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Cervical spine injuries occur in 1% to 2% of all pediatric trauma patients. While the incidence of cervical spine injuries in children with trauma is lower than adults, children have higher rates of mortality (~18%) compared to adults (~10%).1 In children <8 years old, almost three quarters of all spinal injuries occur in the cervical spine,2 and nearly two thirds of these children have associated neurologic deficits and head or other major organ injury.3 In addition, spinal cord injury without radiographic abnormality (SCIWORA) may occur in children and typically involves the cervical spine. The incidence of SCIWORA among pediatric trauma patients ranges from 0.15% to 0.2%, compromising 4.5% to 35% of pediatric spine injuries.4,5,6 Motor vehicle crashes are the most common mechanism of cervical spine injuries, followed by falls, and in teenagers, diving and sports injuries. Boys are affected more often than girls. Child abuse can result in cervical spine injuries in younger patients via a shaking mechanism, although this is a rare manifestation of nonaccidental trauma.7


A number of anatomic differences between the pediatric and adult cervical spine predispose children to different patterns of injury (Table 139-1). In particular, the relatively larger head-to-body ratio in young children creates a fulcrum at C2-C3 (compared to C5-C6 in adults) that accounts for higher rates of cervical spine injury above C3 in children. Weaker muscles and ligaments combined with anterior wedging and shallow facets connecting cervical vertebrae and immature growth centers together allow for easier anterior-posterior slipping of the vertebrae than in adults.

TABLE 139-1Anatomic Considerations in the Pediatric Cervical Spine

Patients younger than 8 years of age incur high ligamentous injuries more often than older children and adults. Fractures tend to occur at the weak points in the bones—synchondroses and ossification centers. Dens fractures occur most commonly along the synchondrosis, especially in children younger than age 7 years. The mechanism of injury is usually a forward facing child in a high-speed motor vehicle crash with rapid forward flexion. Atlanto-occipital and atlantoaxial dislocation injuries are devastating vertical distraction injuries that occur in the very young child, most commonly from a motor vehicle crash, and usually result in rapid death (Figure 139-1).

FIGURE 139-1.

Atlantoaxial dislocation in a 6-year-old boy involved in a motor vehicle crash. A. Lateral plain radiograph reveals atlantoaxial dislocation (blue arrow). B. MRI of the same patient reveals a near-complete transection of the brain stem at the level of the distal medulla, extensive ligamentous injury with resulting atlantoaxial dissociation, extensive intrathecal hematoma and hemorrhage, C1-C2 interspinous ligament tear, and prevertebral ...

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