There is quite a bit of controversy surrounding clearing the cervical spine in children. The trauma and emergency medicine literature have few high quality studies to base recommendations on. However, a few very good studies have been carried out that did include children, and they are the basis for this suggested method for clearance.
There are a few key concepts that must be understood before approaching spine clearance in this patient group.
- Clinical clearance is key! The majority of children’s cervical spines can be cleared clinically
- Limit routine radiographic evaluation, especially by CT. The head and neck is packed with glandular tissue that is sensitive to radiation, especially in early childhood.
- If radiographs are required, be sure to have them read by a radiologist who routinely reads pediatric images. There are many nuances in ossification and bony positioning that may falsely lead to injury diagnoses.
- Memorize the NEXUS criteria. This study included enough children to allow treatment recommendations to be validated. They are:
- Midline cervical tenderness
- Focal neurologic deficit
- Altered level of consciousness
- Evidence of intoxication
- Painful distracting injury
The first step is to determine whether the child is eligible to be clinically cleared. They must be able to verbalize and cooperate with your exam. They may not have a developmental delay, since this may interfere their ability to cooperate with your exam. Frequently, younger children are apprehensive around doctors, and I recommend that you have a parent perform appropriate parts of the exam under your verbal guidance.
Next, evaluate to see if any of the NEXUS critieria are met. The distracting injury criterion is the most difficult to assess. This is a judgment call, but if the child is aware of multiple potentially painful areas, then a distracting injury is probably not present.
If no NEXUS criteria are met, the spine is cleared and should be documented as such. If any are present, a lateral cervical spine xray should be ordered. If the child is >8 years old, a plain odontoid xray should also be obtained. If all are normal, the spine is cleared and should be documented. Children 8 or younger do not have an odontoid that visualizes well. In such cases, a CT from occiput to the base of C2 should be obtained, with appropriate shielding in place.
If, at any point, an abnormality is encountered, expert consultation must be sought in order to safely clear the cervical spine and remove any stabilization.