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.