1. Pediatric cervical injuries
AHMAD ALTHEKAIR, MD
CONSULTANT, PEDIATRIC EMERGENCY AND TRAUMA

2. Objectives
 Epidemiology
 Mechanism of injury
 Clinical presentation
 Approach
 Clinical vs. radiological clearance
 Current evidence

3. Incidence
Annually 30-46/1,000,000
Males 60-80%
MVCs
35%
Falls
25%
MVC vs.
pedestrian
20%
Diving
6%
sports
14%
LEONARD ET AL, PEDIATRICS VOLUME 133, NUMBER 5, MAY 2014

4. Age variation
<8 years are susceptible to higher cervical injuries (C1-C3) because of:
1. Larger heads than bodies
2. Position of C-spine fulcrum
3. Weaker cervical muscles
4. Increased laxity of ligaments
5. Immature vertebral joints

5. Anatomical predispositions

6. Causes

7. Mechanism of injury
COURTESY OF ALISON CHANTAL CAVINESS, MD.

8. Evaluation
Symptoms:
◦ Classic triad of: local pain, muscle spasm, and decreased range of motion of
the neck.
◦ Also may complain of transient or persistent paresthesia or weakness.
◦ A retrospective review of 72 previously normal children with cervical spine
injury found that all those with asymptomatic injuries had both a high-risk
injury mechanism and a distracting injury.
◦ “Burning hand syndrome”
“Neck immobilization should be maintained during evaluation and
management”
BAKER ET A, AM J EMERG MED. 1999;17(3):230.

9. Evaluation
Physical Examination:
◦ Vital signs, Neck exam and
Neurologic exam.
In toddlers and infants with minor
trauma and normal neurological
exam; palpate C-spine and assess
ROM. If normal, clinically cleared.

10. NEXUS criteria
1. No cervical midline tenderness
2. No focal neurological deficit
3. No intoxication
4. Normal alertness
5. No painful distracting injuries
 34,069 trauma victims in 21 nation-wide Emergency departments had 99%
sensitivity for C-spine injuries and 99.6% for clinically significant C-spine
injuries in adults.
HOFFMAN ET AL, N. ENGL. J. MED. 2000;343:94-9

11. Limitations in Pediatric
 3,065 children were involved, 30 had C-spine injuries.
 Sensitivity 100% , Specificity 19.9%.
 None of the children studied was younger than 2 years, and only 817 (27%)
were younger than age 8 years .
PEDIATRICS 2001;108:E20

12. Further studies
 Single-center, 20-year review applied the NEXUS criteria to 190
children with significant cervical spine injury found that the criteria
were 94% sensitive among children aged less than 8 years and 100%
sensitive in those greater than age 8 years.
 A Pediatric Emergency Care Applied Research Network (PECARN)
study found that the NEXUS criteria were 83% sensitive among 539
children with spinal injury who presented to the emergency
department. Of the 90 children missed by the NEXUS criteria, 58 (64%)
were younger than 8 years of age.
GARTON ET AL, NEUROSURGERY 2008;62:700-8
LEONARD ET AL, ANN EMERG MED 2011 AUG;58(2):145-55

13. Canadian C-spine Rules

14. Canadian C-spine vs. NEXUS
Canadian C-spine NEXUS
Sensitivity 99.4% 90.7% P<0.001
Specificity 45.1% 36.8% P<0.001
Radiography rates 55.9% 66.6% P<0.001
 The Canadian C-spine Rule would have missed 1 patient and the NEXUS
would have missed 16 patients with important injuries.
 But, both are not meant for pediatric population.
STIELL ET AL, N ENGL J MED 2003; 349:2510-2518

15. Trauma Association of Canada
CHUNG ET AL, TRAUMA ASSOCIATION OF CANADA PEDIATRIC SUBCOMMITTEE NATIONAL PEDIATRIC CERVICAL SPINE EVALUATION
PATHWAY: CONSENSUS GUIDELINES. J TRAUMA 2011

16. Trauma Association of Canada
CHUNG ET AL, TRAUMA ASSOCIATION OF CANADA PEDIATRIC SUBCOMMITTEE NATIONAL PEDIATRIC CERVICAL SPINE EVALUATION
PATHWAY: CONSENSUS GUIDELINES. J TRAUMA 2011

17. Radiological evaluation
 Children with suspected cervical spine injury based on history or physical
examination must undergo radiologic evaluation (Cross-table lateral, AP
and when obtainable open-mouth odontoid).

18. Indications
 High risk-mechanism:
◦ High speed motor vehicle collision, bicycle injury, diving or other activity with
hyperextension or hyperflexion of neck, falls greater than body height, and
other acceleration-deceleration injuries of the head.
Multiple system with severe injuries
Distracting pain
Injury above clavicle
Altered mental status
Neck pain, tenderness or limitation of movement
Acute neurological deficit

19. C-spine xrays
• Coverage
• Alignment
• Disc spaces
• Prevertebral soft tissues
• Edge of image
Anterior vertebral line
Posterior vertebral line
Spinolaminar line

20. C-spine xrays
• Coverage
• Alignment
• Bone
• Spacing
• Soft tissues
• Edge of image

21. C-spine xrays
• This view is considered
adequate if it shows the
alignment of the lateral
processes of C1 and C2 (red
circles)
• The distance between the peg
and the lateral masses of C1
(asterisks) should be equal on
each side

22. Extra views?
If C7/T1 has not been adequately
viewed on the lateral image

23. Flexion / Extension views
 If Normal plain films AND No neurological deficit AND continued neck pain
AND can actively flex/extend neck for examination.

24. Efforts to reduce radiation
 A simple decision instrument based on clinical criteria can help
physicians to identify reliably the patients who need radiography of the
cervical spine after blunt trauma. Application of this instrument could
reduce the use of imaging in such patients.
The NEXUS decision instrument performed well in children, and its use
could reduce pediatric cervical spine imaging by nearly 20%. However,
the small number of infants and toddlers in the study suggests caution
in applying the NEXUS criteria to this particular age group.
HOFFMAN ET AL, N ENGL J MED. 2000;343(2):94.
VICCELLIO ET AL, PEDIATRICS. 2001;108(2):E20.

25. More efforts
CSI in patients younger than 3 years is uncommon. Four simple clinical
predictors can be used in conjunction to the physical examination to
substantially reduce the use of radiographic imaging in this patient
population.
The protocol used has been effective in detecting cervical spine
injuries in noncommunicative children after trauma. The combination of
clinical information and radiographic studies is essential for safely
clearing the cervical spine in these complex situations. Clearance of the
cervical spine without CT or MR imaging studies is possible in the
majority of cases, even in very young patients.
PIERETTI-VANMARCKE ET AL, J TRAUMA. 2009;67(3):543.
ANDERSON ET AL, J NEUROSURG PEDIATR. 2010;5(3):292.

26. Indications for CT C-spine
Lower or upper C-spines not visualized on plain films
Abnormal or suspicious C-spine on plain films
Suspicion of injury despite normal plain cervical radiographs
As part of initial evaluation of severe head trauma (GCS ≤12) instead of
plain films
CHUNG ET AL, TRAUMA ASSOCIATION OF CANADA PEDIATRIC SUBCOMMITTEE NATIONAL PEDIATRIC CERVICAL
SPINE EVALUATION PATHWAY: CONSENSUS GUIDELINES. J TRAUMA 2011; 70:873.

27. Indications for MRI
Children with an abnormal neurologic examination and those requiring
imaging of the soft tissues of the spinal column and spinal cord
Patients with normal plain films but persistent concern for neurologic
injury based upon history
Patients with prolonged loss of consciousness in whom cervical spine
cannot be cleared by 24 to 72 hours post injury
CHUNG ET AL, TRAUMA ASSOCIATION OF CANADA PEDIATRIC SUBCOMMITTEE NATIONAL PEDIATRIC CERVICAL
SPINE EVALUATION PATHWAY: CONSENSUS GUIDELINES. J TRAUMA 2011; 70:873.

28. Real life cases
7 year old girl cheerleader, fell
from 4 meters on the back of her
head and had loss of
consciousness. C/O tingling
sensation at her arms.

29. Case 2
14 year old involved in a fight and
was hit with a stick to his forhead.
C/O multiple facial fractures

30. Case 3
11 year old boy on a bicycle not
wearing helmet, smashed a phone
booth and fell with severe orbital
swelling.

31. Case 4
1 year and 6/12 old girl fell from
2nd floor balcony to the street.
Unwitnessed. Crying from neck
pain.

34. Take home message
The patient's ability to walk does not exclude cervical spine injury.
Immobilization should be maintained until clearance.
Spinal cord injury can happen without radiological evidence.

35. Thank you