C-Spine Injury - Shawn Safford: Update Course 2014

It takes 600 plain films to equal one neck CT in radiation exposure

C-spine injuries in 18-month-old age group typically present with the child either dead or paralyzed

C-spine injuries in very young children require significant force and would typically be high injuries

NEXUS trial criteria do not cover pediatric patients

If a lateral C-spine film is inadequate, proceeding to CT exposes the patient to radiation from both modalities

In children 2 years and younger, CT does not add anything above an adequate X-ray

Most institutions have protocolized trauma systems where an 18-month-old ejected from vehicle would automatically receive standardized imaging as a level 2 trauma

SCIWORA (spinal cord injury without radiographic abnormality) can present with normal X-ray and CT, requiring MRI for diagnosis, and may show cord contusion and muscle highlighting

SCIWORA symptoms may not appear until 6 to 8 hours after injury

For children with distracting injuries (such as femur fracture), a two-view C-spine followed by observation for at least 6 hours is appropriate

Some institutions leave patients in cervical collars for 1-2 weeks (sometimes up to 6 weeks) rather than obtaining MRI

MRI is the gold standard for evaluating ligamentous injury in the cervical spine

Institutional algorithms for C-spine clearance typically apply up to age 7-8 years, with NEXUS criteria (midline tenderness, altered level of consciousness, distracting injury, focal deficit) used as risk factors

Two-view C-spine (not three-view with odontoid) is the standard plain film protocol in children

Flexion-extension films can be performed two ways: voluntary movement by cooperative older children, or assisted movement under fluoroscopy with neurosurgery or trauma team present

Patients with normal films and normal MRI but persistent midline tenderness are typically discharged home with a soft collar for comfort, which patients usually remove after about a week

For children age 8 and older with high-risk features or midline tenderness, some institutions skip two-view C-spine and proceed directly to CT, especially if head CT is also indicated

MRI is used for C-spine clearance in prolonged intubations and ICU patients despite clear CT

In neurologically devastated patients requiring emergency surgery, the neck should remain in a collar regardless of imaging findings until definitive clearance can be obtained electively