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Clearing the Pediatric C-Spine. Kelly R. Millar, MD, FRCPC Emergency Physician, Alberta Children’s Hospital Assistant Professor, University of Calgary. Overview. Epidemiology Anatomic considerations Clearing the pediatric c-spine Who needs imaging? What films should be ordered?

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Clearing the Pediatric C-Spine

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Clearing the Pediatric C-Spine

Kelly R. Millar, MD, FRCPC

Emergency Physician, Alberta Children’s Hospital

Assistant Professor, University of Calgary


  • Epidemiology

  • Anatomic considerations

  • Clearing the pediatric c-spine

    • Who needs imaging?

    • What films should be ordered?

    • Who needs a CT/MRI?

  • Interpretation of Pediatric c-spine films

  • Cases

Epidemiology of PediatricCervical Spine Injury

  • 5% of all spinal cord injuries occur in children

  • 1000 pediatric spinal cord injuries in the US each year

  • 80% of spinal injuries in children < 8 yrs are cervical (vs 30-40% in adults)


  • Many small case series

  • Often include up to age 20, so data very skewed to older “children”

  • 2 recent large pediatric data sources have fair number of younger children:

  • The largest prospective series is the pediatric subset of the NEXUS trial

  • The largest retrospective series comes from the National Pediatric Trauma Registry

How common are pediatric C-spine injuries?

National Pediatric Trauma Registry

  • Prospective, multi-center database

  • Includes ages 0-20

  • Primary diagnosis traumatic injury

  • Patel et al (2001) J Ped Surg

  • 10 yr review (1988-98)

  • > 75,000 pediatric injuries in database

  • 1.5% had cervical spine injury (N = 1098)

National Pediatric Trauma RegistryKokoska et al (2001) J Ped Surg

  • 6 year review of same database

  • 1994 – 99

  • Age distribution of

    c-spine injuries →

  • Younger age groups well represented

Age (yrs)

Do children have the same injury patterns as adults?


  • Injuries differ in location and type


  • Developing spine has unique anatomy

Anatomic Considerations

  • Large head

  • Torque and acceleration stress occur higher in the c-spine

  • Fulcrum of motion C2-C3 in young children (vs C5-C6 in adults)

  • Younger children have an increased incidence of high C-spine injury

Location of InjuryNational Pediatric Trauma Registry

Kokoska et al


J Ped Surg

Patel et al


J Ped Surg


  • anterior wedging of vertebral bodies

  • horizontal alignment of facet joints

  • Children prone to anterior dislocation

Young Child


University of Hawaii (

  • Underdeveloped neck musculature

  • Ligamentous laxity

  • Younger children have an increased incidence of ligamentous injury

  • Believed that the laxity of the peds spine acts to protect against spinal fracture in low energy trauma, however, may lead to SCIWORA in high-energy trauma

  • More on SCIWORA in a moment…

Type of injury

National Pediatric Trauma Registry:

Kokoska et al (2001) J Ped Surg

How common are neuro deficits?

National Pediatric Trauma Registry:Patel et al (2001) J Ped Surg

What is SCIWORA?

  • Def: Spinal cord injury without radiographic abnormality on plain film or CT

  • Mechanism: transient vertebral displacement with subsequent realignment resulting in damaged spinal cord and normal appearing vertebral column

  • Young spinal column can stretch up to 5cm

  • Spinal cord ruptures after 5mm of traction


  • How common is it?

  • Literature extremely inconsistent with definition and incidence

  • Reported as 0-50% of peds spinal cord injuries

  • National Pediatric Trauma Registry: 17%

  • NEXUS: none!!

SCIWORA – case series

Common themes:

  • Up to half may have delayed onset of symptoms (usually within 48 hrs)

  • SCI can be severe

  • Chance of recovery low if complete

  • May be related to spinal cord infarction

Epidemiology: Bottom Line

  • C-spine injuries in children are rare, but they do occur in about 1.5% of blunt trauma patients

  • In young children, be on look out for:

    • High c-spine injury

    • Ligamentous injury

How can we protect the pediatric C-spine?

Begins in Prehospital Setting: Immobilization

  • Aim for “neutral position”

  • Big head

  • When laying flat on backboard, neck is flexed

  • Must accommodate large occiput, using either an occipital depression or padding under the torso


  • Best immobilization achieved by modified spine board, rigid collar and taping

  • Too large a collar can distract the neck and worsen an injury – blocks are preferable to a poorly fitting collar

OK… Now the collar’s on…How do I get it off?


  • Preverbal or crying children:

    • Difficult to assess tenderness

    • Difficult to perform detailed neurologic exam


  • Who needs imaging?

  • What type of imaging is needed?

  • When do I need a CT or MRI?

Clearing the Pediatric C-SpinePART 1: Who needs imaging?

Is there any pediatric evidence?

  • 1 prospective study

    • Peds subset of NEXUS – Viccellio et al

  • 1 retrospective study

    • Isolated head injuries – Laham et al

Imaging – Peds subset of NEXUSViccellio et al (2001) Pediatrics

  • Prospective study of patients with blunt trauma + cervical spine radiography

  • Used 5 low-risk criteria:

    • No midline cervical tenderness

    • No evidence of intoxication

    • No altered level of consciousness

    • No focal neurological deficit

    • No painful distracting injury

  • If all 5 criteria met – considered low risk

NEXUS – peds subset

  • 3065 patients < 18 years (9% of NEXUS)

  • Total # c-spine injuries: 30

  • 603 / 3065 considered “low risk” (20%)

  • All low risk patients had negative radiographic evaluations (100% sensitive)

NEXUS – peds subset

  • Problem: Numbers are small, so 95% CI for sensitivity: 87.8% - 100%

  • Problem: Very few injuries in younger kids

  • Grouped as follows:

    • 0-2 (lack of verbal skills) N = 88 (0)

    • 3-8 (immature cervical spine)N = 817 (4)

    • 9-17 (older children) N = 2150 (26)

NEXUS – peds subset

  • Bottom line:

  • Authors “cautiously endorse” the use of the NEXUS criteria in children over age 8

  • Not enough power to ensure that the tool is safe to use in younger children

  • However, authors state that there is not a single case in the medical literature of a child with a c-spine injury who would have been classified as low risk using NEXUS

Laham et al (1994) Ped Neurosurg

  • Retrospective review of 268 children with apparent isolated HI

  • 2 high risk criteria = incapable of verbal communication (due to age or HI) and neck pain

  • Did x-rays in all kids

  • No abnormal x-rays in low risk group

  • 7.5% abnormal in high risk group

  • Authors concluded: In isolated HI with no neuro deficits, no x-rays needed if child can communicate and has no neck pain

What about the Canadian C-Spine Rules?

  • Have not been evaluated for use in patients < 16 years

Are there any consensus statements or guidelines?

  • American Association of Neurosurgeons (Guidelines committee of the section on disorders of the spine) [AANS]

    Management of Pediatric Cervical Spine and Spinal Cord Injuries

    Neurosurgery 2002;50(3) March supp

  • Guidelines based on available evidence and expert opinion

AANS Bottom Line:Children > 8 years

  • Evidence supports the use of NEXUS criteria:

  • Image if any one of:

    • Midline tenderness

    • Focal neurological deficit

    • Altered level of consciousness

    • Evidence of intoxication

    • Painful distracting injury

AANS Bottom Line: Children 8 years and under who are conversant

  • Although evidence is lacking, expert opinion supports the use of the NEXUS criteria

  • Given lack of evidence, and possible communication barriers in young children, it would be reasonable to consider imaging in high risk mechanisms:

    • high speed MVC

    • fall > 8 ft

    • axial load injury

What should we do with infants?

  • NEXUS – 88 patients < 2 yo – no injuries

  • NPTR – children < 2 yo : ~ 8 injuries per yr

  • No studies with large enough numbers to generate evidence-based practice recommendations

  • Have to go to expert opinion

AANS Bottom Line: Non-conversant Children

  • Advise obtaining images in all non-conversant children who have “experienced trauma”

  • Practically, this is not what’s done in most Canadian pediatric EDs

What should we do with infants?

  • See them quickly

  • Assess for altered LOC, neuro deficit, distracting injury

  • If no injury apparent, remove immobilization equipment in protected environment

  • Observe for spontaneous movement of neck

  • Most small children will “clinically clear” themselves

Clearing the Pediatric C-Spine

PART 2: What films do I need?

  • General agreement that a lateral and AP c-spine film are necessary

  • The sensitivity of the lateral film alone in peds is comparable to the adult literature ~85%

Odontoid views?

  • Many authors have questioned the need

  • Swischuk surveyed 984 pediatric radiologists (432 responses)

  • Obtained reports of 46 pediatric fractures that were missed on lateral view and seen on odontoid view

  • Calculated a miss rate of 0.007 per year per radiologist

Odontoid views?

  • Buhs et al(2000) J Ped Surg - Retrospective review of all c-spine injuries in children< 16 yrs over 10 year period at 4 Detroit trauma centres

  • can’t r/o fracture with AP/lat alone

But odontoid views are hard to get in young children!!!

  • Consider:

    • 0-3 years: 50% of injuries are at C1 / C2 level

    • 4-12 years: 8% of injuries are at C1 / C2 level

  • Bottom line: If you are worried enough to image the c-spine, you need to get a good look at C1 / C2

    ~need odontoid view or CT

Oblique views?

  • Ralston et al (2003) Ped Emerg Care:

  • Blinded retrospective review (8 year period)

  • Blunt trauma patients ≤16 yrs

  • AP/Lat + oblique views

  • N = 109

Oblique views?

  • All with normal AP/Lat had normal obliques

    (N = 78)

    If AP/Lat normal, obliques unlikely to add additional information

  • 4 obliques resulted in revision of impression:

    • 3 from equivocal to normal

    • 1 from equivocal to abnormal (final dx = no injury)

      May be of assistance in equivocal situation

Flexion-Extension views?Ralston et al (2001) Acad Emerg Med

  • Blinded retrospective review (6 year period)

  • Blunt trauma patients ≤16 yrs

  • AP/Lat (+ odont in 83%) + flex/ex views

  • N = 129

    • 45 patients had initial AP/Lat read as normal – all had normal flex/ex views (no revision of impressions)

      If primary series is normal…flex/ex views do not add info

    • 84 patients had initial AP/Lat read as abnormal (including loss of lordosis -79 had revision of impression)

Revision of Impressions

Flexion-Extension views?

  • Normal flex-ex views do not rule out an injury

  • If plain films worrisome, more sensitive modalities are warranted (CT +/- MRI)

    May consider flex-ex after to look for major instability

  • If the concern is significant pain despite normal plain films, quality of flex-ex view likely limited due to pain and they cannot be used to “rule out” an injury

To CT or not to CT….

  • Routinely used in adults trauma patients to examine c-spine

  • There are significant concerns that exposing children to CT radiation may lead to an increased lifetime risk of cancer

  • Try to be much more selective with the use of CT in children

  • Limit scans to specific areas of interest

Indications for CT

  • Valuable for:

    • Defining anatomy in regions where an abnormality is suspected on plain film

    • Viewing regions not visualized on plain film

      • ie – skullbase to C3 in intubated patient

  • Remember: a large proportion of young children with c-spine injury will have an isolated ligamentous injury, a normal CT cannot be used to exclude a c-spine injury

  • CT can miss odontoid #

Evidence for early CT?Keenan et al (2001) AJR

  • Retrospective study of 63 kids

  • Head injury + C-spine plain films

  • 21/63 had early CT c-spine with initial head CT

  • 42/63 had plain films alone - often repeat attempts

  • Analyzed multiple patient factors + total radiation dose received in process of imaging c-spine

  • Found kids in high speed MVC with GCS <8 had same radiation with repeated plain films as with early CT (new generation, helical CT with recons)

How about MRI ???

  • Keiper et al (1998) Neurorad

  • Retrospective case review

    • Children with hx of blunt c-spine trauma

    • Normal plain films + normal CT

    • One of:

      • Persistent or delayed neuro symptoms

      • Persistent significant neck pain

  • N = 52

  • MRI abnormal in 16/52 (31%)

  • 4 went on to operative management

MRI ???Flynn et al (2002) J Peds Ortho

What do these MRI studies mean for me? (…I can’t just order an MRI!)

  • In children with normal plain films and normal CT who have either:

    • Neurologic deficit

    • Significant persistent neck pain

      ~ they may still have a significant injury, so discuss case with referring neurosurgeon

  • Those with neuro deficits likely need urgent MRI

  • Those with ++ pain may benefit from one or more of Aspen collar, outpatient MRI, and neurosurg follow-up (at discretion of neurosx)

Clearing the Pediatric C-Spine

PART 3: Now I know what tests to do… How do I interpret pediatric C-spine films?

  • Follow same general approach as in adult c-spine films:

    • A – alignment

    • B – bones

    • C – cartilage

    • D – dens

    • S – soft tissues

  • Are some unique features in children that are important to recognize

Alignment – Subluxation of C2/C3?

University of Hawaii (

Alignment - Pseudosubluxation

  • 24% C2 on C3

  • 14% C3 on C4

    (Age <7 years)

  • Swischuk’s line: posterior arch of C1 to C3 – should come within 1 mm of post arch of C2

University of Hawaii (


  • Wedge shaped vertebral bodies

  • Ossification centres

    • Can appear like tear-drop fractures of the vertebral bodies

University of Hawaii (


  • Predental space – allow up to 5 mm in young children

  • Subdental synchondrosis - lucency at base of dens

  • Dens fuses with body of C2 between ages 4 - 6 years

  • A thin lucency may be appreciable on the lateral view for many years (50% up to age 11)

  • May have ossification centre at tip of dens

University of Hawaii (

Prevertebral Soft Tissues

  • Allowable thickness changes with age

  • In general:

    • Above glottis:

      ½ vertebral body

    • Below glottis:

      1 vertebral body

  • Often falsely thickened 2° to neck flexion (big occiput) or expiration

University of Hawaii (

  • Radiographically, most of the adult characteristics are present by age 8

  • Characteristics of peds c-spine injuries trend towards that of adults at about age 8-10 years

  • not equal to adults until about 15 years

Clearing the Pediatric C-Spine

PART 4: Specific injuries to watch for

Case 1

  • 5 yo girl

  • Hit by car while riding bike

  • VSA at scene

  • Vitals recovered by EMS

Rose et al, Am J Surg 2003;185(4)

Atlanto-Occipital Dislocation

  • 2.5 x more common in children than adults

  • Due to small occipital condyles and horizontal atlanto-occipital joints

  • Suspect if distance between occipital condyles and C1 is > 5mm at any point

  • Usually have ++ soft tissue swelling

Wackenheim Clivus Line

The Encyclopaedia of Medical Imaging

Line from clivus should

just touch posterior odontoid tip

Case 2

  • 2 yo female

  • High speed MVA

  • Closed HI (GCS 11)

Proctor (2002) Crit Care Med

C1 – C2 Subluxation

  • Predental space

    = 8mm

  • Prevertabral soft tissue swelling > ½ vertebral body

Case 3

  • 3 yo male

  • Fell out of barn loft

  • Alert, crying but consolable

  • Says his head hurts

  • Makes no attempt to voluntarily move neck

University of Hawaii (

Dens Fracture

  • Suspicious for dens fracture:

    • widening of the synchondrosis

    • anterior tilting of the odontoid

    • (may be posteriorly tilted in normal children)

Dens Fracture

  • Often lack neuro symptoms as spinal canal is wide at that level

  • Most common symptoms:

    • Occipital pain (injury to greater occipital nerve)

    • Refusal to extend neck

  • Believed to have high miss rate – can lead to chronic problems

What injuries should you be watching for in children < 8 years?


█~ atlanto-occipital dislocation


█ ~ C1-C2 subluxation

C2 ~ odontoid fractures

C3-C7 ~ ligamentous injury


  • Patel et al: J Ped Surg 2001;36(2):373-376

  • Viccellio et al: Pediatrics 2001;108(2):e20

  • Kokoska et al: J Ped Surg 2001;36(1):100-105

  • Radiology Cases in Pediatric Emergency Medicine, University of Hawaii (

  • Laham et al: Ped Neurosurg 1994;21:221-226

  • Swischuk et al: Ped Radiol 2000;30:186-189

  • Buhs et al: J Ped Surg 2000;35(6):994-997

  • Ralston et al: Ped Emerg Care 2003;19(2):68-72

  • Ralston et al: Acad Emerg Med 2001;8(3):237-245

  • Keenan et al: AJR 2001;177:1405-1409

  • Keiper et al: Neurorad 1998;40(6):359-363

  • Dare et al J: Neurosurg 2002;97(suppl 1):33-39

  • Rose et al, Am J Surg 2003;185(4)

  • The Encyclopaedia of Medical Imaging (

  • Proctor: Crit Care Med 2002;30(11)

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