POTD: Peds C Spine Clearance

 ·   · 

How do I clear a pediatric C-Spine?


  • While c-spine injury in children is rare, children have some anatomical differences that make their c-spines prone to injury

  • NEXUS and Canadian C-Spine Rule cannot be used in children  

  • PECARN study identified 8 risk factors: 

    • AMS

    • focal neuro deficits

    • torticollis

    • complaint of neck pain

    • significant torso injury, predisposing conditions

    • high risk MVC

    • diving

  • If any of the 8 is present, they found a 98% sensitivity for injury. 

  • The Pediatric Cervical Spine Clearance Working Group put together an algorithm based on the PECARN study (see graphic)

Anatomy Review 

  • Bigger heads

    • Due to the larger head:body mass ratio, children’s natural fulcrums are more caudal, meaning they’re much more likely to sustain high c-spine fractures. 

    • In an infant, this fulcrum is located at around C2-C3 and eventually moves down to C5-C6 by adulthood.

    • Most c-spine injuries occur between the occiput and C3 in children < 8 years of age

  • Spinal column flexibility

    • This does not apply to the spinal cord!

    • Meaning you can have significant spinal cord injury without injury to the spinal column

    • This is how SCIWORA happens (spinal cord injury without radiographic abnormality)

  • Poor musculature

    • Less protection against injury

  • Ossification Centers

    • Can make it difficult to identify injury even with imaging

  • Vertebral facet joints

    • More horizontal than adults

    • Requires less force to cause dislocation


NEXUS (2000) and the Canadian Cervical Spine Rule (2001) are the two most frequently used adult scoring systems for risk stratification, but NEXUS only had 9% of patients under 18 and the Canadian completely excluded patients under 18. 

Should we scan every pediatric trauma patient? (Obviously no!)

In 2011, PECARN published a study identifying risk factors that looked at patients with and without c-spine injury and looked at characteristics that were similar among the group with c-spine injury. What they identified were 8 major risk factors that were associated with c-spine injury (using odds ratios with a CI of 95%):

  1. Altered mental status

  2. Focal neurological deficits

  3. Complaint of neck pain

  4. Torticollis

  5. Substantial injury to the torso

  6. Predisposing conditions (e.g. Down Syndrome or other musculoskeletal abnormalities)

  7. High risk motor vehicle crash

  8. Diving injury


They found that these factors were able to identify c-sine injury with 98% sensitivity when any of the eight were present. Specificity was 26%. They were also able to conclude that this would decrease diagnostic imaging by 25%. 


Keep in mind this study is not perfect and a subsequent validation study only showed 90% sensitivity with a large confidence interval. 

Consensus Statements... 

This year, based on this study, the Pediatric Cervical Spine Clearance Working Group released a consensus statement in the Journal of Bone and Joint Surgery and proposed the following algorithm (PCSCWG algorithm – clearly they need to work on their acronyms). 

peds c spine clearance flowsheet.jpg

Fun EMS related fact: the NAEMSP (National Association of EMS Physicians also released a position statement in 2018 that application of a c-collar is not necessary if a child does not have:

  • Complaint of neck pain

  • Torticollis

  • Neurological deficit

  • Altered mental status (including intoxication and other signs of AMS such as agitation, apnea, hypopnea, somnolence, etc.)

  • Involvement in a high-risk MVC, high impact diving injury, or substantial torso injury



  1. Fischer PE, Perina DG, Delbridge TR, et al. Spinal motion restriction in the trauma patient – a joint position statement. Prehospital Emergency Care. 2018;22(8):659-661.

  2. Leonard JC,Kuppermann N, Olsen C, et al. Factors associated with cervical spine injury in children after blunt trauma. Annals of Emergency Medicine. 2019;58(2):145-155.

  3. Herman MJ, Brown KO, Sponseller PD, et al. Pediatric cervical spine clearance: a consensus statement and algorithm from the pediatric cervical spine clearance working group. J Bone Joint Surg Am. 2019;101;e1(1-9). 

  4. Fox SM. Pediatric cervical spine injury. Pediatric EM Morsels. https://pedemmorsels.com/pediatric-cervical-spine-injury/. Published February 8, 2019. Accessed July 5, 2019.