Pediatric emergency medicine trisk 3583 3583
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obtaining unnecessary CT scans of the cervical spine introduces increased risk of
malignancy due to ionizing radiation exposure, especially for the thyroid, that is
5- to 35-fold higher in children than in adults undergoing the same study with risk
inversely proportional to age and increased in female patients. The issue of
radiation exposure needs to be considered when developing institution-specific
protocols.
The CT scan images soft tissue well; however, it does not approach the
intrathecal, ligamentous, disc, or vascular detail that can be obtained with an MRI
scan. MRI scans are more appropriate when evaluating the subacute or chronic
stages of injury, ligamentous instability or disruption, or, as recommended by the
American Academy of Neurological and Orthopaedic Surgeons when looking for
an acute problem with cord or root impingement. Acute MRI evaluation is
increasing in popularity in the cervical spine evaluation of patients with altered
mental status. However, MRI does not image the cortical bone well and should
not be used as a primary tool to evaluate the cervical spine for fractures.
Additionally, many children may require sedation. Thus, the C-spine is better
evaluated by CT or plain radiograph.
Debate and practice variation exists regarding the clearing of the cervical spine
in a persistently obtunded patient. This should not be an ED debate or practice,
since obtunded pediatric patients should not have their cervical spine cleared in
the ED.
Clinical Considerations
Clinical Recognition
The clinician must assume that all children who sustain multiple trauma, including
infants with suspected abusive head trauma, have significant head or neck injuries,
possible neurologic impairment, and a cervical spine injury until proven
otherwise. The devastating nature of a cervical cord injury makes it imperative not
to miss a potentially unstable cervical spine injury.
Triage Considerations
Patients with potential cervical spine injury should be evaluated in an expeditious
manner and placed in a hard collar to immobilize their cervical spine. Their
evaluation will potentially include radiographic and laboratory studies, specialty
consultation, and continued close monitoring in the ED. Removal of a hard spine
board should occur as soon as possible to avoid unnecessary pain, risk of pressure
sores and skin breakdown, and respiratory compromise. Early transfer to a
