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Updated: Jul 15, 2026
A Novel Vertebral Stabilization Method for Producing Contusive Spinal Cord Injury
Published on: January 5, 2015
A prospective multicenter study of cervical spine injury in children
P Viccellio1, H Simon, B D Pressman
1Department of Emergency Medicine, SUNY Stony Brook University Hospital, Stony Brook, New York 11794, USA. aviccellio@epo.hsc.sunysb.edu
Insights
Cervical spine injury (CSI) is rare in children under 8. The National Emergency X-Radiography Utilization Study (NEXUS) decision instrument accurately identifies pediatric CSI, potentially reducing imaging by 20%.
Area of Science:
- Pediatric Emergency Medicine
- Trauma Surgery
- Radiology
Background:
- Pediatric blunt trauma patients present unique challenges for assessing cervical spine injury (CSI) risk due to developmental and anatomical differences.
- Previous retrospective studies have not identified CSI in patients without specific symptoms like neck pain, neurologic deficits, or altered mental status.
Purpose of the Study:
- To investigate the incidence and spectrum of cervical spine injuries in pediatric blunt trauma patients (<18 years).
- To evaluate the effectiveness of the National Emergency X-Radiography Utilization Study (NEXUS) decision instrument in identifying CSI risk in this population.
Main Methods:
- A prospective, multicenter study involving pediatric blunt trauma victims.
- Clinical evaluation for specific criteria (midline cervical tenderness, altered alertness, intoxication, neurologic abnormality, distracting injury) was performed before imaging.
- Physician discretion guided radiography decisions, not solely the NEXUS criteria.
Main Results:
- 3065 pediatric patients (9.0%) had 30 (0.98%) confirmed CSIs.
- Lower cervical spine fractures (C5-C7) were most common (45.9%).
- The NEXUS instrument demonstrated 100% sensitivity and 100% negative predictive value for pediatric CSI, correctly identifying all injured patients and low-risk individuals.
Conclusions:
- CSI is uncommon in children 8 years or younger.
- Fractures of the lower cervical spine are the most frequent CSI type in pediatric blunt trauma.
- The NEXUS decision instrument is effective for pediatric CSI risk assessment, potentially reducing unnecessary imaging, though caution is advised for infants and toddlers.
Objective:
Pediatric victims of blunt trauma have developmental and anatomic characteristics that can make it difficult to assess their risk of cervical spine injury (CSI). Previous reports, all retrospective in nature, have not identified any cases of CSI in either children or adults in the absence of neck pain, neurologic symptoms, distracting injury, or altered mental status. The objective of this study was to examine the incidence and spectrum of spine injury in patients who are younger than 18 years and to evaluate the efficacy of the National Emergency X-Radiography Utilization Study (NEXUS) decision instrument for obtaining cervical spine radiography in pediatric trauma victims.
Methods:
We performed a prospective, multicenter study to evaluate pediatric blunt trauma victims. All patients who presented to participating emergency departments underwent clinical evaluation before radiographic imaging. The presence or absence of the following criteria was noted: midline cervical tenderness, altered level of alertness, evidence of intoxication, neurologic abnormality, and presence of painful distracting injury. Presence or absence of each individual criterion was documented for each patient before radiographic imaging, unless the patient was judged to be too unstable to complete the clinical evaluation before radiographs. The decision to radiograph a patient was entirely at the physician's discretion and not driven by the NEXUS questionnaire. The presence or absence of CSI was based on the final interpretation of all radiographic studies. Data on all patients who were younger than 18 years were sequestered from the main database for separate analysis.
Results:
There were 3065 patients (9.0% of all NEXUS patients) who were younger than 18 years in this cohort, 30 of whom (0.98%) sustained a CSI. Included in the study were 88 children who were younger than 2, 817 who were between 2 and 8, and 2160 who were 8 to 17. Fractures of the lower cervical vertebrae (C5-C7) accounted for 45.9% of pediatric CSIs. No case of spinal cord injury without radiographic abnormality was reported in any child in this study, although 22 cases were reported in adults. Only 4 of the 30 injured children were younger than 9 years, and none was younger than 2 years. Tenderness and distracting injury were the 2 most common abnormalities noted in patients with and without CSI. The decision rule correctly identified all pediatric CSI victims (sensitivity: 100.0%; 95% confidence interval: 87.8%-100.0%) and correctly designated 603 patients as low risk for CSI (negative predictive value: 100.0%; 95% confidence interval: 99.4%-100.0%).
Conclusions:
The lower cervical spine is the most common site of CSI in children, and fractures are the most common type of injury. CSI is rare among patients aged 8 years or younger. The NEXUS decision instrument performed well in children, and its use could reduce pediatric cervical spine imaging by nearly 20%. However, the small number of infants and toddlers in the study suggests caution in applying the NEXUS criteria to this particular age group.
