Cervical spine injuries are serious but rare events in children.^1–7 Emergency physicians are often the first to evaluate children with cervical spine injury and must quickly triage those with potential for worsening neurological deficits from those with either no injury or cervical sprain. Occasionally these decisions are made in the absence of cervical spine imaging when dealing with a child’s unstable airway or other life-threatening injuries. These challenges raise some specific questions. Are there specific subsets of children at the highest risk for cervical spine injuries? Which children should receive spinal motion restriction, and how is this best achieved? How is the cervical spine “cleared”?

Cervical spine injury represents a small subset of injured children. Cervical spine injury affects up to 1.8% of children evaluated in the emergency department (ED) after blunt trauma.^3,4–6 Overall mortality associated with cervical spine injury in children is 7.4%; however, this rate may be as high as 26% in children <2 years.^3,4,7 This increased risk of mortality is likely associated with proportionately higher rates of upper cervical spine injuries in young children.^3,4,7

Motor vehicle crashes are the most common cause of cervical spine injuries.^3,7–9 However, the mechanisms vary by age. Neonates may suffer cervical spine injuries from birth trauma, particularly in the case of breech or forceps deliveries.^10,11 The incidence of nonaccidental trauma is likely underestimated in the pediatric population.¹² Sports-related injuries, pedestrians hit by motor vehicles, and falls are common mechanisms of cervical spine injury in older children and adolescents, whereas violent injuries, including assault and gunshot wounds, occur in the late teenage years.^7–10,13

Although the development of the subaxial vertebrae is relatively consistent, the components of the craniocervical junction and upper cervical spine (occiput, atlas, and axis) have distinctive developmental patterns. Recognition of this is critical in differentiating fractures from normal developmental anatomy.

The atlas (C1) has three primary ossification centers: one anterior arch and two neural arches. There are open cartilaginous synchondroses between the anterior arch as well as posteriorly between the two neural arches. By age of 3 years, the neural arches are typically fused to form the solid posterior ring of C1. The neurocentral synchondrosis fuses by age of 7 years.^14,15 Four identifiable ossification centers are present in the developing axis (C2).^14–16 The neural arches of C2 fuse posteriorly by age of 3 years. The body of C2 fuses with the neural arches and the dens between ages 3 and 6 years. However, the subdental synchondrosis may be seen until ages 10 to 11. Any lucency at the base of the dens beyond this age is abnormal and should be considered a fracture.¹⁶ Each vertebra of the subaxial cervical spine (C3 to C7) follows the same developmental pattern. Three primary ossification centers occur at each level: a centrum for the body and two neural arches. In the subaxial spine, the neural arches fuse by age 3 years, whereas the body fuses with the neural arches by ages 3 to 6 years.^14–16 Secondary ossification centers in the transverse and spinous processes are present by puberty and fuse completely by the third decade.^14–16

A relatively large head compared with the remainder of the body, immature neck and paraspinal musculature, underdeveloped ligaments, incompletely ossified bone, anterior wedging of vertebral bodies, absent uncinate processes, and shallow, horizontally oriented facets all contribute to hypermobility in the pediatric cervical spine.^17–21 As a result, the fulcrum of motion in the pediatric cervical spine is at C2 to C3, and with maturation of the spine and supporting soft tissues the fulcrum migrates to C5 to C6 by age 14 years, making the biomechanics of the cervical spine and the injuries sustained similar to those observed in adults.^18,21,22

All trauma evaluations begin with attention to the ABCs: airway, breathing, and circulation. Airway obstruction is common in the unconscious or severely injured child and should be treated rapidly. The unconscious child may be unable to cough or clear mucus, vomitus, blood, or other debris. Be cognizant of the potential for a cervical spine injury, which could be worsened by excessive motion of the spine, and stabilize the cervical spine (Fig. 25-1).

The spine-injured patient may become hypopneic because of diminished diaphragmatic activity or intercostal muscle paralysis. Provide oxygen, assist ventilations if needed. Although the bag-mask technique will permit ventilation, prolonged use increases the risk of aspiration. Cervical spine immobilization with an orthotic device makes direct laryngoscopy three times more difficult than manual immobilization during intubation.²³ Manual in-line cervical stabilization, rapid sequence induction, and oral endotracheal intubation are the preferred techniques to achieve airway stabilization in children with suspected cervical spine injury (Fig. 25-2). In children, blind nasotracheal intubation is unreliable because it can be technically difficult. The emergency physician must ensure an adequate airway and should not delay doing so while waiting for the cervical spine to be cleared.

Hypotension in the injured child may be secondary to either hypovolemia or spinal shock. A clue to differentiating these is the pulse, which is slow in spinal shock and rapid in hypovolemic shock. Adequate fluid (crystalloid, colloid, and blood) is administered to combat hypovolemia. In the case of spinal shock, vasopressors, such as dopamine, may be needed. The patient with spinal shock may be more sensitive to temperature variations than other patients and may require warming or cooling if subjected to extreme environmental temperatures either at the scene or during transport. Protect areas of the body that may have lost sensation from hard, protruding objects, as they may cause skin necrosis, especially on long transports.

Once the patient’s cardiopulmonary status is stabilized, a thorough physical assessment and neurologic examination is performed. Each sensory modality (proprioception, vibration, and pain and temperature) should be checked. Evaluate the patient for weakness by having the child handle an item or hold each extremity off of the stretcher for a count of five if the child is conscious and old enough to follow commands. More ingenuity is needed for the infant and toddler. A useful diagnostic mnemonic is to evaluate the “six P’s”: pain, position, paralysis, paresthesia, ptosis, and priapism. Conscious children old enough to talk may complain of pain localized to the involved vertebra. Younger children may resist lying flat or in positions that increase pain or neurological symptoms. Head injury with diminished level of consciousness or intoxication may make the localization of cervical pain unreliable. The patient’s head and neck positioning may indicate a spine injury. A head tilt may be associated with a rotary subluxation of C1 on C2 or a high cervical injury. The prayer position (arms folded across the chest) may signify a fracture in the C4 to C6 area. Paresis or paralysis of the arms or legs should always suggest spine injury. Paresthesia, a “pins-and-needles” sensation or numbness or burning, may be related to peripheral nerve injury; however, these symptoms when occurring bilaterally can be taken as indicators of potential spine injury. Some patients complain of a transient shock-like or electrical sensation transmitted down the spine during neck flexion and/or rotation (Lhermitte sign). Horner syndrome (ptosis and a meiotic pupil) suggests a cervical cord injury. Priapism is present only in approximately 3% to 5% of spine-injured patients, but indicates that the sympathetic nervous system is involved. Absence of the bulbocavernosus reflex in the presence of flaccid paralysis carries a grave prognosis. To elicit the bulbocavernosus reflex, a finger is inserted into the rectum, and then the glans of the penis or the head of the clitoris is squeezed. A normal response is a reflex contraction of the anal sphincter.

There are also characteristic cord syndromes (Table 25-1). In spinal shock, there is flaccid paralysis below the level of the lesion, absent reflexes, decreased sympathetic tone, and autonomic dysfunction. Sensation may be preserved but if it is absent, the prognosis for recovery is poor. Central cord syndrome is often associated with extension injuries, which can cause compression of the spinal cord by the ligamentum flavum. The anterior cord syndrome is associated with severe flexion injuries, especially teardrop fractures, in which a fragment of the fractured vertebral body is driven posteriorly into the anterior portion of the spinal cord.

Upper extremity position and function may provide clues not only to the presence of a cervical cord injury but also to the level of injury. With injuries at C5, patients can flex at the elbows but are unable to extend them; with injuries at C6 to C7, they can flex and extend at the elbows, and injuries at the T1 level allow finger and wrist flexion.

During trauma evaluation, determine whether the child is at risk for cervical spine injury and warrants application of a rigid cervical collar and radiographic evaluation. Clinical criteria for “clearing” the cervical spine have been established in adults. The National Emergency X-Ray Utilization Study (NEXUS) collaboration identified five clinical screening criteria (posterior midline cervical tenderness, altered alertness, distracting injury, intoxication, and focal neurologic findings), which have nearly 100% sensitivity for cervical spine injury and had good interrater agreement among emergency physicians.^24–27 Alternatively, the Canadian C-spine Rule has been reported to have nearly 100% sensitivity for cervical spine injury in alert and stable adult trauma patients. The Canadian C-spine Rule was based on clinical, epidemiologic, and mechanism of injury variables.^28,29 Neither of these studies focused on children. The Pediatric Emergency Care Applied Research Network (PECARN) conducted a large multicenter retrospective case-control study which included 540 children with cervical spine injury and identified eight risk factors that predicted injury (Table 25-2).³⁰ When one or more of these factors were present, these factors were 98% sensitive and 26% specific for detection of cervical spine injury.³⁰ Although this eight-variable model requires prospective refinement, the consistency of the model with smaller pediatric studies and large adult trials supports the use of these risk factors until further evidence is developed (Fig. 25-1).³⁰

Unstrap and promptly remove all trauma victims from the rigid long board, when used for extrication in the out-of-hospital setting. This aspect of providing “spinal precautions” is known to be associated with adverse effects. Ventilation of trauma victims may be encumbered by use of both a rigid cervical collar and a rigid long board. Studies in healthy adults and children who were fully immobilized demonstrated a mean reduction in forced vital capacity (FVC) to 80% of their unrestrained supine FVC.^31–33 Spinal precautions are also associated with pain and discomfort, which may last beyond the immediate period of immobilization.^33–36 Furthermore, pain caused by spinal precautions may be confused with pain caused by injury, leading to unnecessary diagnostic evaluations.³⁷ In spine-injured patients, prolonged immobilization on a rigid long board is associated with an increased risk of developing pressure sores during the immediate post-injury period.^38,39 The American College of Surgeons, the American College of Emergency Physicians, and the National Association of Emergency Medical Services Providers have position statements advocating the limited use of spinal precautions, particularly the rigid long board, due to these harmful effects.^40,41 The cervical collar can be discontinued once it has been determined either clinically or with imaging that the victim is free of cervical spine injury.

If a child may be at risk for cervical spine injury, take precautionary steps to maintain neutral cervical spine positioning. In this position, the cervical spine is in lordosis, and there is maximal spinal canal diameter. Achieving this position in children can be difficult; depending on habitus, supine positioning can result in nonphysiologic positions ranging from up to 27-degree flexion or extension from neutral.^42,43 In children younger than 8 years, supine positioning without shoulder padding results in cervical kyphosis due to a relatively large head (Figs. 25-3 and 25-4).^43,44 In adults, however, supine positioning causes relative cervical lordosis.^45,46 Thus, as a child grows, padding may be required in either the shoulder or occipital regions to provide neutral positioning. Avoid forcing children into positions that cause pain or worsening neurological complaints. Reserve rigid long boards for prehospital extrication and remove immediately on patient hospital arrival.

Rigid collars are available for infants and children; however, the availability of these devices is limited in the prehospital setting. Prehospital providers may have to rely on using padding around a child’s head and neck to minimize motion. The decision regarding the type of orthosis needed depends on the age of the patient, the affected levels, and the restriction of movement needed (flexion, extension, rotation, etc.). Studies have demonstrated that the commonly available rigid cervical collars, such as Aspen, Miami J, and Philadelphia, all provide significant restriction in neck movement but have subtle variations, and the final choice of cervical collar is often based on availability and the recommendations of a spine surgeon.⁴⁷