CT catches these too: Characterizing pediatric cervical spine injuries managed with rigid collars

Clinically significant pediatric cervical spine injuries (CSIs) are rare, and most literature focuses on operatively managed cases. However, many children with persistent neck pain after trauma are discharged in rigid collars despite normal or equivocal CT findings. This group remains poorly characterized. We aimed to characterize injury patterns, imaging findings, and management of pediatric CSI patients, with a specific focus on those discharged in rigid collars.

We performed a retrospective cohort study of pediatric trauma patients (<18 years) at a Level 1 Pediatric Trauma Center from 2012 to 2021. Patients were included if they underwent cervical spine imaging (radiograph, CT, and/or MRI) and were diagnosed with a CSI. Demographics, injury mechanisms, imaging results, and treatments were collected. Subgroup analysis was performed on patients discharged in rigid collars. Univariate logistic regression stratified by injury level assessed associations between age and operative intervention.

Among 4477 pediatric trauma patients who underwent cervical spine imaging, 309 (6.9 %) were diagnosed with a CSI. Of these, 60 (19 %) underwent surgical intervention, 138 (45 %) were observed without immobilization, and 106 (34 %) were discharged in rigid collars. Operative intervention was associated with increasing age (p = 0.006) and high-energy trauma (p = 0.012), particularly for subaxial injuries. Most patients discharged in collars had persistent pain despite normal or mild CT findings and underwent MRI or neurosurgical consultation prior to discharge. CT identified all patients ultimately discharged in collars. Five injuries initially concerning to the trauma team were reviewed by a pediatric spine surgeon and determined not to be unstable; MRI showed ligamentous strain or normal variants, and none required surgery.

A substantial proportion of pediatric CSI patients are managed nonoperatively with rigid collars due to persistent symptoms. CT identified all patients needing further evaluation, and MRI clarified soft tissue injuries in symptomatic cases. Spine surgeon review confirmed these injuries were not unstable and did not require surgery. These findings highlight CT as an effective screening tool, the value of MRI in select cases, and the importance of clinical judgment and multidisciplinary evaluation in managing children discharged in collars.