Cervical Spine Clearance
What are the differences between pediatric and adult C-spines?
The cervical spine of a child is still developing and has different proportions than an adult's. Children have larger heads and thus a higher fulcrum point which leads to higher c-spine injuries. The majority occur between C1 and C4. More horizontally-oriented vertebral facet joints promote sliding and dislocation. The cervical spine of a child is more mobile with greater ligamentous laxity than an adult's, which can reduce the risk of bony injuries but the spinal canal is narrower in children, making them more vulnerable to spinal cord injury without radiographic abnormality (SCIWORA)
The mechanism of injury for a cervical spine injury in children is often different than in adults. Children are more likely to sustain a spinal cord injury from a high-velocity injury, such as a motor vehicle accident, while adults are more likely to sustain a spinal cord injury from a fall.
Why is clearing the C-spine important?
The cervical spine, or the neck, is a crucial part of the body that supports the head and allows for movement. When someone experiences trauma, the cervical spine may be injured, which can be potentially life-threatening. If the spine is not cleared, it could result in long-term damage, paralysis, or even death. C-spine clearance is TIME SENSITIVE. The goal is to either clear the c-collar or determine a cervical injury promptly after the patient's arrival. Greater than 20 minutes in a c-collar or board can result in increased pain, rates of admission, and radiographs.
How do you clinically clear a C-spine?
-
The NEXUS criteria have a sensitivity of 99.6% for ruling out cervical spine injury in the original study validating the criteria (95% confidence interval, 98.6-100%). However, it had few children <9 years old and there were low numbers of children of any age with any true c-spine injuries. Potentially useful in children 9-17 years old.
A commonly used mnemonic to remember the criteria is "NSAID":
No Neurological deficit
No Spinal tenderness
No Altered mental status
No Intoxication
No Distracting injury
If any of the above criteria are present, the C-Spine cannot be cleared clinically by these criteria.
-
The initial study demonstrated a sensitivity of 98% and a specificity of 26%.
When ALL features are absent c-spine injury can be ruled out.
Altered Mental Status
Focal Neurologic Findings
Substantial Torso Injury
Neck Pain
Torticollis
High-risk predisposing conditions (ie Trisomy 21)
Diving
High-Risk Motor Vehicle Crash
Imaging considerations:
Patients with GCS <14 or signs of focal neurologic deficits should receive a CT C-spine w/o contrast OR MRI.
CT C-spine w/o contrast
If negative imaging but continued midline cervical spine tenderness, then discharge with a cervical collar and f/u with PMD, trauma surgery, or neurosurgery in 24 hours (and clear if no neck pain). Consider MRI to assess for ligamentous injury and SCIWORA (spinal cord injury without radiographic abnormality)
MRI
MRI is less sensitive than CT for certain cervical fractures, however, it is superior for visualizing soft tissue injuries and identifying ligamentous injuries, intervertebral disk herniations, and spinal cord injuries (SCIWORA).
Patients with GCS >14 and normal neurologic exam should receive a cervical XR.
XR Cervical Spine (AP, Lateral, Odontoid): The use of a cross-table lateral view radiograph provides a 79% sensitivity; the addition of the AP and odontoid views increases sensitivity to 94%. Important to include all seven vertebrae.
If inadequate images were obtained and suspicion is low, then DC
If inadequate or abnormal images were obtained or suspicion is high, then obtain a CT or MRI
References
Baker C, Kadish H, Schunk JE. Evaluation of pediatric cervical spine injuries. Am J Emerg Med. 1999 May;17(3):230-4.
Gopinathan N, Viswanathan V, Crawford A. Cervical spine evaluation in pediatric trauma: A review and an update of current concepts. Indian J Orthop. 2018;52(5):489-500.
Kush S. Mody, Martin Herman, Darshan Parikh, Philip Petrucelli, Kristin Brown; Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. Pediatrics August 2019; 144 (2_MeetingAbstract): 732. 10.1542/peds.144.2MA8.732
Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC; Pediatric Emergency Care Applied Research Network (PECARN) Cervical Spine Study Group. Cervical spine injury patterns in children. Pediatrics. 2014 May;133(5):e1179-88.
Rosati SF, Maarouf R, Wolfe L, Parrish D, Poppe M, Manners R, Brown K, Haynes JH. Implementation of pediatric cervical spine clearance guidelines at a combined trauma center: Twelve-month impact. J Trauma Acute Care Surg. 2015 Jun;78(6):1117-21.
