Pediatric C-spine “clearance”[1]

 

 

 

 

 

Pediatric C-Spine

  • There are no quality studies that help us determine how to clear a child who is <8 years of age; there are several studies that include pediatric patients, but none include large numbers of young patients to draw substantial conclusions from.[2]
  • Children < 8 yrs are less likely to sustain bony fractures, but their spinal cords are at great risk due to disproportionally large heads, less supportive cervical musculature, and elastic ligaments. (SCIWORA)
  • Children > 8 yrs have less mobile c-spine architecture and more likely to have boney injuries.

 

  • There is no consensus supported by professional organizations on which young children require imaging; that being said, here is some reasonable thoughts:
    • Children ≤ 8 yrs
      • “Severe mechanism,” evidence of trauma to neck, or neurologic deficit, x-rays may be helpful, but if normal should still consider SCIWORA.
    • Children ≥ 9 yrs
      • NEXUS rules can be followed to determine whether further imaging is warranted.

Imaging

  • C-spine plain films are often of better quality in children than adults.
    • The amount of significant injuries missed on x-ray that are picked up on CT is not as substantial as in adults. [3]
    • Most recommend CT to be used in children with “severe” injury (ie, the intubated or obtunded), presence of neurologic deficit or evidence of trauma to the neck, or when x-rays are inadequate or abnormal.
    • Recall, it is this age group that is most sensitive to radiation (see Aug 6th Morsel).
  • BUT… MRI is the preferred modality for those in whom you are concerned for SCIWORA.

BONUS Morsel: The kid usually knows best: If you remove the collar, allow the child to actively range his/her own neck. Do not passively range it. If they look around for a parent and jump up, you are good. If they resist moving their head and neck, put the collar back on and image. This isn’t “evidence-based,” but my limited “experience-based” way of assessing the little ones.

1. Easter, J.S., et al., Cervical Spine Injuries in Children, Part I: Mechanism of Injury, Clinical Presentation, and Imaging. J Emerg Med.
2. Viccellio, P., et al., A prospective multicenter study of cervical spine injury in children. Pediatrics, 2001. 108(2): p. E20.
3. Hernandez, J.A., C. Chupik, and L.E. Swischuk, Cervical spine trauma in children under 5 years: productivity of CT. Emerg Radiol, 2004. 10(4): p. 176-8.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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