Cervical Spine Clearance in Pediatric Patients

Clinical Assessment

The American College of Radiology recommends a structured approach using appropriate clinical assessment criteria followed by selective imaging for pediatric patients with suspected cervical spine injury, with radiographs as the initial imaging modality for most children with concerning findings 1, 2
Children <8 years of age have unique cervical spine characteristics, including incomplete ossification, unfused synchondroses, ligamentous laxity, and a large head-to-body ratio, making upper cervical spine injuries more common 2
Normal variants in young children <8 years, such as pseudosubluxation of C2-C3, absence of lordosis, and widened atlantodental interval, can complicate imaging interpretation 1
The Pediatric Emergency Care Applied Research Network (PECARN) criteria demonstrated 98% sensitivity for identifying cervical spine injuries in children 2, 3

Initial imaging should include anteroposterior (AP) and lateral cervical spine radiographs in children who are not alert, nonconversant, have neurological deficit, midline cervical tenderness, painful distracting injury, or are intoxicated 1
Two or more radiographic views detect cervical spine abnormalities with a sensitivity of 90% 1, 4
CT cervical spine is recommended as follow-up when radiographs show abnormal or ambiguous findings 1, 5
MRI is recommended for children with abnormal neurological examination, suspected SCIWORA (Spinal Cord Injury Without Radiographic Abnormality), or suspected ligamentous injury 6, 5, 7

For unevaluable children (unconscious, intubated), radiographs alone may be insufficient, with lateral radiographs in unconscious intubated patients showing sensitivity of only 51.7% for unstable injuries 1
MRI has been suggested for children in whom unconsciousness is predicted to last beyond 48 hours or in whom clinical clearance within 72 hours is unlikely 7
Consider CTA or MRA for children with risk factors for vascular injury, such as fractures involving the transverse foramen, traumatic facet dislocations, ligamentous injury, neurological deficits, and fractures of C1-C3 7, 8
Cervical vascular injury can be seen in 11.5% of pediatric patients with blunt trauma 7

Flexion/extension views in acute settings are rarely needed in children and may be limited by pain and muscle spasm 1, 4
Young children and those with developmental delays may require sedation for CT and MRI, which carries additional risks 1
Children with certain conditions (Down syndrome, achondroplasia, mucopolysaccharidosis, Marfan syndrome) or on systemic glucocorticoid therapy have higher risk for cervical injuries 2, 3
While MRI has high sensitivity for soft-tissue injury, its lack of specificity may make it less suitable for operative decision making 7