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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.

  • Young children sustain more upper cervical spine injuries compared to older children and adults due to anatomic differences.

  • Spinal cord injury without radiographic abnormality (SCIWORA) is more common in teenagers than younger children.

  • In the setting of a normal MRI, most children with SCIWORA have normal neurological outcome.

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

  • Use of a cervical collar and long board to restrict the motion of the spine should be limited to children with risk factors for cervical spine injury.

Cervical spine injuries are serious but rare events in children.1–7 Emergency physicians are often the first to evaluate children with cervical spine injury and must quickly triage those with potential for worsening neurological deficits from those with either no injury or cervical sprain. Occasionally these decisions are made in the absence of 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 receive spinal motion restriction, and how is this best achieved? How is the cervical spine “cleared”?

EPIDEMIOLOGY

Cervical spine injury represents a small subset of injured children. Cervical spine injury affects up to 1.8% of children evaluated in the emergency department (ED) after blunt trauma.3,4–6 Overall mortality associated with cervical spine injury in children is 7.4%; however, this rate may be as high as 26% in children <2 years.3,4,7 This increased risk of mortality is likely associated with proportionately higher rates of upper cervical spine injuries in young children.3,4,7

Motor vehicle crashes are the most common cause of cervical spine injuries.3,7–9 However, the mechanisms vary by age. Neonates may suffer cervical spine injuries from birth trauma, particularly in the case of breech or forceps deliveries.10,11 The incidence of nonaccidental trauma is likely underestimated in the pediatric population.12 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.7–10,13

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 fractures from normal developmental anatomy.

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

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