Guidelines in Focus: Pediatric Cervical Spine
Key Guideline Reference:
Rozzelle CJ, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Ryken TC, Theodore N, Walters BC, Hadley MN. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery. 2013 Mar; 72 Suppl 2:205-26.
Link to guideline: PediatricCspineGuideline
This recent guideline was developed by the American Association of Neurologic Surgeons (AANS) and the Congress of Neurological Surgeons (CNS). It addresses several different facets of pediatric cervical spine management, including prehospital immobilization, imaging, and injury management.
The solitary Level I recommendation involves the use of CT to determine the condyle-C1 interval in patients with atlantooccipital dislocation. This is a thankfully rare, but quite serious injury.
More commonly, this guideline speaks to the value of assessing the cervical spine of injured children WITHOUT the use of imaging, if certain criteria are met: alert, no neurological deficit, no midline tenderness, no painful distracting injury, no unexplained hypotension, and no intoxication. In addition children <3 years old should have a GCS >13 and an injury mechanism that is not motor vehicle collision (MVC), fall > 10 feet, or nonaccidental trauma (NAT). These recommendations are supported at a Level II grade of evidence. This recommendation supports the practice of “clinically clearing” the cervical spine of children of all ages, as long as they are at low risk of cervical spine injury.
While it could be hoped that a guideline such as this would put to rest the “CT vs. plain X-ray” controversy, it honestly does not. Perhaps even better is that the section on imaging walks through the available evidence regarding the different modalities for the pediatric cervical spine. Whatever your current practice, this section of the guideline is quite informative. If nothing else, the section on imaging builds the case that the reductionism of “CT vs. plain X-ray” is overly simplistic.
Finally, this guideline addresses elements of pediatric cervical spine injury that go beyond the central concern of “stable vs. unstable” injuries, including age appropriate immobilization, neonatal spinal cord injuries, development of syringomyelia, and long term deformity from ligamentous cervical spine injuries.
Three recent publications contribute to our understanding of pediatric cervical spine management.
Article 1: Hannon M, Mannix R, Dorney K, Mooney D, Hennelly K. Pediatric cervical spine injury evaluation after blunt trauma: a clinical decision analysis. Ann Emerg Med. 2015 Mar;65(3):239-47.
Link to article: Decision analysis pediatric Cspine
This is a novel study designed to determine the optimal method to screen for cervical spine injuries in blunt trauma patients younger than 19 years old. The study design uses a decision analysis tree, constructed from a literature-based hypothetical population. Sensitivity analysis was utilized to balance missed injuries with malignancy risk. In this hypothetical cohort, clinical clearance and screening plain radiography with focused CT use were preferred to a CT all strategy.
Article 2: Pannu GS, Shah MP, Herman MJ. Cervical Spine Clearance in Pediatric Trauma Centers: The Need for Standardization and an Evidence-based Protocol. J Pediatr Orthop. 2016 Jun 18. [Epub ahead of print]
Link to article: Survey Cspine clearance practices
Practice patterns for clearance of the pediatric cervical spine at 25 separate institutions were surveyed. Of these institutions, 21 were level 1 trauma centers. Despite the fact that these centers shared similar characteristics, the patterns of practice were quite different. The trauma surgery service was the most common service responsible for the clearance of the cervical spine, in 44% of the centers. Spine consultation is supported by a rotating schedule of neurosurgery and orthopedics in 63% of centers. More centers use CT (46%) than X-ray (42%) as the primary imaging modality to clear the pediatric cervical spine. Perhaps surprisingly, only 46% of centers used a standardized, written protocol to clear the cervical spine.
This article highlights the wide variability of personnel and practice to clear the pediatric cervical spine across different institutions.
Article 3: Dorney KD, Kimia K, Hannon M, Hennelly K, Meehan WP, Proctor M, Mooney DP, Glotzbecker M, Mannix R. Outcomes of pediatric patients with persistent midline cervical spine tenderness and negative imaging results after trauma. J Trauma Acute Care Surg. 2015;79: 822-827.
Link to article: Outcomes for children with Cspine tenderness
The study’s objective was to determine the prevalence of clinically significant cervical spine injury among pediatric blunt trauma patients discharged from the emergency department with negative imaging studies but persistent midline cervical tenderness. The authors conclude that the overall incidence of clinically significant findings in patients with midline cervical spinal tenderness but with negative initial imaging study findings after blunt trauma is extremely low (1.4%). The patients in this study followed up in a specialty spine clinic, but the authors suggest that children who are discharged home from the ED in rigid cervical collars could potentially be referred to their primary care providers for initial follow-up, as opposed to subspecialists. Patients with persistent midline cervical tenderness or any other concerning signs or symptoms at the time of follow up should be evaluated in a subspecialty spine clinic.
Link to care pathways: Cspine care pathways on PTS site
Check out some of the care pathways for cervical spine management on the PTS website. These are a few example of how different institutions are managing these children. These care pathways use different approaches based on patient age and on patient neurological status. Example #2 has a great section on skin care and pressure ulcer prevention for patients in cervical collars. Does the care pathway at your institution address this? Example #3 does not use CT at all in the listed care pathway, but it does invoke early neurosurgery consultation. This would put decisions about CT in the hands of the neurosurgery consultants. Example #5 incorporates a risk assessment based on injury mechanism, but some of the others do not.
What do you think? What are you doing at your institution? What have you learned?
If you want to submit your C-spine care pathway, email it to:
Keep an eye on the PTS website for new ideas and ways to make the care of injured kids better.