Cervical spine assessment in PICU
This document is only valid for the day on which it is accessed. Please read our disclaimer.
- There is evidence to support guidelines only, not protocols
- All patient should be stabilised prior to cervical spine clearance
- Mechanism of injury is a poor predictor of spinal cord injury
- One in six children with spinal injury have multiple levels of injury
- Ligamentous instability may be more common than thought
- The true incidence of C spine injury is not known, nor how many missed.
Common normal XR changes in paediatrics
- Overriding of anterior atlas relative to odontoid on extension
- Exaggerated atlanto-dens intervals
- Radiolucent synchondrosis between odontoid and C2.
- Pseudosubluxation of C2 on C3. (To differentiate between physiological and traumatic subluxation, draw a line through post arches of C1 and C3. In pseudosublux, line passes through, touches or lies up to 1 mm anterior to the anterior cortex of posterior arch of C2. If anterior cortex of C2 is 2mm or more behind line, then is true dislocation.
Technically adequate Xrays
Must see base of occiput and upper border of T1, odontoid which shows lateral masses of C1 and all of odontoid process.
Cervical Spine Guidelines
Collars do not prevent forced flexion when supine on spinal boards
Collars alone do not prevent injury and may worsen respiratory function, lead to skin ulceration and thrombosis of neck veins
No collar provided acceptable immobilisation when used alone
Neutral position desirable:
- <4 years old, need elevation of torso by more than 25 mm to eliminate positional neck flexion and achieve neutral alignment.
- <8 years, need elevation of torso by 25 mm to achieve positional neck flexion and achieve neutral alignment
<8 years, should elevate thorax or recess the occiput. Achieve this by placing extra folded blanket to thickness of 25mm under the patient's body.
Combination of half spine board, rigid collar, sandbags and tape is best, but may affect respiratory function
|Low risk||no cervical tenderness, alert, able to
communicate, no neurological deficit, no
intoxication, no unexplained hypotension or absent
Recommendation: no imaging
|Medium risk||with any of the above:
• lateral and AP XR
• If XR normal but pain, do flexion / extension views
|High risk/ Comatose (majority of PICU patients)||Non verbal, due to age, head injury and
Recommendation for all ages:
• AP and lateral Xray of spine. Odontoid view not required
• CT scan of upper two C vertebrae with axial CT at 3mm intervals. If possible this can be done with the initial
• For children transferred in to the PICU, CT of C1 and C2 should be requested with head CT at the referring
hospital. If CT has already been taken at the time of referral call, then CT of C1 and C2 should be requested in
Starship with the follow up CT head, or separately if no further cerebral imaging is planned.
• Axial CT at 3mm intervals for suspicious areas or areas not well seen on lateral XR.
• If view are adequate and no abnormality is seen, consider the spine to be stable and remove collar. False negative
rate of <0.1% with Xrays and CT
• MRI indicated only for
- unstable spinal injuries who require surgical stabilisation,
- exclusion cord or nerve root compression
- evaluation of ligamentous integrity
- information re neurological deficit
• Flexion/extension views: <9 years if XR normal, few injuries below C3. No evidence for use, not more accurate
than recommendations, high false negative rate and not cost effective
• Routine MRI: sensitive but not specific, difficult to perform in unstable patient
SCIWORA: Spinal Cord Injury without Radiological Abnormality
• Severe pain/ spasm:Immobilise until flexion/ extension views confirm stability
• Transient or persisting neurological symptoms. Presenting examination relates strongly to outcome
• Plain XRs: Whole spine to exclude fractures. Fracture, subluxation or pathological motion rules out SCIWORA
- if suspected neurological injury
- To exclude compressive cord or nerve root lesions
- To exclude ligamentous disruption
- To determine time for immobilisation
- To predict outcome: hematomyelia or disruption associated with severe permanent neurological injury, signal
change may improve over time, normal do well.
• spinal angiography or myelography
Did you find this information helpful?
- Date last published: 31 October 2005
- Document type: Clinical Guideline
- Services responsible: Paediatric Intensive Care Unit
- Owner: Brent McSharry
- Editor: John Beca
- Review frequency: 2 years
SIGN UP TO RECEIVE GUIDELINE UPDATES
Subscribe below if you want us to let you know about new or updated guidelines