A 14 year old male presents to your Emergency Department by private car with neck pain following a failed back-flip whilst playing on the family trampoline at home.
You are approached by the Triage Nurse to ‘try and clear his neck’ so he can avoid a spinal collar and the unnecessary use of a bed. So you head over to see the patient…
He reports attempting a back-flip, however paused halfway through the rotation causing him to fall and land directly on his head. His neck extended significantly during this impact. There was no loss of consciousness and he has not had any specific neurological symptoms (altered sensation, weakness etc).
He reports immediate left sided neck pain and poor range of motion, but was able to mobilise immediately afterwards.
He is normally fit and well
No significant PMHx
No regular medications
No known allergies
Back to the question – are you able to clear his neck clinically?
The two commonly used clinical decision rules for clearance of the cervical spine are the Canadian C-spine Rules (CCR) and NEXUS. But are they helpful in the paediatric population?
Canadian C-Spine Rules:
The CCRs excluded patients less than 16 years of age. They cannot therefore be applied to our patient in this case.
The NEXUS study enrolled over 34,000 patients (aged less than 1 year to 101) and identified all but 8 of the 818 patients who had cervical spine injury (sensitivity 99.0%).
There were 3065 children in the study with only 30 cases of spinal cord injury. Only 905 children age <8 years were enrolled of which only four had injuries.
NEXUS performed well in this paediatric subgroup;
- Sn 100%, Sp 19.9%
- NPV 100%, PPV 1.2%
- No ‘low-risk’ patients with subsequent spinal injury
- Potential to reduce cervical spine imaging by ~20%.
With this in mind, you examine the patient who essentially has an unremarkable primary survey.
- Patent & protected airway.
- Chest clear without chest wall tenderness, crepitus or subcutaneous emphysema
- Normal haemodynamics. Warm and well perfused
- Normal neurological exam (GCS 15, normal tone/power/reflexes, pupils equal & reactive).
- No bruising or contusion.
On examination of the neck, there is no midline tenderness, physical step or deformity. He does however have significant left sided neck tenderness on palpation and is unable to rotate his neck due to pain.
Based on the degree of tenderness & inability to rotate the neck laterally you order a plain cervical spine X-ray series…
There is an obvious disruption of the anterior and posterior vertebral line at C3/4 with ~5mm of anterior displacement. A facet joint appears subluxed anteriorly.
Based on these findings you elect to proceed with a CT scan of the cervical spine.
Now, how are we going to tackle this clinical question next time around …
Paediatric c-spine clearance.
Alert, asymptomatic and normal examination.
…and for those less than 5 years of age
The absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger.
- Normal neurological exam
- Normal mentation
- No neck pain
- No torticollis
…then take the collar off & observe.
Painless range-of-motion, normal behaviour & neck movement = cleared spine.
Cervical spine signs & symptoms.
A CT scan or MRI is most likely indicated.
Now we’ve seen what’s normal, let’s consider the potential injuries using the mnemonic – Jefferson Bit Off A Hangman’s Thumb.
Burst fracture of C1.
Bilateral facet dislocation
A flexion distraction type of dislocation of the C-spine, often a result of buckling force.
Odontoid fracture (types II & III)
Specifically, types II & III.
Severe injuries including both atlanto-occipital dislocations and atlanto-occipital subluxations.
Bilateral lamina and pedicle fracture at C2 with anterolisthesis of C2 on C3. Associated with judicial hangings.
Tear drop fracture (extension)
Typically resulting in an avulsion of the anteroinferior corner of the vertebral body.
Often associated with central cord syndrome.
Any injury involving two or more of Denis’ columns are considered unstable. One of the more extreme examples of this is the ‘Chance fracture’, a flexion-distraction injury.
An anterior crush fracture of >50% loss of height in the thoracolumbar spine or >25% of the cervical spine is considered unstable.
Slack, S. E. (2004). Clearing the cervical spine of paediatric trauma patients. Emergency Medicine Journal, 21(2), 189–193. https://doi.org/10.1136/emj.2003.012310
Hannon, M., Mannix, R., Dorney, K., Mooney, D., & Hennelly, K. (2015). Pediatric cervical spine injury evaluation after blunt trauma: a clinical decision analysis. Annals of Emergency Medicine, 65(3), 239–247. https://doi.org/10.1016/j.annemergmed.2014.09.002
Hale, D. F., Fitzpatrick, C. M., Doski, J. J., Stewart, R. M., & Mueller, D. L. (2015). Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. The Journal of Trauma and Acute Care Surgery, 78(5), 943–948. https://doi.org/10.1097/TA.0000000000000603
Viccellio P, Simon H, Pressman BD. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001; 108(2):E20. [pubmed]
Pediatric C-spine Clearance – via ERCAST
Pediatric Cervical Trauma Overview – via OrthoBullets
Clearing The Pediatric C-spine – via PEM ED
Pseudosubluxation of the C spine – via Wheeless’ Textbook of Orthopaedics