical spine if necessary
d. Stabilizing sand bags or blocks and tape to provide additional immobilization
e. Additional padding under the heads of young infants in order to protect the head
11. Common presenting symptoms of neurological compromise from atlantoaxial instability in
children with Down syndrome include all of
the following EXCEPT:
a. Incoordination and clumsiness
b. Hyperreflexia
c. Changes in speech patterns
d. Neck pain or decreased mobility
e. Spasticity
12. With regard to appropriate restraint systems
for pediatric patients, which of the following
statements is FALSE?
a. Infants under 1 year of age should be re
strained in a rear facing position in the back seat of the car.
b. Infants who weigh more than 20 pounds can transition to a forward facing position prior to their first birthday.
c. Children should be restrained in a forward facing car seat until they are 4 years of age and weigh 40 pounds.
d. Children over the age of 4 years who weigh more than 40 pounds should be restrained in a belt positioning booster seat until the vehicle’s seat belt fits properly.
e. All providers who care for children should reinforce the safety benefits of appropriate vehicle restraint systems with children, adolescents, and their families.
8. NEXUS criteria for radiographic evaluation
of the cervical spine following blunt trauma
include all of the following EXCEPT:
a. Altered level of consciousness
b. High speed/force mechanism of injury
c. Painful distracting injury
d. Midline cervical tenderness
e. Focal neurological deficits
EBMedicine.net • July 2008
23
Pediatric Emergency Medicine Practice © 2008
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Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and effectiveness
Level of Evidence:
• One or more large prospective studies are present (with rare exceptions)
• High-quality meta-analyses
• Study results consistently positive
and compelling
Class II
• Safe, acceptable
• Probably useful
Level of Evidence:
• Generally higher levels of evidence
• Non-randomized or retrospective
studies: historic, cohort, or case
control studies
• Less robust RCTs
• Results consistently positive
Class III
• May be acceptable
• Possibly useful
• Considered optional or alternative
treatments
Level of Evidence:
• Generally lower or intermediate
levels of evidence
• Case series, animal studies, consensus panels
• Occasionally positive results
Indeterminate
• Continuing area of research
• No recommendations until further
research
Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent, contradictory
• Results not compelling
Significantly modified from: The
Emergency Cardiovascular Care
Committees of the American Heart Association and representatives from the
resuscitation councils of ILCOR: How
to Develop Evidence-Based Guidelines
for Emergency Cardiac Care: Quality of
Evidence and Classes of Recommendations; also: Anonymous. Guidelines
for cardiopulmonary resuscitation and
emergency cardiac care. Emergency
Cardiac Care Committee and
Subcommittees, American Heart Association. Part IX. Ensuring effectiveness
of community-wide emergency cardiac
care. JAMA. 1992;268(16):2289-2295.
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