Spinal Injuries in Children

Authors: Liz Herrieven / Editor: Charlotte Davies / Reviewer: Iain Marshall / Codes: MuC8, RP4, SLO4, SLO5, TP2 / Published: 26/10/2021 / Reviewed: 29/07/2025

Spinal injuries are thankfully not common in children. Less than 2% of all children involved in major trauma will have a spinal injury. About 80% of these are high cervical injuries, compared to adults in whom thoracic or lumbar injuries are more common (70%) and in whom cervical injuries are more often the lower c-spine (refresh your paediatric trauma anatomy here).

The biggest cause of spinal injuries in children is road traffic collisions, particularly those with high speed, a rollover or an ejection from the vehicle, with second place going to falls in younger children and sporting injuries in older children.

So, why do children get a different pattern of injury compared to adults? Some of this will be mechanism of injury, but a lot is down to anatomy. I’m an ED physician, so I like to keep things simple. Think of a child’s head as a large lollipop, sitting on a weak and flimsy lollipop stick. That stick, the cervical spine, has weak and elastic ligaments and muscles and, until the age of 7, the vertebral bodies are wedged anteriorly, giving much more room for movement than in the adult spine with its square vertebral bodies. The largest amount of movement occurs just under the lollipop, right at the top of the cervical spine, so this is where most injuries occur.

Management starts in the ED with the Primary Survey. The best way to prevent secondary spinal injury is to ensure good oxygenation and a decent circulation. At the same time, we need to consider restriction of c-spine movement (ROCSM). We have moved away from hard collars in children, partly as they don’t do a great job of preventing movement and secondary injury and partly because there’s a relatively high rate of complications, ranging from pressure sores to worsening injury due to a child fidgeting to get comfortable. Instead, manual inline stabilisation (MILS) is a great option. A hand either side of the head can be reassuring, along with some eye contact and a friendly voice. For older children, it might be enough to ask them to stay still. How about children who are having a wriggle or refusing to lay still? A decision needs to be made: are they wriggling because their neck and back don’t hurt and they want to sit up, or are they distressed, with a spinal injury and in need of either convincing to stay still or even sedation? Take a look at our C-spine skills blog for further information about c-spine immobilisation. 

We may need to roll a child – to get them off the transport scoop, to examine their back or to support them if vomiting. APLS now recommends a ‘20^o Tilt’ rather than a traditional 90^o log roll. This is to emphasize the damage you may cause by disrupting an existing injury when moving the child. The mantra, ‘the first clot is the best clot’, is useful here – you don’t want to exacerbate bleeding, an unstable pelvis, or a spinal injury by unnecessary movements. Our aim here is controlled minimal movement, the technique is otherwise similar to traditional log rolling.

This is also a good time to remind you how horrible it is to lay flat on your back, staring at the ceiling, whilst people you can’t see prod, poke and talk about you (this is probably why RCEM Best Practice Guidelines say you should have something on the ceiling. Do you?). Make sure someone keeps contact with the patient, letting them know what’s going on and letting them see a friendly face. If possible, a parent should be in sight too.

After the Primary Survey, when you have a bit more time to look for evidence of a spinal injury, the 6 Ps are a good starting point:

• Pain: not just tenderness, as anyone will be tender if you poke them hard enough, but are they in pain?
• Position: is there any torticollis? Are they laying comfortably and naturally?
• Paralysis or weakness
• Paraesthesia or altered sensation
• Priapism
• Ptosis or squint: can be a sign of high cervical injury, for example with compression of the 6^th cranial nerve.

Those small children, in whom a full neurological examination might be more challenging, are often the ones who will clear their own neckby having a wriggle, moving about, showing you they are not in pain and have no neurological deficit.

When considering thoracolumbar injury, it’s worth re-visiting your abdominal examination. 50% of children with abdominal bruising from a seatbelt will have a spinal injury. It’s fairly difficult to bruise the soft abdomen of a child, so abdominal bruising in trauma is always significant, for example a handlebar bruise to the abdomen in a child who has come off their bike is a sign of an intra-abdominal injury until proven otherwise. In an RTC, if the lapbelt part of the seatbelt sits higher than it should, across the abdomen instead of across the thighs, which it might do if the seatbelt doesn’t fit properly, or if it’s not being worn correctly, then a sudden deceleration will cause hyperflexion across the lapbelt. This bruises the abdomen and potentially causes a spinal fracture such as a Chance fracture.

If the child is very unlucky, they might have Seatbelt Syndrome: abdominal bruising, spinal injury and intra-abdominal injury.

Imaging the C-spine

So, which children do we image and how? NICE guidelines previously advised using the Canadian C-spine rules, however the latest guidelines have used a modified version of this to develop a decision-making flowchart. Somewhat confusingly there are different NICE guidelines. Here I reference the guidelines on Head Injury, which include algorithms for imaging of children and adults with C-spine and head injuries, as opposed to the older guidelines on spinal injury. These algorithms are referenced in the Royal College of Radiologists guidance too.

The development of imaging protocols is guided by balancing sensitivity to make sure we do not miss a C-spine injury and accepting the compromise of lower specificity and performing more imaging.

Many of you will be used to using CT as your primary imaging modality for all adults with potential C-spine injury, whereas with children we still sometimes do plain X-rays. It’s not that we are just lagging behind in paeds, but the decision has other factors, which include the increased radiation risk and also some evidence, (although not great), that the sensitivity and specificity of plain X-rays in children is better. We also know that C-spine injuries are much rarer in children, which does shift the risk-benefit ratio of any investigations.

So, back to the question of which children do we image? We have to explore all the risk factors before we even think about clinically clearing the C-spine, which personally was a bit of a shift as I perhaps relied too much on the clinical examination before.

The bits that stand out to me as clinically important from the flow chart are the high risk factor of “clinical suspicion of cervical spine injury and other areas are being scanned…” and the note about adequacy of the X-rays (how often do you find these aren’t quite good enough to be definitive?). So, for that child who has some neck pain and is going round for a CT head, maybe we should add the C-spine at this time. 

How about MRI? Isn’t this meant to be the gold standard? MRI is generally felt to be better at detecting ligamentous injuries, while CT is better at detecting bony injuries. We all know that getting a CT is faster, easier and more practical in acute trauma, plus there is no evidence that MRI is the best form of initial acute trauma imaging. MRI does have to be done in addition for any child with neurological signs and symptoms suggesting a C-spine injury.

Imaging the Rest of the Spine

There are no reliable rules for helping us to decide which children should have imaging of their thoracic or lumbar spine, so we need to rely on clinical suspicion. It’s worth remembering, though, that those children with thoracolumbar injuries are most often those children with multiple injuries from major trauma. Don’t forget, force dissipates up and down the spine, so after one injury is found, the whole spine should be imaged looking for others.

An X-ray is the first line investigation for thoracic or lumbosacral injuries, then CT if an abnormality is found or if there are signs and symptoms of a spinal cord injury.

Normal Imaging

What about when you have abnormal neurology but a normal CT? Because the cervical spine is very flexible, particularly in small children, the spinal column, (the bones, muscles and ligaments), can move up to 5cm from their starting point if enough force is applied. Their elasticity allows them to move back again to their starting point. The spinal cord, however, is not very mobile and can move only 5mm. So, the column might look pretty normal, with a very damaged cord. This is known as SCIWORA – spinal cord injury without radiological abnormality. 70% of cases occur in those under 8 years of age and SCIWORA makes up 20% of all spinal injuries in children.

Neurogenic Shock

Something else to consider with spinal injuries is neurogenic shock. This occurs with an injury above T6, which affects the sympathetic outflow from the spinal cord. This causes peripheral and splanchnic venous dilatation which results in hypotension. This doesn’t respond to transfusion and might complicate things if there’s a mixture of haemorrhagic and neurogenic shock. If the injury is above T2, then there may also be bradycardia, caused by interruption of the sympathetic supply to the heart. The child will be unable to mount a compensatory tachycardia in the face of hypovolaemia. Treatment is with vasopressors to squeeze blood in from the peripheral circulation, and positive chronotropic agents to counteract the bradycardia.

A note on Torticollis

Torticollis is an abnormal neck position. Normally, this is atraumatic, or starts with an action such as turning or reaching suddenly, and we manage it easily in children. Occasionally it is linked with trauma which you wouldn’t expect to cause a problem, and with no associated abnormal neurology, e.g. diving into a swimming pool, with no head injury. Your gut often says that there is no significant injury, but your brain says, “but what if….”  My management here is normally to provide excellent analgesia, positive encouragement, and review. If pain persists, I normally obtain plain film imaging.

If, however we find a child with torticollis following a more significant trauma it can be the presenting feature of atlantoaxial rotary subluxation, which is the most common C-spine injury in children.

Interpreting the Paediatric C-Spine X-ray

Children can have pseudo-subluxation of the c-spine. If you’re not sure whether the injury is true or not, seek further advice. Read more about C-spine X-ray interpretation from our friends at DFTB.

Summary

So, spinal injuries in children might not be very common, but they can be completely devastating. Remember the importance of the mechanism of injury, consider ROCSM, work your way through the Primary Survey and then the 6Ps and use the NICE guideline flowchart to work out the best imaging. But most importantly, keep some human contact with your patient, explain what’s going on, reassure them and watch how they lay and move, and you’ll get the answers you both need.

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Further reading

• Ronán Murphy. Cervical Spine Injuries Module, Don’t Forget the Bubbles, 2020.
• Nikki Abela. Shedding light on Paediatric Trauma Imaging, RCEMLearning, 2016.
• Matt Burton, Charlotte Davies. C-spine skills – Induction. RCEMLearning, 2020.
• Jules Blackham, et al. Cervical Spine Injury. RCEMLearning, 2021.