Clearance of Cervical Spine after Blunt Injury
Unrecognized cervical spine injury (CSI) can produce catastrophic neurologic disability. CSI are rare in children (0 to < 18 years of age) occurring in 1% of blunt trauma patients who are evaluated with cervical spine radiographs (plain radiographs, computed tomography and/or MRI). The occurrence is extremely rare in children less than 2 years of age. Evidence-based criteria that can be used to predict which blunt trauma children necessitate radiographic studies do not exist. The lack of such criteria is due to the rare occurrence of CSI in children. The following guidelines are based on a multi-center prospective observational study of 3065 children (0 to 18 years) who were included in the National Emergency X-Radiography Utilization Study. Caution is recommended when applying these guidelines, particularly to younger pre-verbal pre-cooperative children. Limitation of data requires practical (instead of evidence-based) management recommendations.
Who needs radiographs of the cervical spine after blunt trauma?
Indications for radiographic studies include the presence of one or more of the 5 criteria listed below. (AP, lateral and odontoid plain films for children > 5 years. AP and lateral for age 5 years and below. Flexion/extension plain films are not routine, and only should be consider when requested and supervised by the neurosurgery service).
- Midline posterior cervical tenderness
- Evidence of intoxication
- Altered level of consciousness
- Abnormal neurologic examination
- Distracting painful injury
NOTE: If any one of the criteria cannot be evaluated, the criteria is considered present and radiographs are indicated. In non-communicative/ non-cooperative children (especially < 3 years of age) with a significant mechanism of injury, consider radiographs even in the absence of the 5 criteria listed above.
Who needs CT scan of the cervical spine after blunt trauma?
- Patients who need an urgent CT scan of other body area (head, abdomen, chest).
- High risk patients (significant mechanism of injury, pre-verbal and/or pre-cooperative, focal neurologic findings, significant altered level of consciousness and/or significant posterior midline neck pain).
- Patients who will likely have inadequate cervical spine plain films secondary to obesity/muscle bulk.
Who needs a neurosurgical service consultation?
- Abnormal cervical spine radiographs (plain films and/or CT scan)
- Abnormal neurologic examination (focal neurologic findings or altered level of consciousness).
- normal radiographs but continued presence of significant posterior midline cervical spine pain/tenderness.
- normal radiographs but history and resolution of focal neurologic findings.
- normal radiographs but significant mechanism of injury in a pre-verbal/pre-cooperative child.
Who can be cleared of a cervical spine injury by a non-neurosurgeon?
- no posterior midline cervical tenderness
- normal neurologic examination
- no intoxication
- no altered level of consciousness
- no painful distracting injury
- normal radiographs and resolution of significant midline tenderness and/or altered level of consciousness when either one was the criteria that necessitated the radiographs.
NOTE: Radiographic studies of children < 2 years of age must be interpreted by the radiology attending physician.
- Viccellio P, et al. A Prospective Multi-center Study of Cervical Spine Injury in Children. Pediatrics 2001;108:e20
- Holmes JF, Akkinepalli R. Computed Tomography Versus Plain Radiography to Screen for Cervical Spine Injury: A Meta-Analysis. J Trauma 2005;58:902-905
- Anderson RCE, et al. Cervical Spine Clearance After Trauma in Children. Neurosurg Focus 2006;20:e3
- Slack SE, Clancy MJ. Clearing the Cervical Spine of Paediatric Trauma Patients. Emer Med J 2004;21:189-193
- Hendey GW, et al. Spinal Cord Injury Without Radiographic Abnormality: Results of the National Emergency X-Radiography Utilization study in Blunt Trauma. J Trauma 2002;53:1-4
- Woods WA. Pediatric Cervical Spine Injuries: Avoiding Potential Disaster. Trauma Reports 2003;4:1-9