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Cervical Spine Injuries Module


TopicCervical spine injury
AuthorRonán Murphy
DurationUp to 2 hours
Equipment requiredComputer with projector for imaging
  • Introduction and Basics: (10 mins) pre-reading, glossary of terms, anatomical considerations
  • Main session: (2 x 15 minutes) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering diagnostic dilemmas; advanced management and escalation
  • Sim scenario (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

EMS – Emergency Medical Services

CSI – Cervical Spine Injury

SCIWORA – Spinal cord injury without radiological abnormality

XR – X-radiography

ED – Emergency Department

NEXUS – National Emergency X-radiography utilization study

PECARN – Paediatric Emergency Care Applied Research Network

GCS – Glasgow Coma Scale

MILS – Manual in line stabilization

MVC – Motor Vehicle Collision 

ATV – All terrain vehicles

NPV – Negative Predictive Value

PEM – Paediatric Emergency Medicine

TBI – Traumatic Brain Injury

NICE – National Institute for Health and Care Excellence, United Kingdom

MRI- Magnetic Resonance Imaging

The incidence of cervical spine injury is low and represents only 1-2% of all paediatric major trauma (1). 

The cervical spine is overrepresented as the region where more than half of all paediatric spinal injuries occur and the main reason for this is the relatively larger head size leading to the fulcrum of flexion being in the cervical column (2-4). Other features also make it susceptible to injury: ligamentous laxity, incompletely ossified vertebrae and more horizontally orientated facet joints (5). 

The incidence of ligamentous injury is thought to be higher in younger, non-communicative children under 3 years of age (6).

The precise location of injury in the cervical spine can be variable across the age range (7-9).

Four injury patterns are common in children with cervical spine trauma:

  • Fracture
  • Subluxation with fracture
  • Subluxation without fracture

Dislocations or subluxations are more common in upper cervical spine injuries and associated with greater morbidity (9). To compare with adults, children are over twice as likely to suffer atlanto-axial injury (8).

Weaker musculature and underdeveloped interlocking bony processes contribute to the subluxation/dislocation and SCIWORA (spinal cord injury without radiological abnormality) type injury patterns we see in children (10). SCIWORA refers to CT and plain film. A lesion may be detected on MRI.

SCIWORA is the presence of myelopathy as a result of trauma with no evidence of fracture or ligamentous instability on imaging. The mechanism relates to the flexibility of the paediatric spine being greater than that of the spinal cord which becomes damaged as it is stretched beyond its limits. Neurological signs or symptoms even if transient must be elicited in the history to make this diagnosis (2). 

Manage the cases below as you would in your own setting using local guidelines and procedures to make this whole exercise as realistic as possible and also to stimulate further analysis and discussion. 

A 13 year old boy arrives in your ED. He came off his bicycle at speed whilst engaged in a downhill mountain racing contest. He was wearing a helmet and protective clothing but hit his head against a tree as he landed. He did not lose consciousness. He describes immediate onset neck pain which now persists. Volunteer ambulance services were supervising the event and treated his pain with paracetamol and ibuprofen whilst preparing him for transfer in full spinal precautions. He is brought into your ED strapped to a spinal stretcher with a hard cervical collar in place as well as head blocks and tape. On handover it is noted that he felt a weird sensation in his right arm at the time of the event which lasted perhaps 3-5 mins and has not returned. The crew found his neck to be diffusely tender on examination.

What features in history and on examination are we concerned about regarding the potential for cervical spine injury?

How do we take handover of these patients and protect them whilst we work up their injury?

Predisposing vulnerability to bony or ligamentous failure: Down Syndrome(T21), Rheumatoid Arthritis, Rickets, Osteogenesis Imperfecta, Ehlers-Danlos Syndrome, Achondroplasia, Marfans Syndrome, Renal osteodystrophy, Klippel Feil disease, Morquio Syndrome, Grisel syndrome.

A high risk MVC is one of the following: Head on collision, rollover, patient ejected from the vehicle, death of another passenger occurred, speed of collision over 88kph (55mph).

Distracting injury is vaguely defined by NEXUS to include burns and long bone fractures etc. It can be refined to mean any substantial injury of the upper torso due to proximity to the cervical spine (14).

As described above (11), the Viccelilo study (2001) looked at the performance of NEXUS in the paediatric subgroup. In 2017 however, Cochrane (2017) found there was conflicting evidence to support use of NEXUS in children and called for additional well designed studies with larger sample sizes to better evaluate this population (15). 

Some points to consider regarding immobilization: 

Where a cervical spine injury is suspected, appropriate immobilization must be achieved. 

Ask the co-operative child to lie still. Apply gentle manual in line stabilisation (MILS) and give lots of encouragement (age appropriate) to minimise movement. The neck should reside neutrally or in a position of comfort for the child. Bear in mind that babies may require a pad or similar thoracic elevation device laid onto the trauma mattress to elevate the torso and preserve neutral alignment of spine due to their relatively larger heads. This will prevent any forced flexion occurring.

While providing MILS and reassurance, we must address pain as a matter of urgency. Immobilisation may increase leverage on the neck in a sore and struggling child.  Once deemed safe to do so (and rapport has been established where applicable), radiolucent blocks and straps can be applied to free up that team member from the task of MILS. As well as helping limit movement, blocks also serve as a communication tool / visual reminder to the team that we are worried about this spine and to handle with care.

Transfer: If coming in by EMS, transfer using scoop from ambulance mattress to radiolucent ED trauma mattress. During transferring manoeuvres, the team leader should ensure that the minimal number of movements and gentle max 30 degree tilts are all that’s needed to get them on and off a scoop stretcher. The leader should also ensure that all team members understand their role and are given adequate prompts prior to any movements being performed “ready, steady, move”. Use the opportunity allowed by tilting to complete your standard assessment of the spine (and the patients back for other injuries or relevant findings). Document appropriately. Sometimes children 6 years old and above (not possible to put on below this age) may come in via EMS wearing cervical collars. These are removed to assess the cervical spine in ED while MILS is being applied and hard collars should not be placed back on as they can have a number of negative effects, particularly with prolonged use (16).Two piece collars are different and are often recommended by spinal specialists as a treatment modality for stable fractures or as a bridge to definitive management. 

A 10 month old girl who was a back seat occupant in a rearward facing baby seat is involved in a head on RTC at 30kph (18mph). The incident occurred in a housing estate. She presents with her Mother who was the restrained driver for review at a mixed Adult and Paediatric ED. You have already assessed and cleared Mum from any serious injury. You now examine her baby who is crawling away from you on the bed saying “mama”. 

Discuss how we need to adapt our assessment to suit younger children. 

Are we worried about this baby and do we want imaging? 

Outside of the factors looked at in the large studies, are there any other items which we should consider important in history and on physical examination for all children? 

The studies we have looked at so far don’t have many children under the age of three years old. We will now explore some which do:

Expert Consensus on factors which are suspicious for CSI (18-21):

Suspicions of CSI in the history:

Suspcions of CSI in the examination

Where the child does not have any concerning features on history or examination, we can look at some low risk factors which offer us some reassurance:

Low risk factors identified by NICE (ref 20)

Further learning points

An 11 year old boy is involved in a single vehicle RTA as a front seat passenger restrained in a booster seat. The vehicle slid at 120kph (75mph) and spun out of control demolishing a fence at the side of the dual carriageway and impacting a treeline before being propelled back onto the road. There is extensive damage to the four door saloon and all airbags deployed. The boy’s father was driving at the time and they self extricated by kicking out a front door which was slightly wedged by the distorted frame. They stood by the side of the road awaiting help to arrive. The father states he is fine apart from a few scrapes from broken glass and declines further assessment by Paramedics. The son complains that he now notices neck pain on moving his head backward and forward. EMS reviewed and decided to treat him with full spinal precautions. He arrives in your ED and is assessed as having no evidence of bruising or deformity of the neck and no midline bony tenderness. He has a normal neurological examination. His neck pain is persistent despite ibuprofen and paracetamol given by EMS en route. He is reluctant to move it much.

Do you want to image this child and if so, what imaging do you want to perform?




A 2 year old girl presents with her father after landing awkwardly post a fall down the last two steps of stairs in her home yesterday evening. She has been starting to walk up and down the stairs and is always supervised. Last night, she complained of some pain which responded to the paracetamol syrup given to her by Dad. She slept well but since this morning, she has been holding her neck strangely and prefers to lie down.

You are the senior registrar on duty and one of your colleagues asks for your review. She is lying in a position of comfort on her left side. When you go to examine her she sits up and clings to her father crying and making it clear that she does not want to be examined, saying bye-bye. She has a torticollis to the left and is moving all limbs. Analgesia was given and plain films were obtained. These looked normal to you and the patient was reviewed and looks more comfortable now, although the torticollis persists.

Should we be concerned? Outline your steps in this patient’s management.

Torticollis in the setting of trauma, even in the absence of neurological signs or symptoms is concerning. 

There is an association between torticollis and cervical spine injury, particularly rotatory subluxation of C1 on C2 (Atlanto axial rotatory subluxation or fixation as it is sometimes termed), however it can also be seen in other patterns of cervical spine injury too (34-38). 

Typically, in trauma, the ipsilateral sternocleidomastoid muscle is in spasm. This differs from torticollis from other causes (benign paroxysmal torticollis, cervical lymphadenitis, cervical spine/cord tumours, posterior fossa tumours) where the contralateral sternocleidomastoid is in spasm (37). 

Despite the fact this little girl’s neurological assessment remained normal, it was decided to proceed to MRI under general anaesthesia. This demonstrated atlanto-axial rotatory subluxation. 

This case emphasises the concerning nature of traumatic torticollis, even in the absence of neurological signs or symptoms.

Injuries sustained by mechanism (33):

Hyper-flexionHyper-extensionAxial Load
Flexion teardropHyperextension dislocationBurst fracture (If occurs to C1 the eponym of Jefferson applies)
Bilateral facet dislocationExtension teardrop
Unilateral facet dislocationHangman’s fracture  (C2 Pedicles)
Anterior subluxation
Wedge fracture
Spinous process fracture

Falls from elevation, MVCs, being struck by motor vehicles while walking or riding and blunt blows to head and neck are more likely to result in axial (C2 and above) CSIs. 

Sports related cervical spine injuries are more likely to result in injuries to the sub-axial (below C2) region or SCIWORA. Children involved in diving and motor sports (All-terrain-vehicles and motorcycles) are more likely to sustain sub-axial cervical spine injuries (8).

Question 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3

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2. Jones TM, Anderson PA, Noonan KJ. Pediatric cervical spine trauma. J Am Acad Orthop Surg. 2011;19(10):600-11.

3. Adib O, Berthier E, Loisel D, Aube C. Pediatric cervical spine in emergency: radiographic features of normal anatomy, variants and pitfalls. Skeletal Radiol. 2016;45(12):1607-17.

4. Davies J, Cross S, Evanson J. Radiological assessment of paediatric cervical spine injury in blunt trauma: the potential impact of new NICE guidelines on the use of CT. Clin Radiol. 2016;71(9):844-53.

5. Brown P, Munigangaiah S, Davidson N, Bruce C, Trivedi J. A review of paediatric cervical spinal trauma. Orthopaedics and Trauma. 2018;32(5):288-92.

6. Anderson RC, Kan P, Vanaman M, Rubsam J, Hansen KW, Scaife ER, et al. Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age. J Neurosurg Pediatr. 2010;5(3):292-6.

7. Polk-Williams A, Carr BG, Blinman TA, Masiakos PT, Wiebe DJ, Nance ML. Cervical spine injury in young children: a National Trauma Data Bank review. J Pediatr Surg. 2008;43(9):1718-21.

8. Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC. Cervical spine injury patterns in children. Pediatrics. 2014;133(5):e1179-88.

9. Patel JC, Tepas JJ, 3rd, Mollitt DL, Pieper P. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg. 2001;36(2):373-6.

10. Egloff AM, Kadom N, Vezina G, Bulas D. Pediatric cervical spine trauma imaging: a practical approach. Pediatr Radiol. 2009;39(5):447-56.

11. Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001;108(2):E20. 

12. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286(15):1841–8.

13. Leonard JC, Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Leonard JR, et al. Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics. 2019;144(1).

14. Michelle L. Paucis Verbis: Distracting injuries in c-spine injuries California2011 [Available from:

15. Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, et al. Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database of Systematic Reviews. 2017(12).

16. Chan M, Al-Buali W, Charyk Stewart T, Singh RN, Kornecki A, Seabrook JA, et al. Cervical spine injuries and collar complications in severely injured paediatric trauma patients. Spinal Cord. 2013;51(5):360-4.

17. Pieretti-Vanmarcke R, Velmahos GC, Nance ML, Islam S, Falcone RA, Jr., Wales PW, et al. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma. J Trauma. 2009;67(3):543-9; discussion 9-50.

18. Herman MJ, Brown KO, Sponseller PD, Phillips JH, Petrucelli PM, Parikh DJ, et al. Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am. 2019;101(1):e1.

19. Lee SL, Sena M, Greenholz SK, Fledderman M. A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results. J Pediatr Surg. 2003;38(3):358-62; discussion -62.

20. National Institute for Health and Care Excellence UK. Head injury: assessment and early management, Clinical Guideline 176 2014 [updated September 2019. Available from:

21. Council P-hEC. Pre-hospital spinal injury management– PHECC position paper: Pre-Hospital Emergency Care Council (PHECC), Republic of Ireland; 2016 [updated June 2016. Available from:

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23. Maxwell MJ, Jardine AD. Paediatric cervical spine injury but NEXUS negative. Emerg Med J. 2007;24(9):676-.

24. Kadom N, Palasis S, Pruthi S, Biffl WL, Booth TN, Desai NK, et al. ACR Appropriateness Criteria((R)) Suspected Spine Trauma-Child. J Am Coll Radiol. 2019;16(5s):S286-s99.

25. Swischuk LE, John SD, Hendrick EP. Is the open-mouth odontoid view necessary in children under 5 years? Pediatr Radiol. 2000;30(3):186-9.

26. The Royal College of Radiologists UK. Paediatric Trauma Protocols 2014 [updated 2017. Available from:

27. Jimenez RR, Deguzman MA, Shiran S, Karrellas A, Lorenzo RL. CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks? Pediatr Radiol. 2008;38(6):635-44.

28. Lennon P, editor Thyroid cancer in Ireland, a 10 year review of the national cancer registry. 17th European Congress of Endocrinology; 2015; Dublin, Ireland: European Society of Endocrinology.

29. Puchalski AL, Magill C. Imaging Gently. Emerg Med Clin North Am. 2018;36(2):349-68.

30. Brockmeyer DL, Ragel BT, Kestle JR. The pediatric cervical spine instability study. A pilot study assessing the prognostic value of four imaging modalities in clearing the cervical spine for children with severe traumatic injuries. Childs Nerv Syst. 2012;28(5):699-705.

31. Tat ST, Mejia MJ, Freishtat RJ. Imaging, clearance, and controversies in pediatric cervical spine trauma. Pediatr Emerg Care. 2014;30(12):911-5; quiz 6-8.

32. Booth TN. Cervical spine evaluation in pediatric trauma. AJR Am J Roentgenol. 2012;198(5):W417-25.

33. Easter JS, Barkin R, Rosen CL, Ban K. Cervical Spine Injuries in Children, Part I: Mechanism of Injury, Clinical Presentation, and Imaging. Journal of Emergency Medicine. 2011;41(2):142-50.

34.      Schwartz GR, Wright SW, Fein JA, Sugarman J, Pasternack J, Salhanick S. Pediatric cervical spine injury sustained in falls from low heights. Ann Emerg Med. 1997;30(3):249-52.

35.      Brown P, Munigangaiah S, Davidson N, Bruce C, Trivedi J. A review of paediatric cervical spinal trauma. Orthopaedics & Trauma. 2018;32(5):288-92.

36.      Leonard JC, Kuppermann N, Olsen C, Babcock-Cimpello L, Brown K, Mahajan P, et al. Factors associated with cervical spine injury in children after blunt trauma. Annals of emergency medicine. 2011;58(2):145-55.

37.      Copley PC, Tilliridou V, Kirby A, Jones J, Kandasamy J. Management of cervical spine trauma in children. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2019;45(5):777-89.

38.      Klimo P, Jr., Ware ML, Gupta N, Brockmeyer D. Cervical spine trauma in the pediatric patient. Neurosurgery Clinics of North America. 2007;18(4):599-620.

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  • Ronán is an Emergency Medicine Registrar in Dublin. He has a keen interest in PEM, Critical Care and QI. He is passionate about teaching both in EM and the field of Aviation as a Flight Instructor


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