Clinical Assessment: Children

Children’s cervical spines are different to those of adults (see page earlier in the session), with injury to the upper cervical spine and purely ligamentous injury being more common. In addition, younger children are often harder to assess, being frightened and uncooperative.

Clinical exclusion of cervical spine injury in children:

Viccellio and colleagues [9] performed a subgroup analysis of the NEXUS study, specifically evaluating children with neck injury. This group consisted of 3,065 children aged under 18 of whom 30 (0.98%) sustained a cervical spine injury. This incidence is lower than that in the adult population, but this may be due to more liberal use of radiography in children. There were no children with proven spine injury who were negative on all five NEXUS criteria, and no cases of SCIWORA. 45.9% of injuries occurred in the lower cervical spine (C5-C7). There was no spinal injury in children under 2 years and only 4 cases in children under 8 years of age in this study population, which means that, despite its apparently impressive performance, the NEXUS rule should be used with caution in these younger age groups.

A recent study compared the NLC and CCR in children [10]. The study evaluated children under 10 years of age, who had radiographs of their cervical spine over a 10 year period. Of the 125 children who had radiographs, 7 (3%) had clinically significant fractures. If the NLC was applied 3 fractures would have been missed (sensitivity=43%, specificity =96%) whereas the CCR would have missed 1 fracture (sensitivity=86% and specificity=94%). They concluded that, although the CCR performed better than NLC, neither could be used with confidence in children.

Clinical bottom line: There is no robust evidence base for a clinical 'rule-out for cervical spine injury in children less than 10 years of age.