Written by Vivian Lei
These are the top 10 things to know about safely clearing the pediatric cervical spine after trauma while minimizing unnecessary imaging and immobilization.
A pain in the neck – pediatric c-spine clearance
We’ve covered pediatric c-spine clearance before. C-spine injuries occur in <1% of pediatric trauma cases but require vigilant assessment due to unique anatomical vulnerabilities in young children, such as large head-to-body ratios and ligamentous laxity, especially in patients under age 9. Here are the top 10 take-aways on best practices for pediatric cervical spine clearance following blunt trauma:
- Cervical collars have limited immobilization benefit and can cause harm (e.g., pressure ulcers, increased ICP). Remove promptly when clearance criteria are met.
- Avoid over-imaging. Use clinical judgment and validated tools to reduce unnecessary radiation.
- The PECARN Rule (2024) is the most robust pediatric-specific tool for cervical spine imaging decisions. Implementation can cut CT use by over 50%.
- X-ray is often sufficient for low-to-moderate risk, alert patients, and it delivers 1/10th the radiation of CT.
- Use CT for high-risk or critically ill children, especially those with altered mental status or neurologic deficits.
- Retroclival hematoma on head CT is a red flag for craniocervical junction injury, and prompt MRI is warranted.
- MRI is most sensitive for ligamentous injuries, but has downsides: long acquisition time, sedation needs, and over-detection of clinically insignificant findings.
- Limited-sequence MRI (LSMRI) shows promise in reducing scan time and sedation needs while preserving diagnostic accuracy.
- In obtunded children, MRI is still recommended until more prospective data are available regarding CT-based clearance.
- Use pediatric-trained radiologists when possible, as they improve accuracy, especially for subtle or high cervical injuries.
- Implement and adhere to a standardized cervical spine clearance protocol, such as the algorithm below, proven to reduce radiation, delays, and costs.
- Discharging children with persistent midline tenderness and negative x-rays in a c-collar is acceptable, with follow-up imaging or specialist consultation if symptoms persist.
Figures/Resources from the article:
How will this change my practice?
Clearing the cervical spine in pediatric trauma requires a thoughtful, evidence-based approach that balances the low risk of serious injury with the high risk of unnecessary imaging. Tools like the PECARN rule and standardized protocols can guide our decision-making while minimizing radiation exposure and overuse of cervical collars.
Editor’s note: We recreated the c-spine algorithm here in higher resolution. Also, understand the limits of c-spine x-ray accuracy. A study from 2017 at Vanderbilt found the sensitivity of x-ray was 51% for all injuries and just 62% for clinically significant injuries (as defined by NEXUS). Some institutions strongly favor use of c-spine CT over plain x-ray. ~Clay Smith
Source
Cervical spine clearance in the pediatric trauma population: What you need to know. J Trauma Acute Care Surg. 2025 Apr 1;98(4):541-549. doi: 10.1097/TA.0000000000004460. Epub 2024 Nov 28. PMID: 39621439
