Cervical spine injury – Emergency management in children

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) in Queensland with a possible cervical spine injury following blunt trauma.

This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Orthopaedic and Spinal surgeons, Queensland Children’s Hospital, Brisbane. It has been endorsed for statewide use by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Introduction

Serious paediatric cervical spine injury following blunt trauma is rare, occurring in approximately 1% of all paediatric blunt trauma cases, with incidence ranging from 0.4% in the preschool population to 2.5% in the adolescent age group.^{1, 2} Of these injuries, the majority are stable injuries, while approximately 35% have varying degrees of instability requiring bracing or operative fixation.³

Severe cervical spine injuries generally occur from high-risk mechanisms and present with clinical red flags. Owing to the complexity of radiological interpretation and assessments of stability, and the large ‘denominator’ of children with blunt trauma, there is a critical need for stepwise risk stratification, so that greater expertise and imaging with higher radiation or more sophisticated modalities is reserved for higher-risk children and mechanisms.

The traditional cervical spine clearance algorithms (NEXUS and Canadian C-Spine Guidelines) have demonstrated significant value in assessing adult populations. However, the Canadian C-Spine guidelines have not been validated in children and the Viccellio analysis of the NEXUS rule in 3065 blunt trauma paediatric patients to age 18, included only 30 children with cervical spine injuries, and only 4 under 9 years of age. The PECARN multicentre case-control analysis of factors distinguishing 540 cervical spine injuries in children aged under 16 years, and subsequent prospective study of over 4091 children⁴ provides the most paediatric specific evidence available and forms the basis of this guideline. Results from a larger child specific PECARN prospective study are expected in the next year or so, and are expected to inform future guidelines. The Australia/NZ multicentre SONIC study (recruitment commenced in 2021) will in future provide better understanding of the use and value of these three risk factor sets in our local paediatric population. Meanwhile it is important to ensure a broad interpretation of their model and to be aware of other mechanisms known to be associated with spinal injury including falls, tumbling and trampolining.

A review of paediatric CSI cases at the two Queensland children’s hospitals during the six-year period of 2008-2013 identified 38 patients aged less than 16 years who sustained a severe spinal injury requiring neurosurgical input (fractures, dislocations, spinal cord injury or combination of these, with input being surgery, traction, brace or plaster fixation). Of these 38 patients, 18 were 8 years of age or younger, and all patients in this age group had occiput-C2 lesions. In patients aged 9-16 years of age, 8 out of 20 had low velocity “facet joint dislocation” type injury.⁵

Assessment

Emergency care should always involve a rapid primary survey with evaluation of (and immediate management of concerns with) airway, breathing, circulation and disability (ABCD) followed by a thorough secondary survey. Pay specific attention to the maintenance of neutral spine positioning.

Patients with suspected CSI or high risk traumatic injury transferred from other hospitals should have a full C-spine assessment undertaken on arrival in ED or ICU, in view of the high risk of subtle or occult injury.

History

History is critical in the risk assessment of paediatric patients with suspected CSI.
Questioning should include information on:

• mechanism of injury
• past medical history (see below for conditions that may predispose to CSI)
• symptoms post-incident including neurological symptoms, neck pain, ambulation and respiratory distress.

Examination

Pain vs tenderness

A traumatic cervical spine injury like any other traumatic deformation causes the conscious infant, child or adolescent to be acutely aware of pain and dysfunction, and to protect the area with muscle spasm. The PECARN study found a complaint of neck pain to be a significant risk factor for CSI while midline “tenderness” was NOT associated with CSI. Asking children (where appropriate) where they are sore, and assessing posture, mobility and clinical responses can help differentiate pain from tenderness.

Active range of motion

An assessment of active range of motion is only recommended for patients with no pain, no abnormal neurology, and no altered conscious state as an indication for imaging. While active neck rotation to 45⁰ bilaterally is considered an appropriate range of motion in adults, asymmetrical or painful limitation of movement at 45-90⁰ may be significant in children.

Assessing infants and young children

Assessment of infants and young children presents a particular challenge for the clinician. While relevant history may be obtained from parents or other witnesses, subjective description of symptomatology is unreliable and difficult. History and objective examination findings must be synthesised to determine the need for investigations and/or observation.

In general, CSI in young children is very rare: a 10-year review of more than 12,000 cases of blunt trauma from 22 Trauma Registries in USA identified only 83 children aged up to 36 months with CSI. All children had at least one of the following features: MVA, GCS less than 14, GCS eye = 1, reduced neck mobility, or face or skull fractures.⁶

The radiation risk in this age-group is higher while the sensitivity of plain films for injury or instability is lower. Assessment of the young child and interpretation of the young child’s radiology may require a high degree of sophistication and experience.

Thoracolumbar spinal injury

Risk factors include:

• high velocity MVA particularly if sash or harness restraint devices have not been worn
• ejection from MVA
• high speed motor bike/bicycle collisions in which patient has gone over handlebars landing on head prior to impact
• multi-trauma victims with unclear mechanism of injury and altered conscious state
• abnormal focal neurology
• localised thoracolumbar pain
• spinal injury at other levels

Investigations

Imaging is associated with radiation risks (exact exposure dependent on the machine used and site-specific protocols) and interpretation of findings can be complex. Imaging based on risk approach is recommended. Analgesia and reassessment prior to immediate imaging may be an appropriate management strategy in some children.

The risks and benefits of each imaging modality needs to be carefully considered. While in adult populations CT is generally preferred where available, this is not routinely recommended in children due the increased risks associated with radiation and the potential need for sedation.

Imaging to identify CSI in children

Considerations for each imaging type are outlined below.

Plain films

• sensitivity estimated at 90% but may be as low as 75% in age 0-3 years with severe mechanisms, as distraction failure in the occiput-C2 region is not readily apparent on plain films
• 10-20% of radiation exposure when compared with CT scan
• three views (antero-posterior, lateral and odontoid peg) where technically feasible, increase the sensitivity to detect clinically-significant CSI compared to fewer views
• odontoid peg views are technically difficult (may be obscured by teeth or occiput)
• able to identify malalignment e.g. facet joint subluxation/dislocation in sagittal view and torticollis in coronal plain view

Of the 542 children with CSI in PECARN, 18 had no abnormality detected on plain films. However, all had at least one risk factor for CSI. The four who required operative stabilisation presented with abnormal focal neurology following a high-risk mechanism of injury (os odontoideum and fall/flip (n=2), atlanto-occipital dislocation from MVA (n=1) and unilateral facet fracture/dislocation (n=1) following a trampoline fall.⁷

CT scan

• gold standard for identifying bony injury
• sensitivity to detect significant CSI in children is not 100% as findings can be subtle (e.g. small avulsion demonstrated in a single slice of a CT series). Careful assessment of overall risk is important
• potential cancer risks exist from the ionising radiation:
  • CT scans have been estimated to triple the risk of leukaemia and brain cancer – 10 years after the first CT scan in children less than 10 years of age, one excess leukaemia case and one excess brain tumour case per 10, 000 head CT scans is estimated to occur.⁸
  • extrapolation of physical data for radiation exposure during imaging on models at QCH demonstrated that the risks are greater in younger children and females, and that the radiation in a cervical spine CT series has an effective thyroid radiation dose approximately 10 times that of the 3-plain film series.⁹

MRI scan

• superior sensitivity for identifying ligamentous and soft tissue injury, particularly infants with high energy mechanisms¹⁰

MR angiography

• can identify vertebral artery injuries that may be associated with CSI
• consider in the following children:
  • high cervical spine injuries
  • fractures involving transverse foramen
  • neurological signs suggestive of vertebral artery insufficiency including vertigo, mental state changes or unilateral weakness

Decision making should include radiological and spinal teams in consideration of the risks of imaging and of potential treatment in the clinical context. In practice anticoagulation would rarely occur due to the severity of associated blunt trauma.

In view of the above considerations and the availability of local resources, general recommendations are outlined below.

Imaging to identify CSI in children

Seek senior emergency advice on choice of imaging for a child with risk factor/s for CSI.

Management

Refer to flowchart [PDF 738.83 KB] for a summary of the emergency management of a child following a CSI.

Spinal immobilisation in children

Immobilisation and spinal precautions are recommended for all children with risk factor/s for CSI until assessment has taken place and CSI has been excluded. Patients at risk of thoracolumbar spinal injury should be kept flat, with neutral positioning of the entire spine and log-rolling.

Infants may be brought into ED having been immobilised in a whole-body vacuum splint. These splints facilitate safe transport from the pre-hospital setting, however must be removed to allow full assessment. This involves deflating the splint, applying a cut-down soft collar if not already applied and log roll for any transfers.

The Queensland Ambulance Service, Princess Alexandra Hospital (PAH) Spinal Injuries Unit and Queensland Children’s Hospital recommend the MOR approach which involves LESS discomfort and risk of pressure complications (the change from stiff to soft collars) but MORE attention to addressing Moments of Risk (MOR) in the smaller number of higher-risk patients.

Neck collars

As with all mechanical trauma to the skeleton, deformations causing spinal cord injury or ischemia occur at the time of the initial massive angulating / displacing forces and are unlikely to be reproduced during normal handling. No orthopaedic immobilisation device can prevent angulation during transfers when high level instability is present, and the differences in angulation between one-piece, two-piece and soft devices with cervical spine precautions during handling is small.¹¹ Standard cervical collars cannot prevent anteropulsion of horizontally unstable injuries, or the risks associated with atlanto-occipital instability.

Soft collars should be used to immobilise the cervical spine. If needed, soft collars can be cut along the lower edge to ensure a snug fit under the chin.

Thoracic elevation device (TED)

TEDs are foam wedges designed to improve spinal and airway positioning in children.¹³

Moments of risk

Child with no risk factors or pain as only risk factor for CSI

• C-spine imaging is not required initially
• explain to patient and guardian that the risk of a clinically significant C-spine injury is very low
• if required administer Ibuprofen 10mg/kg + Paracetamol 15mg/kg if no contraindications
• prop patient up
• consider soft collar
• observe for 30-60 minutes if neck pain and/or limited range of motion
• consider further imaging if neck pain and/or limited range of motion persists on re-assessment

Consider seeking senior emergency advice as per local practice for child with persistent pain.

Child with at least one risk factor/s for CSI other than pain

Seek urgent orthopaedic advice (onsite or via Retrieval Services Queensland (RSQ)) if suspect acute cervical facet joint dislocation or spinal cord injury.

Unstable child

Seek immediate onsite assistance (anaesthetics/critical care/ENT) as per local practice to manage airway.

Seek urgent paediatric critical care advice (onsite or via RSQ) for unstable child.

Manage ABCD as per APLS.

Immobilise with soft collar. If aged less than eight years use a thoracic elevation device (refer to Immobilisation and spinal precautions section below).

Trauma patients with altered conscious state must be considered at high risk of unstable cervical spine injury +/- spinal cord injury. Recommended actions include:

• where possible, document all four limb movements/sensorimotor responses prior to paralysis for ventilation
• exercise care when interpreting cervical spine imaging as even CT evaluation may fail to identify ligamentous instability
• monitor mean blood pressure with a rigorous and interdisciplinary evaluation of hypotension
• consider neurogenic shock (characterised by persistent and refractory hypotension without accompanying tachycardia) while simultaneously actively pursuing other traumatic causes of haemorrhagic shock
• consider cerebral and spinal perfusion pressure to avoid secondary hypoperfusion injury. Inotropic support may be required (on paediatric critical care advice).

Stable child

• C-spine imaging is recommended (refer to Investigations)
• administer Ibuprofen 10mg/kg + Paracetamol 15mg/kg if no contraindications as required
• reassess child (including active range of motion) if no abnormality is detected on imaging

Prompt referral to local orthopaedic team is required for child with abnormality detected on imaging.

Seek senior emergency/orthopaedic advice as per local practice for a child with no abnormality detected but ANY of the following:

• altered mental status
• focal neurological deficit
• persistent neck pain
• persistent torticollis

Following CSI clearance:

• explain to patient and guardian that the risk of a clinically significant C-spine injury is very low
• remove splinting and cease spinal precautions
• recommend sitting posture and encourage gradual mobilisation

In practice many of these children are slow to mobilise particularly if they have been transported with spinal injury precautions.

Escalation and advice outside of ED

Clinicians can contact the services outlined below to escalate the care of a paediatric patient as per local practices.

Child who is unstable or requiring time-critical care

Stable child not requiring time-critical care

Inter-hospital transfers

Disposition

When to consider discharge from ED

Consider discharge for patients in whom CSI has been excluded providing there are no other concerns.

On discharge parents/caregivers should receive appropriate advice regarding analgesia and expected recovery (which may take weeks).

Follow-up

• with GP within a week.

Patients who have been assessed by the orthopaedic or spinal team may be discharged home for early outpatient review, with or without ongoing immobilisation, at the subspecialty team’s discretion.

When to consider admission

Patients with confirmed CSI, altered conscious state or focal neurological deficits require admission with spinal immobilisation and spinal precautions until function can be adequately assessed. Clearance of these children is a multidisciplinary responsibility requiring input from PICU, radiology, and spinal services. Handling to maintain neutral positioning and minimise pressure effects can be challenging.

Children in whom there are persistent symptoms such as pain or torticollis despite normal initial imaging may require a period of admission at the discretion of the treating specialist team.