Cervical spine injuries are uncommon in pediatric trauma patients. Delayed or missed diagnosis is usually attributed to failure to suspect an injury to the cervical spine, or to inadequate cervical spine radiology and incorrect interpretation of radiographs. New imaging techniques have become available, but did not solve the problem, adding their own ‘baggage’, such as cost, availability, logistic difficulties, radiation dosage, lack of specificity and evidence of effectiveness or safety.

1. Pediatric cervical spine clearance: A review
and understanding of the concepts

2. Review Article
Pediatric cervical spine clearance: A review
and understanding of the concepts
Pankaj Kumar
Consultant Orthopaedic and Spine Surgeon, Apollo Reach Hospital, Karimnagar 505001, India
a r t i c l e i n f o
Article history:
Received 16 August 2012
Accepted 2 February 2013
Available online xxx
Keywords:
Spine
Cervical spine injury
Cervical spine clearance
Pediatric cervical spine
a b s t r a c t
Spinal injuries to children account for somewhere between 1% and 10% of all spinal
trauma. Evaluations of cervical spine injuries required multidisciplinary approach for
definitive management. Knowing which patients are at highest risk for injuries will un-
doubtedly influence decisions on how aggressively to pursue a potential cervical spine
injury. This can be achieved by establishing a multidisciplinary team that provides stan-
dards for cervical spine immobilization, assessment, and clearance. Implementation of
such guidelines will decrease time for cervical spine clearance and incidence of missed
injuries. In this article different aspect of cervical spine injuries and cervical spine clear-
ance protocols are reviewed.
Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
Cervical spine injuries are uncommon in pediatric trauma
patients. Delayed or missed diagnosis is usually attributed to
failure to suspect an injury to the cervical spine, or to inade-
quate cervical spine radiology and incorrect interpretation of
radiographs. New imaging techniques have become available,
but did not solve the problem, adding their own ‘baggage’,
such as cost, availability, logistic difficulties, radiation dosage,
lack of specificity and evidence of effectiveness or safety.1
2. Epidemiology
Spinal injuries to children account for somewhere between 1%
and 10% of all spinal trauma.2
The most common cause of
spinal trauma in children is motor vehicle crashes and failure
to recognize a cervical spine injury can produce catastrophic
neurologic disability.3,4
The incidence of traumatic spinal
injury increases with age, and the leading mechanism of
injury often varies with age.2,5
Children under 1 year of age,
motor vehicle crashes were the leading mechanism, but for
children aged between 2 and 9 years of age, falls accounted for
the majority of injuries.6
In children aged 10e14 years injuries
were sports related 6 and 60e80% of all pediatrics vertebral
column injuries are located in the cervical region while in
adults, injury to the cervical region usually accounts for about
30e40% of vertebral injuries.7
Atlanto-occipital dislocation is a
rare injury, however it has been reported to occur 2.5 times
more frequently in children than in adults, particularly in
younger children.8
The reported incidence of spinal cord
injury without radiographic abnormality (SCIWORA) in chil-
dren has varied enormously, with some authors suggesting
they occur in 5% of spinal injuries while others have estimated
the incidence to be as high as 65%.8
However, it appears that
SCIWORA is more common among younger children.2
Some
studies of spinal trauma have recorded a missed injury rate as
high as 33%.2
E-mail addresses: drpankaj06@yahoo.co.in, drpankaj06@gmail.com.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/apme
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Please cite this article in press as: Kumar P, Pediatric cervical spine clearance: A review and understanding of the concepts,
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http://dx.doi.org/10.1016/j.apme.2013.02.003

3. 3. Anatomical considerations
There are several features peculiar to the pediatrics cervical
spine, when compared to that of adults.8,9
A relatively large head leading to a fulcrum of flexion at C2/3
rather than at C5/6, as compared to adults.
There are horizontally aligned facet joints as compared to
oblique orientation in adults. This is the most noticeable in
upper cervical vertebrae.
Underdeveloped uncinate processes of C3eC7, leads to
flatter articular surfaces.
There is anterior “wedging” of the vertebral bodies.
Synchondrosis at the junction of the odontoid peg and C2
vertebral body, allows physeal injuries to occur.
Less rigid ligamentous support and weaker supportive
muscles, allows greater displacement for a given force.
These anatomical differences can be expected to lead to
different patterns of injuries in children. Horizontal facet joints,
increased ligamentous laxity and weaker musculature make
the child’s bony cervical spine more mobile, with a lower
expectation of bony injury. The higher fulcrum of flexion would
be expected to lead to injuries occurring at a higher level than
those seen in adults. Although there is inevitably some indi-
vidual variation, the cervical spine is believed to take on a more
adult structure and behavior at around the age of 8e9 years.10,11
4. Clinical evaluation
Evaluation of the stability of the cervical spine in pediatric pa-
tients has been inconsistent and controversial. Pediatric sur-
geons as well as emergency room physicians and trauma,
orthopedic spine surgeon and neurosurgeons often are asked to
rule out cervical spine injuries.12e14
When to contact subspecia
lists, when to obtain computed tomography (CT) and magnetic
resonance imaging (MRI) scans, and how to show the absence of
a ligamentous injury in comatosed patients.1
The solution often
is the overuse of cervical spine radiographs. However, guidelines
as to which patients require imaging as well as what constitutes
“routine screening” are variable and still evolving.13,14
Pediatric patients with the following risk factors for cervi-
cal spine injury undergo cervical immobilization and radio-
graphic evaluation1
:
Unconscious patient or patient with abnormal neurologic
examination findings
Mechanism of injury potentially associated with cervical
spine injury (high-speed motor vehicle collisions, falls greater
than body height, bicycle or diving accidents, forced hyper-
extension injuries, accelerationedeceleration injuries
involving the head)
Neck pain
Focal neck tenderness or inability to assess secondary to
distracting injury
Abnormal neurologic examination findings (complete testing
of motor, sensory, and reflex functions of all extremities is
required)
History of transient neurologic symptoms suggestive of
SCIWORA (weakness, paresthesias, or lightning/burning
sensation down the spine/extremity or related to neck
movement)
Physical signs of neck trauma (ecchymosis, abrasion,
deformity, swelling, or tenderness)
Unreliable examination secondary to substance abuse
Significant trauma to the head or face
Although the issue of radiographic assessment of children
with suspected cervical injury has been addressed in several
studies, there is still insufficient evidence to support diag-
nostic standards.
To date, the Nexus criteria absence of: (1) midline cervical
tenderness, (2) altered alertness, (3) intoxication, (4) neuro-
logical deficit, and (5) painful distracting injury provide the
most reliable instrument for assessing the need. Absence of
all 5 of these had a negative predictive value of 99.9% (95%
confidence interval 99.8e100%).15
5. Prehospital
Manual spinal protection should be instituted immediately. If
there is any pain, neurological deterioration or resistance to
movement the procedure should be abandoned and the neck
splinted in the current position. Patients may also be trans-
ferred on a scoop stretcher and/or vacuum mattress. Children
less than four years of age required greater elevation than
those four years of age or older (P 0.05). Because of these
findings it was recommended that when immobilizing chil-
dren less than eight years of age that either the torso is
elevated or an occipital recess be created to achieve a more
neutral position for immobilization of the cervical spine.
6. In-hospital
Full immobilization should be maintained. This slight degree
of flexion is rarely a problem, though it can give rise to diffi-
culties in X-ray interpretation.2
This can be corrected by
placing a folded towel or sheet under the patient’s shoulders
can better position the head and airway.16e19
There is little
literature available that documents the methods used for
immobilizing young children. We chose to immobilize them
flat on a spine board in a semi rigid one-piece cervical collar
and a head immobilizer, and for children less than 2 year of
age we use towels and staff or parents holding the head. The
log-roll is the standard maneuver to allow examination of the
back and transfer on and off back boards. Anesthesia may be
necessary to allow adequate diagnosis and therapy.
7. Transfer to secondary units
Patients may require transfer to other units for definitive care
of other injuries such as head or pelvic trauma. The spine
should be immobilized and protected for the transfer.
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Please cite this article in press as: Kumar P, Pediatric cervical spine clearance: A review and understanding of the concepts,
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4. 8. Radiological assessment
There is still insufficient evidence to support diagnostic
standards. The lateral view alone is inadequate and will miss
upto 15% of cervical spine injuries. According to Hoffman
et al19
if the lower cervical spine is not visualized in X-ray a CT
scan of the region is indicated. With technically adequate
studies and experienced interpretation, the combination of
plain radiology and directed CT scanning provides a false
negative rate of less than 0.1%. In intubated patient CT scan
from the occiput to C2 is mandatory.
9. Magnetic resonance imaging
All patients with an abnormal neurological examination
should be evaluated in a specialist unit and have an MRI scan of
the spine. Patients who report transient neurological symp-
toms (the ‘stinger’ or ‘burner’) but who have a normal exam
should also undergo an MRI assessment of their spinal cord.
10. Who
If the patient is to be discharged from the emergency depart-
ment, the Registrar from the following units may clear the
cervicalspine after discussionwith theemergencydepartment:
Intensive care
Orthopedic
Neurosurgery
General surgery
If the patient is an inpatient the cervical spine can only be
cleared after consultation with the Neurosurgical or Ortho-
pedic Consultant, or the Emergency Consultant if the patient
is still in the emergency department.
11. How
Several questions need to be asked when attempting to clear
the cervical spine. These are:
Can pain and tenderness be assessed?
Are there other distracting (painful) injuries?
Is there neck pain?
Is there tenderness over the cervical spine?
Are there any motor or sensory abnormalities?
Is there limitation of active neck movement?
Emergency
Is there limitation to head control?
12. Conclusions
There is insufficient evidence to support treatment standards
and insufficient evidence to support treatment guideline.
Establishing a multidisciplinary team provides standards for
cervical spine immobilization, assessment, and clearance.
Implementation of such guidelines will decrease time for
cervical spine clearance, and ongoing analysis of sensitivity
is encouraging. Team members consisted of pediatric sur-
geons, orthopedic surgeons, neurosurgeons, emergency room
physicians, and trauma nurse practitioners. Cervical spine
injuries in children are uncommon, but present many po-
tential pitfalls in management. Knowledge of current practice
is essential to future development of guideline for managing
pediatric trauma patients for whom cervical spine injury is a
consideration.
Conflicts of interest
The author has none to declare.
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Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.003

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