The Needle Tip: An Update on Pediatric Cervical Spine Clearance

by Nathaniel Kreykes, MD

NB: What do you get if you put 15 orthopedic surgeons, 3 pediatric emergency medicine physicians, 3 pediatric neurosurgeons, 2 pediatric trauma surgeons, and 2 radiologists in a room together? If you’re lucky, you get an evidence-based consensus statement that allows you to safely clear the cervical spines of children who have experienced blunt trauma. A recently published paper in the Journal of Bone and Joint Surgery¹ is the latest attempt to shed some light on the difficult and continually discussed topic of clearance of the pediatric cervical spine.

Many factors make clearing the pediatric cervical spine a difficult problem to overcome. The ideal algorithm identifies all clinically significant cervical spine injuries and expedites the removal of the cervical collar while simultaneously limiting the patient’s exposure to radiation. Being able to safely and expeditiously discontinue cervical spinal motion restrictions makes it easier to care for that patient and their families.

Toddlers, however, are about as reasonable as intoxicated adults and follow directions equally well, but unlike the intoxicated, they will not be any more reliable the next day. Getting an accurate clinical assessment, therefore, can be difficult, but it is essential for clearing the pediatric cervical spine. The challenge to trauma clinicians caring for children is balancing the diminutive risk of radiation exposure against the risk of potential missed or delayed diagnoses in a patient population that is often (appropriately) non-verbal and uncooperative.

Subtle anatomic differences of the young cervical spine result in different injury patterns as compared to adults. Younger children have increased flexibility of the cervical spine. This increase in mobility is explained by incomplete ossification of the vertebral bodies, ligament laxity, and incomplete development of the spinous processes. When combined with an increase in head-to-torso ratio and relatively weak cervical musculature, this increase in flexibility leads to cervical spine injuries at higher levels. By eight years of age, the cervical spine is nearing maturity and the injury profile is similar to that of adults.

With the exception of blunt injury of solid organ management, most of the algorithms and protocols used today in caring for injured children are extrapolated from our adult guidelines; the pediatric cervical spine clearance algorithms are no exception. Nearly all of the pediatric cervical spine clearance protocols are based on the NEXUS decision instrument and Canadian C-spine rules. These landmark papers have very few pediatric patients in their data sets: only 2.5 percent of patients in the NEXUS study were under the age of eight, and the Canadian C-spine rules paper excluded patients younger than sixteen years of age.

So which kids need a collar? This decision is usually made by the prehospital team, but often, particularly in the case of non-accidental trauma, recognition of injury happens in the hospital setting. The American College of Surgeons Committee on Trauma (ACS-COT), the American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP) recently updated their joint position on spinal motion restriction. ² Based on the best available pediatric evidence from studies that have been conducted through the Pediatric Emergency Care Applied Research Network (PECARN), a cervical collar should be applied if the patient has any of the following:

1. Complaint of neck pain

1. Torticollis
2. Neurologic deficit
3. Altered mental status including GCS <15, intoxication, and other signs (agitation, apnea, hypopnea, somnolence, etc.)
4. Involvement in a high-risk motor vehicle collision or has substantial torso injury

Now, how do we safely remove the collar? This newly published paper provides consensus statements for three groups of pediatric patients: (1) patients with a GCS score of 3–8, (2) patients with a GCS score of 9–13, and (3) patients with a GCS score of 14 or 15. Additionally, the paper provides a highly desirable, single working algorithm.

Take home points for children with a GCS of 14 or 15:

1. Clinical clearance can be performed in children who are less than three years of age.
2. Clinical clearance can be performed in a child with neck tenderness when it’s NOT located in the posterior midline.
3. The liberal use of the spine consulting service is encouraged in cases with abnormal neurological exams.
4. A child with suspected abusive head trauma should undergo an MRI of the cervical spine.
5. Stronger consideration of imaging should be given to children with the following mechanisms of injury: diving, axial load, “clothes-lining,” or a high-risk motor vehicle collision.
6. Clinical clearance cannot be performed with distracting injuries (defined in this paper as visible or known substantial injury to the chest, abdomen, or pelvis).
7. Flex-extension radiographs (defined as: ≥30^o flexion and ≥30° extension) can be used to rule out ligamentous injuries.

Take home point for children with GCS of 9­–13:

1. For a child whose GCS score falls in the range of 9 and 13 and has normal radiographs, continue spinal motion restrictions. In addition, a repeat clinical examination should be performed in 12 hours.

Take home points for children with a GCS of 3–8:

1. The initial imaging modality should be a CT of the C-spine if there are concerns about a cervical spine injury.
2. An MRI is sufficient to clear the cervical spine in the absence of a clinical exam.

 Here’s a tip for a common scenario we often see: An otherwise healthy baby is transported to your emergency room after a trauma event with a (usually poor-fitting) cervical collar in place. In the asymptomatic preverbal child with a normal GCS, it is acceptable to remove the cervical collar and observe for range of motion and signs of pain. If the range of motion appears normal and no signs of pain are noted, the cervical collar may be left off and imaging is not required to clear the cervical spine. If discomfort or decreased range of motion is observed, reapply the collar and pursue radiological clearance. ^3,4 This situation requires an attentive exam and focus on the range of motion of the child’s neck for an amount of time sufficient to make a meaningful assessment.

In a recent survey of 21 Level I pediatric trauma centers, only 46 percent of institutions had a written pediatric cervical clearance protocol. ⁵ A best practice is for each trauma center is to develop a policy and performance improvement process regarding pediatric cervical collar removal and indications for performing cervical imaging. Close cooperation with your institution’s orthopedic surgeons, emergency medicine physicians, neurosurgeons, trauma surgeons, and radiologists is crucial to developing a protocol that works well and aligns with nationally recognized standards and guidelines. With the above information, more trauma centers caring for children will most likely develop pediatric cervical clearance protocols and not only gain a higher level of comfort in their applied work, but also achieve better results when caring for our injured children.

1. Herman MJ, Brown KO, Sponseller PD, et al. Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. The Journal of Bone and Joint Surgery American volume. 2019;101(1):e1. doi:10.2106/JBJS.18.00217.
2. E FP, G PD, R DT, et al. Spinal Motion Restriction in the Trauma Patient – A Joint Position Statement. Prehospital Emergency Care. 2018;22(6):659-661. doi:10.1080/10903127.2018.1481476.
3. Chung S, Mikrogianakis A, Wales PW, et al. Trauma Association of Canada Pediatric Subcommittee National Pediatric Cervical Spine Evaluation Pathway: Consensus Guidelines. The Journal of Trauma and Acute Care Surgery. 2011;70(4):873-884. doi:10.1097/TA.0b013e3182108823.
4. Rozzelle CJ, Aarabi B, Dhall SS, et al. Management of Pediatric Cervical Spine and Spinal Cord Injuries. Neurosurgery. 2013;72(2):205-226. doi:10.1227/NEU.0b013e318277096c.
5. Pannu GS, Shah MP, Herman MJ. Cervical Spine Clearance in Pediatric Trauma Centers: The Need for Standardization and an Evidence-based Protocol. Journal of Pediatric Orthopaedics. 2017;37(3):e145-e149. doi:10.1097/BPO.0000000000000806.