What are the guidelines for C (cervical) spine clearance in pediatric patients?

Guidelines for Cervical Spine Clearance in Pediatric Patients

For pediatric patients with suspected cervical spine injury, a structured approach using appropriate clinical assessment criteria followed by selective imaging is recommended, with radiographs as the initial imaging modality for most children with concerning findings. 1

Clinical Assessment

Age-Based Considerations

• Children <8 years of age have unique cervical spine characteristics including incomplete ossification, unfused synchondroses, ligamentous laxity, and a large head-to-body ratio, making upper cervical spine injuries more common 1
• After age 8, spinal column development matures and injuries more commonly involve the lower cervical spine 1
• Normal variants in young children <8 years (pseudosubluxation of C2-C3, absence of lordosis, widened atlantodental interval) can complicate imaging interpretation 1

Clinical Decision Rules

• The Pediatric Emergency Care Applied Research Network (PECARN) criteria demonstrated 98% sensitivity for identifying cervical spine injuries in children 1
• While the National Emergency X-Radiography Utilization Study (NEXUS) criteria have been applied to children, the sample size of young children in validation studies was small 1, 2
• Most pediatric cervical spine clearance protocols (75%) utilize some or all NEXUS criteria, though significant variability exists in implementation 2

Imaging Algorithm

For Alert, Conversant Children Without Risk Factors

• Cervical spine imaging is not necessary if the child is alert, conversant, has no neurological deficit, no midline cervical tenderness, no painful distracting injury, and is not intoxicated 3

For Children with Risk Factors

• Initial imaging should include anteroposterior (AP) and lateral cervical spine radiographs in children who are not alert, nonconversant, have neurological deficit, midline cervical tenderness, painful distracting injury, or are intoxicated 1, 3
• For children ≥9 years with risk factors, add open-mouth views to AP and lateral radiographs 3
• Two or more radiographic views detect cervical spine abnormalities with a sensitivity of 90% 1

Follow-up Imaging

• CT cervical spine is recommended as follow-up when radiographs show abnormal or ambiguous findings 1
• Consider limited CT of C1-C4 rather than full cervical spine CT in children <8 years to reduce radiation exposure, as most pediatric CSIs occur between the occiput and C4 4
• MRI is recommended for children with abnormal neurological examination, suspected SCIWORA (Spinal Cord Injury Without Radiographic Abnormality), or suspected ligamentous injury 1
• MRI is the modality of choice for evaluation of soft tissues, with fat-saturated T2 sequences best for visualizing soft-tissue injuries 1

Special Considerations

Unconscious or Intubated Children

• For unevaluable children (unconscious, intubated), radiographs alone may be insufficient; lateral radiographs in unconscious intubated patients have shown sensitivity of only 51.7% for unstable injuries 1
• Recent evidence suggests multidetector CT has 100% sensitivity for detecting clinically significant cervical spine injuries in pediatric trauma patients, regardless of age or mental status 5
• MRI has been suggested for children in whom unconsciousness is predicted to last beyond 48 hours or in whom clinical clearance within 72 hours is unlikely 1

Vascular Imaging

• Consider CTA or MRA for children with risk factors for vascular injury: fractures involving the transverse foramen, traumatic facet dislocations, ligamentous injury, neurological deficits, and fractures of C1-C3 1
• Cervical vascular injury can be seen in 11.5% of pediatric patients with blunt trauma 1

Young Children (<3 years)

• Protocol-driven approaches have been shown effective in detecting cervical spine injuries in noncommunicative young children 6
• For children <8 years, consider thoracic elevation or an occipital recess when immobilized supine to achieve better neutral alignment due to their relatively large head size 3

Pitfalls and Caveats

• Flexion/extension views in acute settings are rarely needed in children and may be limited by pain and muscle spasm 1
• Young children and those with developmental delays may require sedation for CT and MRI, which carries additional risks 1
• Children with certain conditions (Down syndrome, achondroplasia, mucopolysaccharidosis, Marfan syndrome) or on systemic glucocorticoid therapy have higher risk for cervical injuries 1
• While MRI has high sensitivity for soft-tissue injury, its lack of specificity may make it less suitable for operative decision making 1