Cervical Spine Injury: Update Course 2016

Tincture of time—observing a child overnight in a collar and re-examining when calm—is a valid alternative to immediate advanced imaging in some cases.

NEXUS trial criteria do not cover pediatric patients.

Physical examination reliability for C-spine clearance is limited in 18-month-old children who cannot verbally report tenderness and may be distressed from the trauma evaluation itself.

MRI requires sedation or anesthesia in young children, which is a significant barrier to obtaining the study emergently.

One neck CT delivers radiation equivalent to approximately 600 plain films.

If an initial lateral C-spine film is inadequate, proceeding to CT results in radiation exposure from both modalities.

In children under 2 years, CT imaging does not add diagnostic value above adequate plain radiographs for C-spine evaluation.

Institutional protocols typically drive imaging decisions in level 2 trauma patients, with automatic CT scanning common in many centers.

C-spine injuries in children under 2 years typically require significant force and present with either death or paralysis, rarely with normal neurologic examination.

Patients sometimes remain in cervical collars for 6 weeks due to clinic follow-up patterns rather than clinical indication.

Two-view C-spine films (not three-view with odontoid) are the standard initial imaging in pediatric patients at some institutions.

Flexion-extension films can be performed two ways: voluntary patient movement in cooperative older children, or assisted movement under fluoroscopy with a physician present.

Patients with normal plain films and normal MRI but persistent midline tenderness are typically discharged home in a soft collar for comfort.

MRI is the gold standard for evaluating ligamentous injury and SCIWORA (spinal cord injury without radiographic abnormality).

The degree of midline tenderness, believability of patient report, and presence of paraspinal muscle spasm guide the astute clinician in deciding whether to pursue MRI.

Children without distracting injuries, without neurologic symptoms, and with minimal or no tenderness are likely over-imaged for C-spine injury.

For children 8 years and older, high-risk features warrant skipping plain films and proceeding directly to CT, especially when head CT is already indicated.

In neurologically devastated patients requiring emergency surgery, the neck should remain immobilized in a collar regardless of imaging findings until definitive clearance can be obtained electively.