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High-Yield Facts

  • Suspect cervical spine injury in any child who has suffered traumatic respiratory arrest and perform rapid sequence orotracheal intubation with in-line cervical spine stabilization.

  • Because of differences in anatomy and physiology, children sustain proportionally more upper cervical spine and spinal cord injury without radiographic abnormality (SCIWORA) injuries compared with adults.

  • CT scan is more sensitive for bony injury, and MRI for soft-tissue injury.

  • Although spine immobilization is indicated when cervical spine injury is suspected, complications can occur. Decisions to immobilize should target those at greatest risk for cervical spine injury.

Cervical spine injuries are serious, but rare events in children.13 Emergency physicians are often the first to evaluate pediatric trauma patients with cervical spine injury and must quickly triage children with the potential for worsening neurologic deficits from those with either no cervical spine injury or cervical sprain. Occasionally, these decisions are made in the absence of adequate cervical spine imaging when dealing with a child's unstable airway or other life-threatening injuries. These challenges raise some specific questions. Are there specific subsets of children at the highest risk for cervical spine injuries? Which children should be immobilized and how is this best achieved? How is the cervical spine “cleared”?


Cervical spine injury represents a small subset of injured children. Cervical spine injury affects less than 1% of children undergoing trauma evaluation and only 1.5% of children enrolled in the National Pediatric Trauma Registry.35 It is estimated that there is an overall 17% mortality associated with cervical spine injury in children; however, this rate may be as high as 60% in children ≤8 years.3,5 This increased risk of mortality is likely associated with proportionately higher rates of upper cervical spine injuries in young children.3,5

Motor vehicle collisions are the most common cause of cervical spine injuries.3,6,7 However, the mechanisms vary by age. Neonates may suffer cervical spine injuries from birth trauma, particularly in the case of breech or forceps deliveries.8,9 The incidence of nonaccidental trauma is likely underestimated in the pediatric population.10 Sports-related injuries, pedestrians hit by motor vehicles, and falls are common mechanisms of cervical spine injury in older children and adolescents; whereas violent injuries, including assault and gunshot wounds, occur in the late teenage years.6,7

Anatomy and Physiology

Although the development of the subaxial vertebrae is relatively consistent, the components of the craniocervical junction and upper cervical spine (occiput, atlas, and axis) have distinctive developmental patterns. Recognition of this is critical in differentiating fracture from normal developmental anatomy, as they may appear nearly identical radiographically.

The atlas (C1) has three primary ossification centers: one anterior arch and two neural arches. There are open cartilaginous synchondroses between the anterior arch ...

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