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

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology And Pathophysiology
6. Differential Diagnosis
   1. Cervical Spine Injuries
      1. Second Spinal Fractures
      2. Spinal Shock
      3. Spinal Cord Injury Without Radiographic Abnormality
      4. Atlantoaxial Rotary Injuries
7. Prehospital Care
   1. Spinal Immobilization
      1. Spinal Immobilization Of Children
   2. Patient Transfer
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Examination Of The Cervical Spine
9. Diagnostic Studies
   1. Low-Risk Criteria For Cervical Spinal Injury
      1. The National Emergency X-Radiography Utilization Study (NEXUS) And The Canadian C-Spine Rule
      2. Other Studies Addressing Low-Risk Criteria
   2. Plain Film Radiography
      1. Challenges In Interpretation Of Plain Films
         • Pseudosubluxation
         • Other Normal Variants In Pediatric Cervical Spines
         • Misdiagnosis And Missed Injuries
         • Swimmer's View
   3. Computed Tomography
   4. Magnetic Resonance Imaging
   5. Diagnostic Studies Summary
10. Treatment
    1. Initial Stabilization
    2. Management Of Neurogenic Shock
    3. Pain Management
    4. Use Of Steroids For Cervical Spine Injuries
    5. Surgical Consultation
11. Special Population
12. Controversies And Cutting Edge
    1. Therapeutic Hypothermia
    2. Minocycline
13. Disposition
14. Summary
15. Risk Management Pitfalls For Patients With Cervical Spine Injuries
16. Time- And Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway For Management In The Emergency Department Of Pediatric Patients With Suspected Cervical Spinal Cord Injury
19. Tables and Figures
    1. Table 1. Incomplete Spinal Cord Injury Patterns
    2. Table 2. Common Axial Vertebral Column Injuries (More Common In Children Aged < 8 Years)
    3. Table 3. Common Subaxial Vertebral Column Injuries (More Common In Children Aged > 8 Years)
    4. Table 4. Physical Examination Findings Concerning For Cervical Spinal Cord Injury
    5. Table 5. Low-Risk Criteria For Cervical Spinal Injury In Children
    6. Table 6. Prognostic Factors For Spinal Cord Injury Without Radiologic Abnormality.
    7. Figure 1. C2 Fracture With Anterior Dislocation
    8. Figure 2. Normal Anatomy Of The Pediatric Cervical Spine On Plain Radiograph
    9. Figure 3. C5 Flexion Teardrop Fracture
    10. Figure 4. Pseudosubluxation Of C2-C3 And C3-C4
    11. Figure 5. Undisplaced Jefferson Fracture Observed On X-Ray And Computed Tomography Scan
20. References

Abstract

Spinal injuries from blunt trauma are uncommon in pediatric patients, representing only about 1.5% of all blunt trauma patients. However, the potentially fatal consequences of spinal injuries make them of great concern to emergency clinicians. Clinical goals in the emergency department are to identify all injuries using selective imaging and to minimize further harm from spinal cord injury. Achieving these goals requires an understanding of the age-related physiologic differences that affect patterns of injury and radiologic interpretation in children, as well as an appreciation of high-risk clinical clues and mechanisms. This issue reviews current approaches to prehospital immobilization, identification of low-risk patients who may be clinically cleared from immobilization, a rational approach to the use of radiologic imaging, and the existing evidence for medical management of spinal cord injuries.

Case Presentations

A 3-year-old girl presents to the ED after a highway motor vehicle crash. The car she was riding in was traveling at 70 mph when it struck another car that was turning onto the highway. The child was in an appropriate child-restraint seat in the rear passenger seat. The driver was declared dead on the scene and the front passenger was severely injured. The child was boarded and collared on scene, and was hemodynamically stable during transport. A primary survey reveals no concerning physical findings. On secondary survey, she has midline tenderness at C2. There are no neurologic deficits, and she has a GCS score of 15. You are concerned about a spinal injury, but how do you proceed to investigate and manage this patient? Does the history of the incident make a spinal cord injury more or less likely? How likely is a cervical spine injury in a young child? Are there normal differences in the radiologic findings for young children? Do you have to perform imaging to clear a cervical spine, or is a clinical examination sufficient at this age? If you image, what do you choose, plain x-ray, CT, or MRI?

A 10-year-old boy is checked from behind while playing hockey. He went headfirst into the boards, striking the top of his head. EMS was called, and he was collared on the ice and transported to the ED. The paramedics noted weakness in both arms and legs on initial examination. The patient reported tingling sensations in his arms. On presentation to the ED, the patient is noted to have 5:5 strength in all limbs and midline tenderness from C3- C7. No other injuries are detected and his cervical spine series is normal. Does this child have SCIWORA? Is a traditional flat spine board appropriate for children? Are there guidelines or tools for clearance of a cervical spine without radiologic investigation that are validated and applicable for older children?

A 16-year-old adolescent boy presents to the ED after being ejected from the back of a pickup truck traveling at approximately 50 mph. He was boarded and collared at the scene. EMS gave 1 L of intravenous crystalloid to treat hypotension of 95/50 mm Hg, which improved to 115/60 mm Hg postbolus. On presentation to the ED, he is drowsy, but arousable. His vital signs are: blood pressure, 90/50 mm Hg; heart rate, 145 beats/min; respiratory rate, 18 breaths/min; oxygen saturation, 96% on 5 L/ min O₂; and temperature, 36.5°C. There is no movement in any of his limbs, his chest is clear, and his abdomen is somewhat distended, though soft and nontender. He has an obvious right lower leg fracture. You suspect a cervical spinal injury. Are there other physical findings that would make a spinal cord injury more likely? How should you immobilize the patient safely? Why is his blood pressure low? Is this neurogenic shock or something else? How do you treat him to minimize further cord injury? Should you give him steroids?

Introduction

A major challenge with spinal cord injury in children is the combination of its relative rarity and its potentially serious consequences. Missed diagnosis of a spinal injury (eg, a C2 fracture with anterior dislocation [see Figure 1]) can lead to permanent injury. Cervical spinal injury (CSI) occurs in about 1% to 1.5% of children evaluated following blunt trauma.^1,2 The majority of these injuries are in older children; < 5% of CSIs are in children aged < 2 years.³ In the largest review of pediatric CSI (75,172 children) by Patel et al, 1098 children were found to have CSI, an overall incidence of 1.5%.¹ The mean age of patients with a CSI was 11 years +/- 5 years, and there was a slight predominance of CSI in boys (61%). The vast majority of the injuries (83%) involved the bony structures. Upper CSIs (C1-C4) were seen with equal frequency across all age groups (42% in children aged ≤ 8 years; 58% in children aged > 8 years). Lower CSIs (C5-C7) were most commonly seen in older children (85% in children aged > 8 years). Importantly, 7% of these children had both upper and lower CSIs.

Approximately one-third of the children had neurologic impairment, and 24% of those were complete cord injuries. Approximately half of those with neurologic impairment had no radiographic evidence of bony injury.¹

Injury patterns differ with age and, thus, interpretation of radiographs is dependent on knowledge of age-related development of the osseous and ligamentous anatomy.

Mortality and morbidity are high, with mortality ranging from 13% to 28%.^4-6 Mortality is highest in young children and in those with upper cervical spinal injuries.⁶ Morbidity is variable, but can be severe. In a retrospective trauma registry review of 37 CSIs, 25 patients (67.6%) completely recovered, 3 patients (8.1%) partially recovered, and 9 patients (24.3%) had no recovery.⁵ A study of spinal cord injury patient outcomes determined that out of 23 patients, only 14 could feed themselves, and 12 could walk well enough to perform daily activities.⁶

The task of separating patients with cervical spine fractures and cord injuries from the multitude of patients with sore necks posttrauma is certainly a challenging one. This issue of Pediatric Emergency Medicine Practice addresses this challenge, and reviews the diagnosis and management of spinal fractures and spinal cord injuries in children. The cervical spine is the focus, as it has been the area of greatest concern for clinicians and the subject of the greatest amount of research. Based on existing literature, an approach to efficiently, cost-effectively, and safely diagnosing these “can’t miss” injuries is proposed.

Critical Appraisal Of The Literature

A literature search was performed in PubMed utilizing the medical subject headingschild, spinal cord injury, and trauma. A total of 3328 articles were reviewed, and 78 were chosen for this review. A search of the Cochrane Database of Systematic Reviews using the search term spinal cord injuries (not specific to pediatrics) identified 31 articles. Pediatric guidelines from 2013 from the Congress of Neurological Surgeons⁷ and general guidelines from 2001 from the American Association of Neurological Surgeons were also reviewed. There were several large studies attempting to determine low-risk criteria for cervical spinal injuries. These mostly focused on adults, but smaller studies have looked at pediatric CSIs. There are limited data on thoracolumbar injuries and, therefore, these are not a focus of this issue. There are no specific pediatric studies regarding pharmacologic therapies for spinal cord injury (ie, whether or not steroids are effective), and relatively few good-quality studies in adults, some of which included older pediatric patients.

Risk Management Pitfalls For Patients With Cervical Spine Injuries

1. “The patient didn’t seem to be very uncomfortable, so I didn’t ask about pain or offer any analgesics.”
   Clinicians tend to underestimate the pain suffered by patients. Every trauma patient should be asked to rate his or her pain on an appropriate pediatric pain scale and be offered appropriate analgesia.


2. “A 6-year-old who fell from a balcony presented with neck pain, but no other injuries. On the lateral plain radiograph, C2 was anteriorly displaced with respect to C3. I immediately consulted neurosurgery.”
   C2-C3 pseudosubluxation is the most common normal variant in children that is mistaken for injury. To differentiate between pseudosubluxation and true subluxation, a line should be drawn through the posterior arches of C1 and C3. In a pseudosubluxation, the posterior arch of C2 should not be posteriorly displaced > 2.0 mm from the C1-C3 line.


3. “I image the cervical spines of all the pediatric traumas I see.”
   There is clear evidence that there are certain patients who can be cleared in the absence of imaging. For patients aged > 9 years, adult-derived rules such as the CCR and the NEXUS criteria are applicable. Acceptable low-risk criteria for younger children are also reasonably well elucidated.


4. “An 8-year-old fell from a window (about 15 feet) and presented with bilateral tibia and fibula fractures. He was placed on a spine board and in a collar. He had no neck pain, tenderness, or neurologic deficit, so I cleared his spine and removed the spinal precautions.”
   Cervical spine clearance with low-risk criteria without imaging is not possible in the presence of a painful or distracting injury. Even an examination that reveals no pain is not reliable in this patient, due to the lower limb fractures. By some rules, the mechanism of his fall would also preclude a no-imaging clearance. Plain radiograph imaging is indicated for this patient, with further imaging as needed.


5. “The patient kept complaining about neck pain even though her CT scan was normal. So I reassured her that she just had muscular pain. I took off her collar and sent her home.”
   A normal CT scan does not exclude the possibility of a CSI. Some studies indicated sensitivities for bony injuries as low as 90%. Additionally, ligamentous injuries are detected at much lower rates with CT. MRI is often needed to find a ligamentous injury, some of which require surgical management. Discharge in a collar with re-evaluation in 10 to 14 days is an appropriate management plan.


6. “We really needed to clear the trauma room for other patients, so I evaluated a 15-year-old to quickly clear him. He had no neurologic signs or symptoms, and there was no midline tenderness, so I cleared him and removed his spinal precautions. When I took his history later, he admitted to drinking and he had an ethanol level of 70 mmol/L.”
   It is important to take a brief history to determine whether there are any conditions present that would make a patient ineligible for low-risk criteria. In an intoxicated patient, plain radiography should be obtained and clearance delayed until the intoxication has resolved.


7. “I was having a lot of trouble with the airway, so I removed his cervical collar to intubate him.”
   Endotracheal intubation is a very high-risk procedure for anyone with a CSI. Unfortunately, the degree of other associated injuries often makes it necessary. It is of vital importance that the cervical spine remain in a neutral position during intubation to prevent additional cord injury. This may be accomplished by a rigid collar, or by a second person performing in-line stabilization.


8. “A 9-year-old was complaining of neck and back pain after a fall. His cervical plain films showed a compression fracture at C5. I did not do further imaging as we had found his injury.”
   Any mechanism that caused a spinal fracture has a relatively high likelihood of causing more than 1 spinal fracture. Any patient with an identified injury needs careful evaluation with examination and imaging for a second injury.


9. “A 14-year-old who was involved in an MVC had persistent hypotension despite 2 liters of crystalloid solution. I presumed he must have intra-abdominal or intrathoracic bleeding and called general surgery to take him to the operating room.”
   Unexplained hypotension in a trauma patient may be the result of neurogenic, hypovolemic, or cardiogenic shock. All hypotensive patients should be carefully evaluated for spinal injury by physical examination and imaging prior to assuming another mechanism of shock is responsible.


10. “I spoke to the neurosurgeon about a 16-year-old with a C5 fracture and generalized weakness. They were going to be unavailable for 6 to 7 hours, so I kept the patient in a rigid cervical collar on a backboard for protection.”
    Backboards are transportation devices only. Even with an identified cord injury, lying flat in a bed in a rigid cervical collar with a slider for transfers is adequate spinal protection. Prolonged periods on backboards are very uncomfortable, and pressure sores may begin to develop within 6 hours, especially with cord injuries.

Tables and Figures

References

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)
66. Otani K, Abe, H, Kadoya S. Beneficial effect of methylprednisolone sodium succinate in the treatment of acute spinal cord injury (translation of Japanese). Sekitsui Sekizui J. 1994;7:633-647. (Randomized control trial; 158 patients)
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)
74. Meacham WF, McPherson WF. Local hypothermia in the treatment of acute injuries of the spinal cord. South Med J. 1973;66(1):95-97. (Prospective cohort; 14 patients)
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)