<< Cervical Spinal Injury In Pediatric Blunt Trauma Patients: Management In The Emergency Department (Trauma CME)


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Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study are included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1.  Patel JC, Tepas JJ 3rd, Mollitt DL, et al. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg. 2001;36(2):373-376. (Retrospective cohort; 1098 patients)
  2. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001;108(2):E20. (Prospective observational cohort; 3065 patients)
  3. * Leonard JC, Kuppermann N, Olsen C, et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med. 2011;58(2):145-155. (Retrospective case-control study; 1600 patients)
  4. Brown RL, Brunn MA, Garcia VF. Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg. 2001;36(8):1107-1114. (Retrospective cohort study; 103 patients)
  5. Platzer P, Jaindl M, Thalhammer G, et al. Cervical spine injuries in pediatric patients. J Trauma. 2007;62(2):389-396. (Retrospective case series; 56 patients)
  6. Partrick DA, Bensard DD, Moore EE, et al. Cervical spine trauma in the injured child: a tragic injury with potential for salvageable functional outcome. J Pediatr Surg. 2000;35(11):1571-1575. (Retrospective cohort; 52 patients)
  7.  Rozzelle CJ, Aarabi B, Dhall SS, et al. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery. 2013;72 Suppl 2:205-226. (Review)
  8.  Hadley MN, Zabramski JM, Browner CM, et al. Pediatric spinal trauma. Review of 122 cases of spinal cord and vertebral column injuries. J Neurosurg. 1988;68(1):18-24. (Retrospective case series; 122 patients)
  9. Cattell HS, Filtzer DL. Pseudosubluxation and other normal variations in the cervical spine in children. A study of one hundred and sixty children. J Bone Joint Surg Am. 1965;47(7):1295-1309. (Cohort study; 160 patients)
  10. Fesmire FM, Luten RC. The pediatric cervical spine: developmental anatomy and clinical aspects. J Emerg Med. 1989;7(2):133-142. (Review)
  11. Sullivan CR, Bruwer AJ, Harris LE. Hypermobility of the cervical spine in children; a pitfall in the diagnosis of cervical dislocation. Am J Surg. 1958;95(4):636-640. (Review)
  12. Leventhal HR. Birth injuries of the spinal cord. J Pediatr. 1960;56:447-453. (Review)
  13. ATLS Subcommittee, American College of Surgeons’ Committee on Trauma, International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013;74(5):1363-1366. (Expert recommendations)
  14. Rozzelle CJ, Aarabi B, Dhall SS, et al. Spinal cord injury without radiographic abnormality (SCIWORA). Neurosurgery. 2013;72 Suppl 2:227-233. (Review)
  15. Pang D, Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg. 1982;57(1):114-129. (Recrod review; 23 children)
  16. Hamilton MG, Myles ST. Pediatric spinal injury: review of 174 hospital admissions. J Neurosurg. 1992;77(5):700-704. (Retrospective case series; 174 patients)
  17. Osenbach RK, Menezes AH. Spinal cord injury without radiographic abnormality in children. Pediatr Neurosci. 1989;15(4):168-174. (Review)
  18. Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children--the SCIWORA syndrome. J Trauma. 1989;29(5):654-664. (Case series; 55 patients)
  19. Phillips WA, Hensinger RN. The management of rotatory atlanto-axial subluxation in children. J Bone Joint Surg Am. 1989;71(5):664-668. (Review)
  20. Pang D, Li V. Atlantoaxial rotatory fixation: Part 1--Biomechanics of normal rotation at the atlantoaxial joint in children. Neurosurgery. 2004;55(3):614-625. (Prospective cohort; 21 patients)
  21. Flynn JM, Closkey RF, Mahboubi S, et al. Role of magnetic resonance imaging in the assessment of pediatric cervical spine injuries. J Pediatr Orthop. 2002;22(5):573-577. (Prospective cohort; 74 patients)
  22. Hauswald M, Ong G, Tandberg D, et al. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214-219. (Retrospective cohort study; 454 patients)
  23. Treloar DJ, Nypaver M. Angulation of the pediatric cervical spine with and without cervical collar. Pediatr Emerg Care. 1997;13(1):5-8. (Case series; 18 patients)
  24. Herzenberg JE, Hensinger RN, Dedrick DK, et al. Emergency transport and positioning of young children who have an injury of the cervical spine. The standard backboard may be hazardous. J Bone Joint Surg Am. 1989;71(1):15-22. (Case series; 10 patients)
  25. Huerta C, Griffith R, Joyce SM. Cervical spine stabilization in pediatric patients: evaluation of current techniques. Ann Emerg Med. 1987;16(10):1121-1126. (Simulation study with 12 immobilization devices)
  26. Schafermeyer RW, Ribbeck BM, Gaskins J, et al. Respiratory effects of spinal immobilization in children. Ann Emerg Med. 1991;20(9):1017-1019. (Prospective cohort; 51 patients)
  27. Mawson AR, Biundo JJ Jr, Neville P, et al. Risk factors for early occurring pressure ulcers following spinal cord injury. Am J Phys Med Rehabil. 1988;67(3):123-127. (Prospective cohort; 39 spinal injury patients)
  28. Hannon M, Mannix R, Dorney K, et al. Pediatric cervical spine injury evaluation after blunt trauma: a clinical decision analysis. Ann Emerg Med. 2015;65(3):239-247. (Theoretical computer model based on published epidemiology)
  29. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National emergency x-radiography utilization study group. N Engl J Med. 2000;343(2):94-99. (Prospective observational cohort; 34,069 patients)
  30. 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):1841-1848. (Prospective cohort study; 8924 patients)
  31. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-2518. (Prospective cohort study; 8283 patients)
  32. Michaleff ZA, Maher CG, Verhagen AP, et al. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012;184(16):E867-E876. (Systematic review)
  33. Garton HJ, Hammer MR. Detection of pediatric cervical spine injury. Neurosurgery. 2008;62(3):700-708. (Retrospective case series; 187 patients)
  34. * Ehrlich PF, Wee C, Drongowski R, et al. Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients. J Pediatr Surg. 2009;44(5):987-991. (Retrospective case-matched cohort study; 375 patients)
  35. Laham JL, Cotcamp DH, Gibbons PA, et al. Isolated head injuries versus multiple trauma in pediatric patients: do the same indications for cervical spine evaluation apply? Pediatr Neurosurg. 1994;21(4):221-226. (Retrospective cohort; 268 patients)
  36. Pieretti-Vanmarcke R, Velmahos GC, Nance ML, 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):543-549. (Retrospective cohort; 83 patients)
  37. Katz JS, Oluigbo CO, Wilkinson CC, et al. Prevalence of cervical spine injury in infants with head trauma. J Neurosurg Pediatr. 2010;5(5):470-473. (Retrospective cohort; 905 patients)
  38. Anderson RC, Kan P, Vanaman M, 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):292-296. (Prospective cohort study; 575 patients)
  39. Swischuk LE, John SD, Hendrick EP. Is the open-mouth odontoid view necessary in children under 5 years? Pediatr Radiol. 2000;30(3):186-189. (Survey; 432 respondents)
  40. Buhs C, Cullen M, Klein M, et al. The pediatric trauma c-spine: is the ‘odontoid’ view necessary? J Pediatr Surg. 2000;35(6):994-997. (Case series; 51 patients)
  41. Woods WA, Brady W, Pollock G, et al. Flexion-extension cervical spine radiography in pediatric blunt trauma. Skeletal Radiology. 1998;5(6):381-384. (Retrospective case series; 137 patients)
  42. Dwek JR, Chung CB. Radiography of cervical spine injury in children: are flexion-extension radiographs useful for acute trauma? AJR Am J Roentgenol. 2000;174(6):1617-1619. (Retrospective case series; 247 patients)
  43. Ralston ME, Chung K, Barnes PD, et al. Role of flexion-extension radiographs in blunt pediatric cervical spine injury. Acad Emerg Med. 2001;8(3):237-245. (Blinded radiographic cohort; 129 patients)
  44. Shaw M, Burnett H, Wilson A, et al. Pseudosubluxation of C2 on C3 in polytraumatized children--prevalence and significance. Clin Radiol. 1999;54(6):377-380. (Retrospective cohort; 138 patients)
  45. Avellino AM, Mann FA, Grady MS, et al. The misdiagnosis of acute cervical spine injuries and fractures in infants and children: the 12-year experience of a level I pediatric and adult trauma center. Childs Nerv Syst. 2005;21(2):122-127. (Retrospective case series; 37 patients)
  46. Rana AR, Drongowski R, Breckner G, et al. Traumatic cervical spine injuries: characteristics of missed injuries. J Pediatr Surg. 2009;44(1):151-155. (Case series; 318 patients)
  47. * Nigrovic LE, Rogers AJ, Adelgais KM, et al. Utility of plain radiographs in detecting traumatic injuries of the cervical spine in children. Pediatr Emerg Care. 2012;28(5):426-432. (Retrospective cohort; 206 patients)
  48. Hernandez JA, Chupik C, Swischuk LE. Cervical spine trauma in children under 5 years: productivity of CT. Emerg Radiol. 2004;10(4):176-178. (Retrospective case series; 147 patients)
  49. Adelgais KM, Grossman DC, Langer SG, et al. Use of helical computed tomography for imaging the pediatric cervical spine. Acad Emerg Med. 2004;11(3):228-236. (Prospective unblinded randomized trial; 136 patients)
  50. Hadley MN, Walters BC. Guidelines for the management of acute cervical spine and spinal cord injuries. 2001. Available at: http://www.aans.org/Education%20and%20 Meetings/~/media/Files/Education%20and%20Meetingf/ Clinical%20Guidelines/TraumaGuidelines.ashx. Accessed August 22, 2015. (Review)
  51. Berne JD, Velmahos GC, El-Tawil Q, et al. Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study. J Trauma. 1999;47(5):896-902. (Prospective cohort study; 58 patients)
  52. * Pang D, Nemzek WR, Zovickian J. Atlanto-occipital dislocation--part 2: the clinical use of (occipital) condyle-C1 interval, comparison with other diagnostic methods, and the manifestation, management, and outcome of atlanto-occipital dislocation in children. Neurosurgery. 2007;61(5):995-1015. (Prospective cohort; 16 patients)
  53. Pang D. Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery. 2004;55(6):1325- 1342. (Review)
  54. Davis PC, Reisner A, Hudgins PA, et al. Spinal injuries in children: role of MR. AJNR Am J Neuroradiol. 1993;14(3):607- 617. (Case series; 15 patients)
  55. Liao CC, Lui TN, Chen LR, et al. Spinal cord injury without radiological abnormality in preschool-aged children: correlation of magnetic resonance imaging findings with neurological outcomes. J Neurosurg. 2005;103(1 Suppl):17-23. (Retrospective case series; 9 patients)
  56. Frank JB, Lim CK, Flynn JM, et al. The efficacy of magnetic resonance imaging in pediatric cervical spine clearance. Spine (Phila Pa 1976). 2002;27(11):1176-1179. (Pre- and post- intervention cohort; 102 patients)
  57. Kaiser ML, Whealon MD, Barrios C, et al. The current role of magnetic resonance imaging for diagnosing cervical spine injury in blunt trauma patients with negative computed tomography scan. Am Surg. 2012;78(10):1156-1160. (Retro-spective case series; 114 patients)
  58. Keiper MD, Zimmerman RA, Bilaniuk LT. MRI in the assessment of the supportive soft tissues of the cervical spine in acute trauma in children. Neuroradiology. 1998;40(6):359-363. (Retrospective case series; 52 patients)
  59. Grabb PA, Pang D. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children. Neurosurgery. 1994;35(3):406-414; discussion 414. (Case series; 7 patients)
  60. Dickman CA, Zabramski JM, Hadley MN, et al. Pediatric spinal cord injury without radiographic abnormalities: report of 26 cases and review of the literature. J Spinal Disord. 1991;4(3):296-305. (Case series; 26 patients)
  61. Levi L, Wolf A, Belzberg H. Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. Neurosurgery. 1993;33(6):1007-1016. (Case series; 50 patients)
  62.  McMahon D, Tutt M, Cook AM. Pharmacological management of hemodynamic complications following spinal cord injury. Orthopedics. 2009;32(5):331. (Review article and expert opinion)
  63. Blood pressure management after acute spinal cord injury. Neurosurgery. 2002;50(3 Suppl):S58-S62. (Review article and expert opinion)
  64. Braughler JM, Hall ED. Effects of multi-dose methylprednisolone sodium succinate administration on injured cat spinal cord neurofilament degradation and energy metabolism. J Neurosurg. 1984;61(2):290-295. (Basic science animal study)
  65. Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. 1990;322(20):1405-1411. (Randomized double-blind placebo-control trial; 333 patients)
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  67. Petitjean ME, Pointillart V, Dixmerias F, et al. [Medical treatment of spinal cord injury in the acute stage]. Ann Fr Anesth Reanim. 1998;17(2):114-122. (Randomized control trial; 106 patients)
  68. Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev. 2012;1:CD001046. (Systematic review and meta-analysis)
  69. Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National acute spinal cord injury study. JAMA. 1997;277(20):1597-1604. (Double-blind randomized control trial; 499 patients)
  70. Geisler FH, Coleman WP, Grieco G, et al. The Sygen multicenter acute spinal cord injury study. Spine (Phila Pa 1976). 2001;26(24 Suppl):S87-S98. (Randomized double-blind placebo-controlled trial; 760 patients)
  71. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the surgical timing in acute spinal cord injury study (STASCIS). PLoS One. 2012;7(2):e32037. (Prospective cohort; 313 patients)
  72. Bosch PP, Vogt MT, Ward WT. Pediatric spinal cord injury without radiographic abnormality (SCIWORA): the absence of occult instability and lack of indication for bracing. Spine (Phila Pa 1976). 2002;27(24):2788-2800. (Retrospective case series; 189 patients)
  73. Negrin J Jr. Spinal cord hypothermia in the neurosurgical management of the acute and chronic post-traumatic paraplegic patient. Paraplegia. 1973;10(4):336-343. (Case report)
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  75. Bricolo A, Ore GD, Da Pian R, et al. Local cooling in spinal cord injury. Surg Neurol. 1976;6(2):101-106. (Prospective cohort; 8 patients)
  76.  Hansebout RR, Hansebout CR. Local cooling for traumatic spinal cord injury: outcomes in 20 patients and review of the literature. J Neurosurg Spine. 2014;20(5):550-561. (Prospective cohort; 20 patients)
  77. Levi AD, Casella G, Green BA, et al. Clinical outcomes using modest intravascular hypothermia after acute cervical spinal cord injury. Neurosurgery. 2010;66(4):670-677. (Prospective case-control series; 28 patients)
  78. Casha S, Zygun D, McGowan MD, et al. Results of a phase II placebo-controlled randomized trial of minocycline in acute spinal cord injury. Brain. 2012;135(Pt 4):1224-1236. (Randomized double-blind placebo-control trial; 52 patients)


Publication Information

Andrew Dixon, MD, FRCPC

Publication Date

March 2, 2016

CME Expiration Date

April 2, 2019

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CME Information

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