Cervical spine injuries

Cervical spine injuries consist of fractures, subluxations, dislocations, and ligamentous injuries of the cervical spinal column with or without an associated neurological injury. They are most commonly caused by blunt trauma, e.g., motor vehicle crashes (MVCs) and falls. During initial evaluation, spinal motion restrictions must be maintained pending cervical spine clearance. NEXUS criteria and the Canadian C-Spine Rule are clinical decision rules used to determine whether imaging studies are indicated. CT of the head and neck is the preferred imaging modality in adults. X-rays of the cervical spine may be used in children to avoid radiation exposure, but expert consultation is recommended. Stable spinal injuries are often treated with external immobilization. Unstable spinal injuries typically require surgical fixation. Because treatment varies with the morphology and location of the injury, expert consultation is always required.

For thoracic and lumbar spine injuries, see “Vertebral injuries.” For injuries involving the spinal cord, see “Spinal cord injury.”

For minor neck ligament or muscle injuries, see “Neck sprain” and “Whiplash injury.”

• ∼ 4% of individuals with blunt trauma have a C-spine injury, of which: ^[1][2]
  • ∼ 40% are unstable spinal injuries.
  • 30–50% are associated with neurological impairment. ^[3]
• See also “Epidemiology of vertebral fractures.”

Epidemiological data refers to the US, unless otherwise specified.

• Blunt neck trauma (common)
  • MVCs
  • Falls
  • Violence
  • Sports-related injuries
  • Occupational injuries
  • Hanging
• Penetrating neck trauma: e.g., gunshot wound, stab wound

See “Classification of vertebral injuries.”

Primary survey ^[4][5][6]

• Apply spinal motion restrictions as soon as C-spine injury is suspected, e.g., during prehospital management, before airway management.
  • Cervical spine immobilization
  • Log roll during examination and/or transfers
• If airway management is required (e.g., signs of airway compromise, respiratory failure): ^[5]
  • Retain the posterior portion of the cervical collar.
  • Apply manual in-line C-spine stabilization while removing the anterior portion of the cervical collar.
  • Perform endotracheal intubation.
    • Rapid-sequence intubation with video laryngoscopy or direct laryngoscopy is appropriate for most cases.
    • If other difficult airway risk factors (e.g., facial and neck trauma) are present, consult anesthesia for awake intubation.
• Stabilize life-threatening concurrent injuries, e.g., TBI or hemorrhagic shock. ^[7]

Maintain spinal motion restrictions until unstable spinal injury is ruled out. ^[4][5]

Secondary survey ^[8][9]

• Using log roll with manual in-line C-spine stabilization, inspect and palpate the entire spine for bruising, tenderness, gaps, and/or steps.
• Perform focused neurological examination, including:
  • Sensory level
  • Segmental motor testing
  • DTRs
  • DRE to assess rectal tone
  • Cranial nerve testing
• Manage concurrent injuries, e.g., facial fracture management, blunt chest trauma. ^[7]

Identify brainstem and spinal cord injury early.

Initial diagnostics and early C-spine clearance

• Apply the NEXUS criteria or Canadian C-Spine Rule (CCSR) to determine the need for imaging.
• Clear C-spine clinically, if possible.
• If indicated, obtain diagnostics for C-spine injury (e.g., CT C-spine).

Discontinue C-spine immobilization as soon as C-spine clearance criteria are met. ^[3][10]

Concurrent spinal cord injury (SCI) ^[5][11][12]

• Provide acute management for SCI.
• See ”Respiratory support for SCI.”
• See “BP management for SCI.”

Prepare to manage acute or delayed-onset respiratory failure in patients with cervical SCI. ^[5][11][12]

Urgent consults

• Consult a spine surgery specialist early for known or suspected C-spine injury.
• Consult neurosurgery for concomitant TBI.
• Consult trauma surgery for polytrauma and other multisystem injuries.

For unstable spinal injuries, urgent surgical intervention is typically indicated to minimize the risk of irreversible neurological injury.

See “C-spine immobilization in children" for indications, steps, and C-spine clearance criteria specific to children.

Definition ^[13]

• The application of devices and techniques to restrict undesirable motion of the vertebral column
• Used to prevent further neurological and mechanical injury caused by patient movement (e.g., during transfers, transportation, or in response to stimuli)

Indications for spinal immobilization ^[4][13][14]

Blunt trauma with any of the following:

• Altered mental status (AMS), e.g., GCS < 15 ^[4]
• Pain or tenderness at the midline of the back or neck
• Focal neurological deficits
• Spinal deformity
• Distracting injuries ^[13]

Spinal immobilization is not required in patients who are alert, neurologically intact, and have no distracting injury (e.g., long bone fracture), obvious spinal deformity, or pain or tenderness in the back or neck. ^[5][13]

Do not apply spinal immobilization after penetrating trauma, as instability is unlikely, and immobilization can delay life-saving resuscitation. ^[4][14]

Technique ^[4][13][14]

• C-spine-specific immobilization methods
  • Rigid cervical collar
  • Manual in-line C-spine stabilization
• Immobilization of the rest of the spine (indicated as part of C-spine immobilization)
  • Maintenance of supine position, i.e., no bending or twisting of the spine
  • Log-roll maneuver to access the patient's back or protect the airway during emesis
• Additional measures during transfers and/or transport
  • Backboard (to immobilize the entire body) ^[13]
  • Supportive blocks on either side of the head (with the head secured to blocks and board)
• Spinal immobilization without cervical collar: can be maintained if there is an ongoing concern for T- or L-spine injury after successful C-spine clearance ^[15]

When C-spine immobilization is indicated, routinely immobilize the entire spine. ^[5][13]

To minimize complications, remove the rigid backboard as soon as possible using a log-roll maneuver once patients have been transferred to a stretcher. ^[15][16]

Manual in-line C-spine stabilization ^[17]

• A cervical spine immobilization technique that involves placing the hands on either side of the patient's head while gripping the skull base to keep it in a neutral position
• Clinical applications
  • Initial application of C-spine immobilization
  • Ongoing C-spine immobilization if a cervical collar is unavailable
  • Temporary C-spine immobilization if the cervical collar needs to be removed to allow unimpeded access to the neck, e.g., during examination or airway management

Log roll maneuver ^[18][19]

• A maneuver used to maintain spinal immobilization when repositioning patients between the supine and lateral decubitus positions
• Helpful for posterior body examination, preventing aspiration during emesis, and for transfers (e.g., from stretcher to examination table)
• Requires synchronized movement of multiple trained healthcare providers
  • At least one provider maintains manual C-spine in-line stabilization.
  • Others secure the limbs and support the patient's weight.

Complications ^[5][15]

• Pain
• Pressure ulcers
• Aspiration
• Ventilator-associated pneumonia
• Elevated ICP

Complications occur more commonly with prolonged spinal immobilization and the use of rigid cervical collars and backboards. ^[15][16]

Cervical spine clearance ^{[5][10][20][21]}

• Definition: the safe discontinuation of unnecessary C-spine immobilization (e.g., rigid cervical collar) as soon as possible to minimize complications
• Clinical clearance (i.e., without imaging) is appropriate for patients at low risk of C-spine injury per the CCSR or NEXUS criteria.
• Radiographic clearance (i.e., no evidence of fracture or instability on CT C-spine) is appropriate for:
  • Awake, lucid, and neurologically intact patients with neck pain
  • Patients with AMS and grossly intact motor function ^[5][20][22]
• Complex cases that require a spine specialist consult (and sometimes an MRI) include:
  • Suspected ligamentous injury
  • Persistent neurological symptoms
  • Clinical examination findings that do not correlate with imaging interpretation
  • High-risk degenerative changes on CT, e.g., disc protrusion ^[23]

Do not clear the C-spine in patients with obvious motor deficits and/or evidence of unstable spinal injury on imaging. ^[5]

See also “Clinical features of vertebral fractures.”

• Neck pain, tenderness, and/or deformity
• Torticollis
• Signs of cervical spinal cord or nerve root injury, e.g.:
  • Upper limb and/or lower cranial nerve neurological deficits
  • Tetraplegia
  • Hypoventilation due to respiratory center or phrenic nerve injury
• Other evidence of blunt head injury or blunt neck trauma
• Signs of airway obstruction, e.g., due to concurrent traumatic brain injury or an expanding perivertebral hematoma
• Signs of blunt cerebrovascular injury (BCVI), e.g., signs of stroke, Horner syndrome)
• For minor cervical injuries, see “Clinical features of neck sprain and whiplash injury.”

Clinical features may be subtle or absent. Consider C-spine injury in any patient with AMS, head injury, facial fractures, polytrauma, or injury to any other part of the spine following blunt trauma. ^[2]

Approach ^[8][24][25]

• Blunt trauma
  • Use clinical decision rules to determine the need for cervical imaging and avoid unnecessary radiation exposure.
  • First-line imaging (if indicated)
    • Adults: CT C-spine without IV contrast
      • Concurrent TBI suspected: Obtain CT head and neck without IV contrast.
      • Polytrauma: Obtain as part of whole-body CT.
    • Children: x-rays (See “C-spine x-rays in children” for details.)
  • C-spine injury identified on first-line imaging: Obtain CT of the whole spine. ^[26]
  • Suspected blunt cerebrovascular injury (BCVI): Obtain CTA head and neck if expanded Denver screening criteria for BCVI are met.
• Penetrating trauma: Obtain CTA neck (see “Penetrating neck trauma” for details).
• Suspected neurological or ligamentous injury: Add MRI head and neck without IV contrast.
• Suspected T- or L-spine injuries: See “Diagnosis of vertebral injuries.”

Maintain a high clinical suspicion for significant vertebral injury in older adults.

NEXUS criteria ^[27][28]

The National Emergency X-Radiography Utilization Study (NEXUS) criteria are a clinical decision rule for determining the need for C-spine imaging following blunt trauma.

• Patients meeting all the following criteria are at low risk for C-spine injury and do not require imaging:
  • No posterior midline cervical spine tenderness
  • No focal neurological deficits
  • Normal alertness
  • No evidence of intoxication
  • No distracting injuries
• Using NEXUS criteria reduces the rate of unnecessary imaging in low-risk patients. ^[24]
• Less accurate in older adults and children ^[29][30]
  • Use with caution in patients ≥ 65 years old; consider cervical imaging even if low-risk. ^[5][8]
  • May be used in children > 3 years of age, consider alternative clinical decision rules (see “C-spine injuries in children”) ^[9]

Canadian C-Spine Rule (CCSR) ^[28][31][32]

• A validated clinical decision rule used to determine the need for C-spine imaging following blunt trauma
• Involves the stepwise assessment of eligible patients
• Using CCSR leads to less unnecessary imaging than using NEXUS criteria. ^[24][33]
• Not applicable to children (see “C-spine injuries in children” for alternative clinical decision rules) ^[34]

CT C-spine ^[8][24][25]

• Best imaging modality to assess bony injuries
• Modality: noncontrast MDCT with thin (2 mm) slices from the skull base to the cervicothoracic junction ^[26]
• Can be obtained alone or in conjunction with other imaging (e.g., CT head and neck, whole body CT)
• Findings depend on injury level and type.
  • See “Upper C-spine injuries.”
  • See “Lower C-spine injuries.”

MRI C-spine ^[8][24][25]

• Best imaging modality to assess neurological or ligamentous injury
• Often obtained in addition to CT in patients with unstable vertebral injuries
• Indicated for known or suspected spinal cord or nerve root injury (with or without fracture on CT) ^[8]
• Not routinely indicated to rule out C-spine injury in patients with AMS and a normal CT C-spine; consider in select cases (see “C-spine clearance” for details) ^[5][20][22]

X-rays of the cervical spine

• Indications
  • Often used as initial imaging in pediatric patients (see “C-spine injury in children”) ^[9]
  • Not recommended in adults ^[5]
• Views
  • Anteroposterior (AP) and lateral views
  • Odontoid view: an AP view of C₂ obtained with the patient's mouth open to better visualize the odontoid process and atlantoaxial joint space.
  • Swimmer's view: a modified lateral view obtained by abducting the arm closest to the detector overhead to better visualize the C₇-T₁ junction
• Abnormal findings: Any of the following requires further workup with CT and/or MRI. ^[33][35][36]
  • Fracture lines
  • Evidence of subluxation or dislocation, e.g.:
    • Misalignment at the anterior vertebral line, posterior vertebral line, or spinolaminar line
    • Basion dens interval ≥ 12 mm in adults and children ^[37]
    • Basion axial interval ≥ 12 mm in adults and children ^[33]
    • Powers ratio ≥ 1 in adults and children ^[33]
    • Predental space ^[36]
      • > 3 mm in individuals > 8 years
      • > 5 mm in children ≤ 8 years

X-ray studies that do not allow complete visualization of all seven cervical vertebrae and the junction of C_7–T₁ are incomplete. ^[35]

See also “Initial management of C-spine injuries.”

Definitive management ^[4][5][33]

Definitive management must be guided by a specialist and is based on injury location, type, stability, and neurological involvement.

• Stable C-spine injuries without neurological involvement
  • Usually managed conservatively with external immobilization
  • Typical examples: clay-shoveler fractures, isolated transverse process fractures
• Unstable C-spine injuries and/or neurological involvement
  • Often require surgical intervention
  • Typical examples: most odontoid fractures, Jefferson fractures, atlanto-occipital dislocations, atlantoaxial dislocations, flexion teardrop fractures

In awake patients with cervical fracture-dislocations, early closed reduction may be attempted before surgical intervention to improve neurological outcomes. Expert consultation is mandatory. ^[4][38]

Disposition ^[33]

• Consider admitting patients with any of the following:
  • Identified fractures, dislocations, and/or ligamentous injuries
  • Neurological impairment (e.g., due to spinal cord injury or nerve root injury)
  • Significant discomfort
• Consider discharge with analgesics and return precautions for patients meeting all the following criteria:
  • Soft tissue injuries only
  • No radiological abnormalities
  • Mild, moderate, or no discomfort
  • See “Treatment of neck sprain and whiplash injury.”

Perform fall risk assessment after all falls in older adults.

Occipital condyle fractures ^[21][39][40]

• Description
  • Uncommon fractures involving the joint between the atlas (C₁) and the base of the occipital bone ^[39]
  • Usually caused by high energy impact, e.g., MVCs
• Clinical features ^[39]
  • AMS
  • Occipital pain and/or tenderness
  • Restricted craniocervical motion
  • Neurological dysfunction (common) ^[40]
    • Limb weakness
    • Hyperreflexia
    • Cranial nerve palsies
    • Vertigo
    • Hypoventilation
  • See also “Clinical features of C-spine injury.”
• Diagnosis ^[39]
  • CT head and neck: to confirm the diagnosis (plain x-rays are insensitive)
  • MRI head and neck: to evaluate for craniocervical ligament disruption (common)
  • See also “Diagnostics for C-spine injury.”
• Management ^[41]
  • Stable vertebral injury: conservative management with external cervical immobilization
    • Unilateral fracture: rigid cervical collar
    • Bilateral fracture: halo vest
  • Overt vertebral instability or neural compression: surgical internal fixation and fusion

Atlanto-occipital dislocation ^[37][42]

• Description
  • Disruption of articular alignment between the atlas and the occipital bone
  • Uncommon but severe traumatic injury
  • Often results in immediate death ^[42]
• Clinical features: highly variable
  • Signs of proximal spinal cord and/or brainstem injury, e.g.:
    • Limb weakness
    • Hyperreflexia
    • Lower cranial nerve injury
    • Respiratory failure and/or cardiac arrest
  • Normal neurological examination (∼ 20%): can lead to a delayed or missed diagnosis ^[37]
  • See also “Clinical features of C-spine injury.”
• Diagnosis
  • Imaging modalities: CT is recommended (plain x-rays are insensitive).
  • Findings: anterior, posterior, or vertical dislocation of the cranium ^[33][37]
    • Prevertebral soft tissue swelling, basion dens interval ≥ 12 mm ^[37]
    • Craniocervical subarachnoid hemorrhage
• Treatment: early surgery for craniocervical internal fixation and fusion

Atlantoaxial dislocation ^[43]

• Description
  • A rare but potentially fatal and disabling disruption of the articular alignment between C₁ and C₂
  • Can be precipitated by trauma, e.g., head injury
  • Usually associated with a risk factor for atlantoaxial instability, e.g., Down syndrome, rheumatoid arthritis
• Clinical features: See “Clinical features of C-spine injury.”
  • Common: neck pain, reduced active and passive ROM, weakness, sensory deficits, pyramidal tract signs
  • Less common: cranial nerve abnormalities, bowel or bladder dysfunction, respiratory distress, clinical features of vertebral artery dissection
• Diagnosis
  • Consult a specialist; dynamic (e.g., active flexion-extension) imaging views may be required to diagnose atlantoaxial instability.
  • See “Diagnostics for C-spine injury.”
• Management
  • Requires specialist consultation
  • Surgical reduction and spondylodesis are common even in asymptomatic individuals.
  • Nonoperative management, e.g., cervical traction, may be used in select cases.

If left untreated, atlantoaxial dislocation can cause respiratory failure, quadriplegia, and death.

Atlas (C₁) fractures ^[40][44][45]

• Description
  • Fractures involving the atlas with or without surrounding ligamentous injury
  • Usually resulting from axial loading or hyperextension of the neck (e.g., falls) ^[45]
  • Jefferson fracture: the combined fracture of the anterior and posterior arches of the C₁vertebra
  • Transverse atlantal ligament (TAL) rupture: disruption of the primary stabilizer of the atlantoaxial junction
• Clinical features: See “Clinical features of C-spine injury.”
  • Nonspecific symptoms (e.g., difficulty swallowing, neck pain) without neurological deficits (common) ^[45]
  • Signs of cranial nerve injury or BCVI (uncommon)
• Diagnosis: See “Diagnostics for C-spine injury.” ^[44][45]
  • X-ray with open mouth odontoid view: Lateral mass displacement ≥ 7 mm suggests TAL rupture. ^[45]
  • CT C-spine without IV contrast: required for definitive diagnosis of C₁ fractures
  • MRI C-spine: required for definitive diagnosis of ligamentous disruption
  • See also “Diagnostics for C-spine injury.”
• Management ^[44][45][46]
  • Isolated nondisplaced C₁ fractures: conservative management with external cervical immobilization
  • C₁ fracture with TAL rupture, concomitant C₂ injury, and/or neurological compromise: surgery

Axis (C₂) fractures ^[40][47]

Odontoid process fracture ^[21][48]

• Description: A fracture of the odontoid process typically caused by a shear injury from anterior-posterior head trauma ^[33]
• Epidemiology: 20% of C-spine fractures ^[21][48]
• Diagnosis: See “Diagnostics for C-spine injuries.”
  • Best seen on CT C-spine
  • Obtain odontoid views if x-rays are performed.
  • Fractures may involve the tip or base of the odontoid process or the body of C₂.
• Management: depends on the Anderson D'Alonzo classification of odontoid fractures

Hangman's fracture ^[33]

• Description: A hyperextension injury of the pars interarticularis of C₂
• Diagnosis: See “Diagnostics for C-spine injuries.”
  • Fracture of the pars interarticularis
  • Traumatic spondylolisthesis of C₂-on-C₃
• Management
  • Stable vertebral injuries: conservative management with external cervical immobilization
  • Unstable vertebral injuries (e.g., involvement of the posterior spinal column, significant displacement or angulation): surgical management ^[49]

Extension teardrop fracture ^[50]

• A rare injury involving avulsion of a bone fragment from the anterior inferior corner of the body of C₂
• Results from forceful hyperextension, e.g., diving, MVC
• Typically considered a stable vertebral injury (unlike flexion teardrop fractures)
• Usually managed conservatively if no severe ligamentous instability is present

General principles ^[51][52][53]

• Subaxial, (i.e., C₃–C₇), cervical injuries account for over two-thirds of C-spine injuries. ^[54]
• Management is case-specific and requires spine surgeon consultation. ^[52][53]
  • Usually guided by AO Spine classification ^[55][56]
  • Unstable vertebral injuries: surgery typically required
  • Stable vertebral injuries: Consider conservative management.

Flexion teardrop fracture ^{[57][58][59][60][61]}

• Description
  • An extremely unstable wedge-shaped fracture of the anteroinferior vertebral body, typically C₄, C_5, or C₆
  • Usually caused by high energy axial compression of the flexed cervical spine
• Clinical features: See “Clinical features of C-spine injury.”
  • Neurological manifestations range from asymptomatic to quadriplegia.
  • Clinical features of spinal cord injury typically present, often complete spinal cord injury
• Diagnosis
  • Imaging: both CT and MRI required for complete assessment
  • Findings
    • Forward displacement of the anterior vertebral body fragment
    • Posterior displacement of the posterior vertebral body (commonly into the spinal canal)
    • Disruption of anterior and posterior vertebral ligamentous structures
  • See also “Diagnostics for C-spine injury.”
• Management: usually requires early surgical decompression and fixation

Clay-shoveler fracture ^[62]

• Description
  • An avulsion fracture of a spinous process in the lower cervical spine or upper thoracic spine, most commonly C₆ or C₇
  • Typically caused by forceful flexion of the cervical spine
  • Most commonly seen following MVCs
• Clinical features
  • Acute onset of pain at the base of the neck
  • Localized tenderness over the spinous process
  • Reduced ROM of the neck
• Diagnosis: See “Diagnostics for C-spine injury."
  • Usually identifiable on lateral neck x-ray
  • CT may be indicated to rule out more severe C-spine injury.
• Management: usually managed conservatively
  • NSAIDs and rest
  • Rigid cervical collar for comfort (optional)

Cervical facet dislocation

Background

• Definition: the displacement of one cervical vertebra over another due to separation of the facet joints ^[63]
  • Facet joint involvement can be unilateral or bilateral.
  • May include facet fracture and/or ligamentous disruption
  • May lead to cervical instability and cause SCI, especially with bilateral facet dislocation
• Location: most commonly involves the C₅–C₇ junction
• Mechanism: : forceful flexion ; and distraction of the neck

Clinical features

See “Clinical features of C-spine injury.”

• Unilateral facet dislocation: normal neurological examination or evidence of monoradiculopathy ^[64]
  • C4/5: C5 radiculopathy
  • C5/6: C6 radiculopathy
  • C6/7: C7 radiculopathy
• Bilateral facet dislocation: clinical features of spinal cord injury (high risk), e.g.: ; ^[64]
  • Bilateral weakness of the upper and lower extremities
  • Sensory deficits below the level of the injury

Diagnostics ^[38][63]

See also “Diagnosis of C-spine injury.”

• Imaging modalities
  • CT C-spine: recommended in all patients
  • X-ray C-spine: Subtle facet subluxations may not be detectable.
  • MRI C-spine; : required in all patients before surgical intervention ^[63][65]
• Findings ^[35][63][65]
  • Vertebral subluxation: ∼ 25% in unilateral dislocation and ∼ 50% in bilateral dislocation
  • Gross malalignment or subtle subluxation of the vertebral facets
  • Widened distance between adjacent spinous processes
  • Disc space narrowing, soft tissue swelling, hypolordosis at injury level
  • Other: facet fractures, spinal cord or nerve root impingement, ligamentous disruption

Management ^[38][63]

• Early closed reduction: performed by a spine surgeon in awake patients ^[38]
• Surgical stabilization and fusion: typically indicated in all patients (even if closed reduction is successful)

Displacement, vertebral instability, and neurological injury are more likely with bilateral than with unilateral facet dislocation. Do not delay spine surgery consult for early closed reduction, especially for bilateral facet dislocations. ^[63]

Epidemiology ^[66]

• C-spine injuries account for 60–80% of spinal injuries in children.
• Overall incidence is lower than in adults.

Etiology ^[36][66]

C-spine injury in children is usually caused by blunt neck trauma.

• MVCs (most common cause in children < 8 years)
• Falls
• Sports-related injuries (common cause in older children)
• Child abuse (common cause in children < 2 years)

Pathophysiology ^[36][66]

• Large head in proportion to body size predisposes to upper C-spine injury. ^[26][66]
  • Craniocervical junction to C₃ level: most common area of injury in young children
  • Lower cervical spine: most common area of injury in children > 9 years of age
• Ligamentous injuries are more common than vertebral fractures.
• Spinal laxity (relative to adults) predisposes to SCIWORA.
• Noncontiguous multilevel spinal injury is less common than in adults. ^[13]

Clinical features

Clinical features in children are similar to clinical features of C-spine injury in adults.

C-spine immobilization in children

Indications ^[13]

Blunt trauma with any of the following:

• Neck pain
• Torticollis
• Neurological deficits
• AMS, e.g., GCS < 15
• Significant injury to the torso
• High-risk injury mechanism: e.g., MVCs, diving

Technique ^[13]

Technique is similar to C-spine immobilization in adults.

• Use an appropriately sized rigid cervical collar.
• In young children, place padding under the shoulders to avoid excessive cervical flexion.
• Minimize time on backboards to avoid complications (e.g., pressure ulcers).
• Consider vacuum mattress or padding to relieve pressure points.

C-spine clearance in children ^[67]

The following steps may be used to determine if removal of the cervical collar is appropriate:

• GCS ≥ 14
  • No neck pain, neurological deficits, abnormal head position, or distracting injuries: Clear cervical spine.
  • All other patients: Obtain x-rays of the cervical spine.
• GCS 9–13: Obtain x-rays of the cervical spine.
  • X-rays and follow-up examination within 12 hours are normal: Clear cervical spine.
  • X-ray or follow-up examination are abnormal: Consult a specialist.
• GCS ≤ 8: Obtain CT of the cervical spine.

Diagnostics ^[9][26][66]

Approach

• Use clinical decision rules, e.g., the PECARN C-spine rule
• Recommendations regarding the initial imaging modality for cervical spine evaluation in children vary; expert consultation is advised.

PECARN prediction rule for C-spine imaging in children ^[9]

• Obtain imaging in children < 16 years old with any of the following: ^[9]
  • AMS
  • Focal neurological deficit
  • Neck pain
  • Torticollis
  • Significant injury to the torso
  • Diving injury
  • High-energy MVC
  • Predisposing conditions (e.g., atlantoaxial instability)
• An updated PECARN C-spine rule has been derived for use in children < 18 years but is not yet externally validated. ^[68]

Other clinical decision rules ^[9]

• NEXUS criteria: can be appropriate for children > 3 years old
• Pieretti-Vanmarcke score
  • Appropriate for children ≤ 3 years old
  • Uses a weighted scoring system that accounts for age in months, GCS, and mechanism of injury (e.g., MVC)

C-spine x-rays in children ^[36][66][69]

• Indications: suspected C-spine injury, often the initial study (to avoid the higher radiation of CT scans) ^[9]
• Views: AP and lateral
  • Open-mouth odontoid views are seldom used. ^[66]
  • Passive flexion-extension x-rays are not routinely indicated in the acute setting. ^[9][26][36]
• Findings
  • See “X-rays of the cervical spine” for abnormal findings.
  • Normal variants in children include: ^[66][69]
    • Anteriorly wedge-shaped vertebral bodies
    • Anterior displacement (pseudosubluxation) of C₂ on C₃ ^[66]
    • Loss of cervical lordosis
    • Vertebral synchondroses ^[66][69]
    • Wider retropharyngeal space compared to adults

Other imaging modalities ^[9][26][66]

• CT of the cervical spine without IV contrast
  • Consider as initial study for children with obtundation, polytrauma, or high-risk injury mechanism.
  • Consider as follow-up study in patients with abnormal x-ray findings.
• MRI of the cervical spine
  • Indicated to evaluate neurological abnormalities
  • Consider as an alternative to CT scan in children < 5 years of age to avoid radiation exposure. ^[66]

Management

Management principles are similar to those in adults, but early involvement of a pediatric spine specialist is advised.

• See “Initial management for cervical spine injury.”
• For specific injuries, see “Upper cervical spine injuries” and “Lower cervical spine injuries.”
• See also “Spinal cord injury without radiographic abnormality” (SCIWORA).

Prognosis ^[36]

Severe sequelae are common:

• Up to 60% irreversible neurological damage
• Up to 40% mortality

• See “Complications of vertebral injuries.”
• See “Complications of spinal cord injury.”

We list the most important complications. The selection is not exhaustive.