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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

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 pediatric cervical spine injury
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
national pediatric trauma registry
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 registry kokoska et al 2001 j ped surg
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
Do children have the same injury patterns as adults?


  • Injuries differ in location and type


  • Developing spine has unique anatomy
anatomic considerations
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 injury national pediatric trauma registry
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
Type of injury

National Pediatric Trauma Registry:

Kokoska et al (2001) J Ped Surg

how common are neuro deficits
How common are neuro deficits?

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

what is sciwora
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
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
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
begins in prehospital setting immobilization
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
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 spine part 1 who needs imaging
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 nexus viccellio et al 2001 pediatrics
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
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 subset27
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 subset28
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
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
What about the Canadian C-Spine Rules?
  • Have not been evaluated for use in patients < 16 years
are there any consensus statements or guidelines
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
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
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
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
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 infants36
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 spine37

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
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 views40
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
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
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 views43
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
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)
flexion extension views
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
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
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
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
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
what do these mri studies mean for me i can t just order an mri
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 spine53

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
Alignment – Subluxation of C2/C3?

University of Hawaii (

alignment pseudosubluxation
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
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 spine61

Clearing the Pediatric C-Spine

PART 4: Specific injuries to watch for

case 1
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
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
Wackenheim Clivus Line

The Encyclopaedia of Medical Imaging

Line from clivus should

just touch posterior odontoid tip

case 2
Case 2
  • 2 yo female
  • High speed MVA
  • Closed HI (GCS 11)

Proctor (2002) Crit Care Med

c1 c2 subluxation
C1 – C2 Subluxation
  • Predental space

= 8mm

  • Prevertabral soft tissue swelling > ½ vertebral body
case 3
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
Dens Fracture
  • Suspicious for dens fracture:
    • widening of the synchondrosis
    • anterior tilting of the odontoid
    • (may be posteriorly tilted in normal children)
dens fracture69
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
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)