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Child Health Guideline Identifier

Cervical Spine Injury

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Introduction

Paediatric cervical spine (C spine) injury is uncommon. However cord injury may have devastating consequences.

C5-C7 is the area most often injured, although the upper cervical spine is more at risk in younger children compared with adults.

Cervical spine injury should be suspected when any of the following are present:

  • Multiple traumatic injuries
  • Significant injury above clavicles
  • Trauma with unexplained hypotension
  • Mechanisms:
    - Pedestrian vs car
    - Passenger in RTC
    - Fall > 3m
  • Patients with limited neck movement
  • Neurological deficit
  • Central neck pain

Cervical spine collars should not be routinely applied in patients suspected of having a neck injury.

Clinicians need to be aware that immobilisation of a distressed/mobile child may be counterproductive and can have negative consequences

eg. Airway compromise
      Increased pain
      Pressure areas

Anatomical and radiological differences in paediatric cervical spine can make management and interpretation of investigations difficult. Children have relatively large occiputs, ligamentous laxity, cartilaginous areas and growth plates.

High doses of ionising radiation are associated with adverse long term effects. The magnitude of this risk in relation to cervical spine imaging has not been precisely defined, however extrapolation of data from significant radioactive events suggests the risk of malignancy for a teenage child from one cervical plain X-ray series is approximately 1 in 31000, and from a CT 1 in 1500. Younger children are exposed to a higher risk, particularly when imaging involves direct radiation to the thyroid.

General principles

  • Consider C spine injury in all trauma presentations
  • Aim to rule out this possibility early in presentation and document clinical clearance if appropriate (see algorithm)
  • C spine immobilisation should not impair airway management and should not result in secondary complications 
  • If radiology is required, it should be completed using the lowest possible dose of ionising radiation. Plain films will be generally preferable, and when CT is required it should be localised to the area of concern. For example, a persistently inadequate 'peg' view should prompt a CT limited to C1-C3.

Spinal protection and collars

  • In both alert and obtunded patients, manual in-line immobilization and removal of any collar, with placement of sandbags either side of the head will be preferable in most situations. The sandbags will function as a visual indicator to staff that the patient's c-spine is not 'cleared'.
  • Compliant patients may be asked to keep their neck still, with sandbags placed to provide a tactile reminder. They may sit to 15 degrees if they do not have back pain or neurological deficit.
  • Non-compliant patients should receive manual in-line immobilization while they have their pain and/or agitation treated.
  • Semi-rigid cervical collars ('hard' collars) will rarely be required. They are likely to cause discomfort to alert patients, and potential harm to head-injured patients, without providing demonstrable benefit.
  • Placement of a Philadelphia collar should be considered for any child who requires cervical spine protection for longer periods. 
    • In Starship these can be obtained on prescription through the Orthotic Department in-hours, and from the Adult Emergency orthotic supply cupboard out-of-hours.
  • Children less than 10 years of age have relatively large occiputs. Placement of a foam-padding Thoracic Elevation Device (TED) under the shoulders of these patients can prevent cervical hyperflexion, making interpretation of plain films easier. The TED is best placed as the patient is transferred from the ambulance stretcher to the hospital bed.

Assessment of Cervical Spine Injury

 C-spine algorithm

Explanatory Notes

  1. Altered Level of Consciousness and Intoxication
    Altered level of consciousness is present if any of the following is present: 
    (a) Glasgow Coma Scale score of 14 or less; or any score other than alert on the AVPU scale 
    (b) Disorientation 
    (c) Persistent anterograde amnesia 
    (d) Delayed or inappropriate response to external stimuli.

    Patients should be considered intoxicated if they have either of the following: 
    (a) A recent history of intoxication or intoxicating ingestion or
    (b) Evidence of intoxication on physical examination. 
  2. Focal Neurological Deficit 
    Any focal deficit found on examination of motor or sensory systems. 
  3. Distracting Injury
    This is defined as any injury that could potentially distract a patient from a cervical spine injury and includes:
    - A long bone fracture
    - A visceral injury requiring surgical consultation
    - A large laceration, degloving or crush injury
    - A large burn
    - Any injury producing acute functional impairment
  4. Midline Tenderness
    When evaluating the neck, stabilise the spine and palpate directly in the midline. Midline posterior bony cervical spine tenderness is present if the patient complains of pain on palpation of the posterior midline neck from the nuchal ridge to the prominence of the first thoracic vertebra. 
  5. Dangerous Mechanism
    Includes: high speed, rollover or ejection MVAs, significant axial loading and falls > 1m
  6. Active neck rotation
    Is the patient able to rotate neck 45 degrees to the left and right without assistance. 
  7. Imaging
    The standard cervical spine imaging series will be a cross-table lateral, an anteroposterior and an open-mouth odontoid view. C7-T1 junction must be seen on lateral films.
  8. Further imaging
    CT Scanning is indicated in the event of a suspected bony abnormality or if plain films have not adequately imaged the cervical spine to the C7/T1 junction. Whenever possible CT scanning should be restricted to the specific part of the cervical spine that requires further investigation (in order to reduce radiation exposure). 
    MRI scanning is indicated when identification of soft tissue injury is required or if there is a suspicion of spinal cord injury without radiological abnormality (SCIWORA). SCIWORA refers to a spinal cord injury that is sustained without cervical spine abnormality being detected on plain film or CT. This injury pattern is more common in the paediatric population because of greater ligamentous laxity.
    As its accessibility increases, there is an emerging role for MRI in the acute assessment of older children with neck injuries not able to be cleared with plain film radiography.

References

  • Dickinson G. Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments. Ann Emerg Med 2004;43(4):507-14.
  • Kwan I, Bunn F, Roberts I, on behalf of the WHO Pre-Hospital Trauma Care Steering Committee. Spinal immobilisation for trauma patients. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD002803.
  • Lukins T, Ferch R, Balogh Z, Hansen M. Cervical spine immobilization following blunt trauma: a systematic review of recent literature and proposed treatment algorithm. ANZ J Surg. 2015 Dec;85(12):917-22.
  • National Research Council. Health risks from exposure to low levels of ionizing radiation. BEIR VII Phase 2. Washington, DC: National Academies Press; 2006.
  • Oteir AO, Smith K, Stoelwinder JU, Middleton J, Jennings PA. Should suspected cervical spinal cord injury be immobilised?: a systematic review. Injury. 2015 Apr;46(4):528-35.
  • Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children: the SCIWORA syndrome. J Trauma 1989;29:654-64.
  • Pandie Z, Shepherd M, Lamont T, Walsh M, Phillips M, Page C. Achieving a neutral cervical spine position in suspected spinal cord injury in children - analysing the use of a thoracic elevation device (TED) for imaging the cervical spine in paediatric patients. Emerg Med J. 2010; 27 (8):573-6.
  • Schöneberg C, Schweiger B, Hussmann B, Kauther MD, Lendemans S, Waydhas C. Diagnosis of cervical spine injuries in children: a systematic review. Eur J Trauma Emerg Surg. 2013 Dec;39(6):653-65.
  • Singletary EM, Zideman DA, De Buck ED, Chang WT et al. Part 9: First Aid: 2015 International Consensus on First Aid Science With Treatment Recommendations. Circulation. 2015 Oct 20;132(16 Suppl 1):S269-311
  • Stiell IG, Wells GA, Vandemheen K, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA 2001;286:1841-8.
  • Stiell IG, Clement CM, McKnight RD et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. NJEM 2003;349(26):2510-8.
  • Viccellio P, Simon H, Pressman BD et al and for the NEXUS Group. A Prospective Multicenter Study of Cervical Spine Injury in Children. Pediatrics 2001;108:e20

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Document Control

  • Date last published: 06 March 2017
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department
  • Author(s): Mike Shepherd, Heidi Baker, Matt Brown
  • Editor: Greg Williams
  • Review frequency: 2 years

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