Version October 2024
| Radiologic study | History and physical |
| None | Low risk mechanism of injury, and |
| No multiple system trauma with substantial injuries to head, face, or torso and no high-risk biomechanics*, and | |
| No conditions that predispose to cervical spine injury¶, and | |
| Awake (GCS score 14 or 15) and cooperative with exam, and | |
| Normal neck and neurologic examination | |
| Lateral, AP, odontoid radiographs◊ | High-risk mechanisms of injury or biomechanics*, or |
| Multiple system trauma with substantial injuries to head, face, or torso, or | |
| Conditions that predispose to cervical spine injury¶, or | |
| Altered mental status (GCS <14), or | |
| Neck pain, tenderness, deformity, or limitation of movement | |
| Computed tomography of the C-spine | Acute neurologic deficit (instead of plain radiographs), or |
| GCS score ≤8 (instead of plain radiographs), or | |
| As part of initial evaluation of patients with head injury and altered mental status (GCS score 9 to 13) instead of plain films, or | |
| Abnormal or suspicious C-spine on plain radiographs, or | |
| High index of suspicion for C-spine injury despite normal plain cervical radiographs | |
| Flexion-extension radiographs§ | Normal C-spine films, and |
| No neurologic deficit referable to C-spine, and | |
| Continued neck pain, tenderness, or muscle spasm, and | |
| Able to actively flex and extend neck for the examination | |
| MRI | Children with an abnormal neurologic examination and those requiring imaging of the soft tissues of the spinal column and spinal cord (eg, patients with normal plain films but persistent concern for neurologic injury based upon history, patients with prolonged loss of consciousness in whom cervical spine cannot be cleared by 24 to 72 hours post injury) |
GCS: Glasgow coma scale; MRI: magnetic resonance imaging.
* High-risk mechanisms include injuries caused by diving, hanging, axial load to the head, clotheslining force, or motor vehicle crashes (speed >55 mph, death of occupant, partial or complete ejection, and intrusion into the passenger compartment [12 inches at sides 18 inches at roof]). Patients with painful injuries not due to high-risk mechanisms for cervical spine injury (eg, isolated extremity fracture despite low force mechanism) may still undergo clinical clearance.
¶ For example, Down syndrome, Klippel Feil syndrome, Morquio syndrome, Larsen syndrome, ankylosing spondylitis, cervical arthritis, prior cervical spine injury, or cervical spine surgery.
Δ Able to move head in flexion and extension and rotate 45 degrees to both sides without pain.
◊ Odontoid plain radiographs may be omitted in uncooperative children. However, children with possible upper cervical spine injury by history or physical examination should undergo computed tomography of C1.
§ If biomechanics of injury and clinical findings do not indicate a high index of suspicion for ligamentous injury, flexion-extensions radiographs may be deferred to outpatient follow-up.Do you want to add Medilib to your home screen?
